Treating Specialist’s Report Found to Be a Request for Treatment Approval

In Brief

• Ideally, a Claimant should write to the Insurer to formally request approval of treatment and care.
• In certain circumstances, however, the context of a treating doctor’s report could constitute a request for approval even without a clearly worded covering letter.

Facts

The decision in Insurance Australia Limited t/as NRMA Insurance v Jennar [2026] NSWPIC 320 was delivered on 4 June 2026 and published on 19 June 2026.

A dispute arose between the parties regarding whether the accident caused the Claimant threshold injuries and whether a proposed three-level discectomy and fusion was reasonable and necessary. Both disputes were referred to the same Medical Assessor for assessment.

The Insurer contended, however, that the assessment regarding the discectomy and fusion was premature because the Claimant had not yet requested the Insurer’s approval for that specific procedure. It followed, in the Insurer’s submission, that the Insurer had not yet determined whether the proposed surgery was reasonable and necessary and related to the motor accident.

The Claimant’s Solicitor argued, however, that the content of the specialist’s report conveyed a clear intention to seek approval for the proposed surgery.

Whether the Claimant had sought approval of the surgical procedure was referred to a PIC Member for determination via a Miscellaneous Assessment.

The Member’s Decision

The Member determined that the letter from the Claimant’s Solicitor did not constitute a request for approval of the surgical procedure because, by its terms, the letter only sought approval of an MRI scan.

The Member determined, however, that the treating report enclosed with the Claimant’s Solicitor’s letter did constitute a request for treatment approval for the following reasons:

• The insurer was aware that a PIC Medical Assessor had already found that a two-level cervical fusion was not reasonable and necessary because it would not provide adequate neural decompression and had raised whether a three-level fusion might be more appropriate.
• The treating specialist’s report picked up on the PIC Medical Assessor’s reasons and supported a three-level fusion.
• The nature of the report was a request that the insurer approve the proposed surgery.
• Whilst not a perfect example of a request for approval, the Insurer was on notice that the treating specialist was providing information in support of a request to approve the proposed surgery.
• A simple letter requesting approval of the surgery and the costings would have been appropriate, but the Claimant’s failure to do so is not a fatal flaw because the legislation does not prescribe a particular format.

Why This Case is Important

The decision in Jennar indicates that Insurers should look at the full context to determine whether a treating specialist’s report constitutes a request for approval of treatment and care.

As the Member indicated, best practice dictates that the Claimant or their legal representatives should formally request approval of treatment and care in a covering letter.

The background circumstances and the content of the specialist’s letter, however, can constitute a request for approval of treatment and care without a specific covering letter.

In this instance, the treating specialist’s report constituted a request for surgery approval because it was part of an ongoing conversation about what surgery might help the Claimant, as distinct from a random, one-off report which lacked any background context.