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What is the extent of the duty of decision makers to address arguments made by a party to a medical dispute? The Supreme Court provides the answer in Stanizzo v AAI Limited t/as GIO.

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Author: Stephanie Ibrahim

Judgment Date: 26 August 2021

Citation: Stanizzo v AAI Limited trading as GIO [2021] NSWSC 1077 (26 August 2021)

Jurisdiction: Supreme Court of New South Wales, Adamson J

Principles

  • A decision-maker must fairly address the arguments put by a party and provide sufficient reasoning in support of the conclusions reached; that is a matter of ‘procedural fairness‘.
  • A decision maker is required to provide an ‘actual path of reasoning‘ by which the conclusion was reached.

Background

Vincent Stanizzo (the Claimant) was injured in a motor accident. The Insurer issued a liability notice accepting that the cause of the accident was the fault of the Insured driver. As he was not at fault, the Claimant was entitled to reasonable and necessary treatment and therefore requested funding of a cervical cord decompression surgery, as per s3.24 (1)(a).

The Insurer declined this medical request on the grounds that the need for the surgery was not caused by the accident. The Claimant then sought an internal review, and the decision was affirmed. The Claimant referred the medical dispute to the Personal Injury Commission and Medical Assessor Dr Raymond Wallace was allocated to determine it.

Although he had pre-existing cervical spine problems, the Claimant contended that he had been asymptomatic for at least four years prior to the accident and symptomatic immediately after the accident. The Medical Assessor issued a certificate in which he agreed with the Insurer that the need for the treatment was caused by a progression of an underlying degenerative condition and was not causally related to the accident. The Claimant applied for a review of the Medical Assessor’s assessment. The Claimant challenged the decision of the Medical Assessor on the grounds that:

(1) there was no evidence to support the Medical Assessor’s finding that the Claimant had suffered symptomatic cervical canal stenosis for 11 years prior to the accident;

(2) the Medical Assessor had failed to address the Claimant’s substantial and clearly articulated submission that he had been asymptomatic for four years prior to the accident;

(3) the Medical Assessor’s reasons were insufficient; and

(4) the Medical Assessor failed to put his assumption about the pre-accident symptomatology to the claimant and thereby failed to accord procedural fairness to the Claimant.

On 20 April 2021, the President’s delegate refused the Claimant’s application and classified the dispute as “simply a difference of opinion between medical practitioners”. This refusal was challenged by application to the Supreme Court.

Decision

The court found that two errors which correspond to grounds (2) and (3) amount to error of law and jurisdictional error.

The Medical Assessor’s decision was set aside, as the Claimant’s submission that he had been asymptomatic in his cervical spine for four years prior to the accident was not addressed by him. Specifically, the Court observed, at [13] & [14]:

“It is an aspect of procedural fairness that a decision-maker consider and address the arguments put by a party against whose interest the decision is to be made…. Where there is a legal obligation to give reasons (as there was in the present case by reason of s 7.23(7)), the decision-maker is required to set out the “actual path of reasoning” by which the conclusion was reached…..

The claimant’s claim (that the injuries sustained in the accident had caused or contributed to the need for surgery) was based on his having been asymptomatic in his cervical spine for four years prior to the accident. Not only was this submission (and the associated evidence) not addressed by the Medical Assessor, but he made a finding to the contrary without referring, or apparently taking into account, what the claimant had put to him. This amounts to a denial of procedural fairness.”

Why is the case so important?

This case illustrates the importance of challenging decisions where arguments properly brought to the decision maker’s attention, are ignored or overlooked, or where the path of reasoning leading to the decision is unclear.

Contributors

Stephanie Ibrahim
Lawyer

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