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The Personal Injury Commission’s recent decision in Allianz Australia Insurance Limited v Mataraci [2025] NSWPICMP 536 provides valuable guidance for claimants seeking approval for medical treatment under the Motor Accident Injuries Act 2017 (NSW). The case offers useful insight into how the statutory requirements for accident-related, and “reasonable and necessary” treatment, are interpreted. While fact-specific, the reasoning illustrates how the law accommodates situations where treatment needs arise from a combination of accident-related injuries and other health conditions.

Background

The matter concerned a claimant injured in a motor vehicle accident on 12 February 2022, when another driver failed to stop at a stop sign. She developed persistent lower back pain, right buttock pain and L5 radiculopathy. Despite an extended course of conservative treatment, including peri-neural steroid injections, medication, and chiropractic care, her symptoms did not resolve. The claimant’s treating specialists documented a gradual decline in her functional capacity, including difficulty with sitting, standing, and sleeping. Considering her deteriorating condition, they recommended a posterior L5/S1 decompression and fusion surgery.

A Medical Assessor initially determined the surgery was both related to the accident and reasonable and necessary. The insurer disputed that conclusion, contending the claimant’s pre-existing multiple sclerosis complicated the causal picture. The matter then came before a Review Panel for reconsideration.

Causation – the material contribution test

In determining whether the surgery was related to the accident, the Panel confirmed that the statutory test does not require the accident to be the sole cause of the treatment need. It is sufficient that the accident made a material contribution, which is consistent with the approach in AAI Limited t/as AAMI v Phillips [2018] NSWSC 1710. This recognises that a claimant’s presentation may be influenced by more than one factor. The focus remains on whether the accident has played a meaningful role in creating the need for treatment.

In Mataraci, the claimant’s pre-existing multiple sclerosis was found not to have caused the need for surgery. The Panel accepted that, on the balance of probabilities, the surgery would not have been required but for the accident. The accident had materially worsened her condition or, at the very least, accelerated the need for surgical intervention. The distinction between unrelated pre-existing conditions and the accident-related injuries was central to this finding.

Reasonable and necessary – a stricter test

The Panel then considered whether the surgery satisfied the “reasonable and necessary” requirement in s 3.24(2) of the Motor Accident Injuries Act 2017 (NSW). The use of the word “necessary” without qualification imposes a stricter threshold than the “reasonably necessary” test found in the workers compensation scheme. In practice, this requires more than showing that surgery is reasonable in the circumstances, it must be shown to be required to address the accident-related injury.

In Mataraci, the Panel considered the overall clinical context, the lack of success of alternative treatments, the likely effectiveness of the proposed surgery, its cost compared with ongoing conservative management, and the weight of medical expert support.

The evidence established that non-operative measures had been exhausted without lasting relief. The surgery was clinically indicated, targeted the symptomatic lumbar nerve root, was likely to be effective, and its cost would not exceed that of prolonged conservative treatment. The fact that the procedure was supported by the claimant’s treating specialists further strengthened the case.

Significance of the decision

The Review Panel ultimately upheld the original Medical Assessor’s determination, confirming that the surgery was both related to the accident and reasonable and necessary.

The decision reinforces that the presence of other health conditions does not prevent a favourable finding where the accident has made a genuine and substantial contribution to the treatment need. It also demonstrates that determinations under s 3.24(2) are multi-factorial, with no single consideration being decisive. The strength of the medical evidence, the elimination of ineffective alternatives, and a clear link between the accident and the ongoing symptoms were all critical to the outcome.

Practical takeaways

For practitioners, Mataraci highlights the importance of carefully collecting medical evidence, particularly where a claimant has pre-existing conditions. Reports that directly address causation, the exhaustion of conservative measures, and the likely effectiveness of proposed treatment will be central to the likely outcome obtained. For claimants, the case demonstrates that the presence of unrelated health conditions is not fatal to an application if it can be shown that the accident has meaningfully contributed to the need for treatment.

The decision provides a timely reminder that the statutory test under the Motor Accident Injuries Act is both rigorous and nuanced, requiring decision-makers to balance cost, clinical effectiveness, and the claimant’s overall presentation against the evidence of treating specialists.

This article was published on 2 October by Carroll & O’Dea Lawyers and is based on the relevant state of the law (legislation, regulations and case law) at that date for the jurisdiction in which it is published. Please note this article does not constitute legal advice. If you ever need legal advice or want to discuss a legal problem, please contact us to see if we can help. You can reach us on 1800 059 278 or via the Contact us page on our website. If you or a loved one have been injured, use our Personal Injury Claim Check now.