An NSW Review Panel has overturned NRMA Insurance's denial of knee replacement surgery for a 79-year-old passenger injured in a bus crash.
In a decision dated February 3, 2026, the Personal Injury Commission Review Panel revoked the medical certificate of Assessor Hyde-Page in Chiarelli v Insurance Australia Limited t/as NRMA Insurance [2026] NSWPICMP 78. The Panel found that claimant Michael Chiarelli suffered a right knee injury because of a November 6, 2022, bus accident and that a proposed total right knee replacement is reasonable and necessary.
According to the decision, Chiarelli was seated near the front of a bus when it collided with a motor vehicle, with both vehicles travelling at over 100 km/h. The impact pushed the bus off the road and down into a ditch. Not wearing a seatbelt, he was thrown forward into the stairwell next to the front door. He sustained a head injury with loss of consciousness, an L1 vertebral fracture, and symptoms in his left wrist, cervical spine, right foot, left shoulder and arm, right elbow and right knee. He was taken to Tamworth Base Hospital, transferred to the Mater Hospital in Newcastle, then to Hunter Valley Rehabilitation Hospital, where he spent eight weeks before discharge.
Before the accident, his right knee was described in the medical material as asymptomatic. He had previously been seen for right knee pain in 2017 and 2018, with imaging showing mild osteoarthritis and a diagnosis of right knee osteoarthritis, but surgery was not recommended. The decision notes that he remained active before the accident, playing and umpiring lawn bowls and fishing from rocks, beach and boat.
The dispute centred on causation and whether the surgery met the statutory test for treatment and care. Under section 3.24(2) of the Motor Accident Injuries Act 2017, no statutory benefits are payable for treatment that is not reasonable and necessary or does not relate to the injury resulting from the accident. The insurer pointed to a gap of about three months before any formal complaint of right knee pain, the lack of knee findings in the acute hospital records, and MRI results showing osteoarthritis and a small medial meniscus tear without what the original Medical Assessor regarded as evidence of acute injury.
The original Medical Assessor accepted that view, concluding there was “no evidence of an acute injury to the right knee” in the accident and that the condition requiring a knee replacement appeared unrelated. He noted that the first documented right knee symptoms were in general practitioner and rehabilitation notes from January and February 2023, after Chiarelli left inpatient rehabilitation.
On review, the Panel reached a different conclusion. Referring to the Motor Accident Guidelines, it noted that the accident did not need to be the sole cause of the knee condition; it only needed to “materially contribute,” in the sense of being more than negligible. The Panel emphasised the circumstances of the crash, the claimant’s age, the seriousness of his spinal and other injuries, and the length of his rehabilitation stay. In that context, it considered it “not unreasonable” that right knee pain was not raised until after he had completed inpatient rehabilitation and increased his activity.
The Panel also highlighted that an MRI of the right knee in February 2023 showed a torn medial meniscus and a chondral defect in the patella with subchondral oedema. Following a panel discussion, it noted that this chondral injury with oedema was consistent with an acute injury and that the motor vehicle accident was a substantial cause of the right knee condition.
In its analysis, the Panel referred to authorities including Kinchela v Insurance Australia Group Ltd t/as NRMA Insurance [2021] NSWSC 804 and Bugat v Fox [2014] NSWSC 888, which indicate that the absence of contemporaneous complaint cannot, by itself, determine causation. The Panel stated that all of the medical and factual evidence needed to be considered.
The decision also records a process issue. Around November 26, 2025, the insurer asked the Panel to issue several notices for production. When the Panel sought more information about the reasons for those notices and whether its certificate should be delayed, the insurer did not respond, despite several enquiries to its solicitors. The Panel proceeded without that additional material to avoid delay.
Treating orthopaedic surgeon Dr Dewar considered the right knee injury directly related to the accident and recommended a total right knee replacement, viewing arthroscopy or partial meniscectomy as unlikely to be successful given the degree of arthritis. In a separate report, Dr Hopcroft concluded that the accident had caused a medial meniscal tear and damage to pre‑existing mild osteoarthritis, requiring right total knee replacement surgery. Senior Medical Assessor Dixon examined Chiarelli, agreed with those opinions, and found the proposed surgery reasonable, necessary and related to the bus accident.
The Review Panel adopted Dixon’s report and concluded that the accident had more than a negligible effect on the need for surgery. It revoked the original medical certificate and held that Chiarelli’s right knee injury arose because of the accident and that the proposed total right knee replacement is reasonable and necessary. The Panel consisted of Member Alexander Bolton and Medical Assessors Shane Moloney and Drew Dixon.
For insurers, the decision underlines that delayed reporting, pre‑existing degeneration and sparse early records, on their own, may not be enough to sustain a treatment denial on review.
