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In Brief
- Pursuant to section 3.24(2) of the Motor Accident Injuries Act 2017, a Claimant is not entitled to statutory benefits for treatment and care where the treatment and care is not reasonable and necessary and/or not related to the injuries sustained in the motor accident.
- Treatment, such as physiotherapy, may not be reasonable and necessary where prior treatment of the same kind has not resulted in any sustained benefit to the Claimant.
- Treatment is not reasonable and necessary where it does not help in the Claimant's recovery.
Facts
The decision in AAI Limited t/as AAMI v Zawit [2026] NSWPICMP 186 was delivered on 12 March 2026 and published on 27 March 2026.
The Claimant was injured in a motor accident on 14 February 2022. He sustained injuries to his left shoulder, back and neck.
On 18 July 2024, the Claimant's treating physiotherapist sought approval for physiotherapy treatment. On 30 July 2024, the Insurer declined the request for further physiotherapy on the grounds that the treatment was not reasonable and necessary. That determination was confirmed on Internal Review. The primary Medical Assessor, however, endorsed the request for further physio. The Insurer successfully sought referral to the Review Panel.
The Review Panel's Decision
The Review Panel accepted that any need for physiotherapy was related to the accident because the Claimant made an early report of lumbar symptoms to his treating doctor, in February 2022, and was referred for physiotherapy at that time.
The Review Panel, however, determined that the Claimant's physiotherapy was not reasonable and necessary for the following reasons:
- The Claimant received regular physiotherapy in 2022 and 2023.
- In November 2023, the Claimant's treating physiotherapist reported that any further physiotherapy was unlikely to improve the Claimant's chronic back pain.
- In January 2024, the Claimant's treating physiotherapist discharged the Claimant from his care and recommended full transition to exercise physiology.
- In July 2024, the Insurer indicated that it was willing to approve an alternative pain program.
- The claim for further physiotherapy was not reasonable and necessary in circumstances where previous physiotherapy had not resulted in any sustained improvement in the Claimant's lumbar spine symptoms and further physiotherapy would not improve the Claimant's recovery.
Why This Case is Important
The decision in Zawit provides a useful illustration of how a Medical Review Panel assesses whether ongoing passive treatment measures, like physiotherapy, constitute reasonable and necessary treatment years after the accident.
Each claim, of course, turns on its own facts.
The Review Panel concluded, in this dispute, however, that further physiotherapy was not reasonable and necessary given that previous physiotherapy had not helped the Claimant. Doubtless, the Review Panel also gave weight to the fact that the Insurer had moved on from physiotherapy and approved an exercise physiologist in the context of a pain program.
Additional McCabes Resources
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