Certificate issued under Division 7.5 of the Motor Accident Injuries Act 2017

1. The Review Panel revokes the certificate of Medical Assessor Christopher Canaris dated

27 March 2024 and issues a new certificate as follows:

(a) The Review Panel certifies the following injury was caused by the motor accident:

(i) persistent depressive disorder.

(b) The Review Panel finds that the above injury results in a whole person impairment of 6% which is NOT greater than 10%.

1. Adel El Dirany (the claimant) was involved in a motor accident on 3 September 2018. He was the driver of a vehicle when another vehicle coming from the opposite direction veered into his lane and there was a head on collision.
2. The claimant says he suffered musculoskeletal and psychiatric injuries as a result of the motor accident.
3. He made an application for personal injury benefits with Insurance Australia Limited t/as NRMA (the insurer), the third-party insurer of the vehicle that he says caused the accident.
4. A medical dispute arose about whether the degree of the claimant's whole person impairment (WPI) is greater than 10% WPI. If there is a dispute about the degree of a claimant's WPI, damages for non-economic loss[1] cannot be awarded and disputes must be referred to a Medical Assessor for determination.
5. On 27 March 2024, Medical Assessor Christopher Canaris found that the claimant suffered from persistent depressive disorder caused by the motor accident. The Medical Assessor assessed the claimant's WPI at 8% which was not greater than 10%.
6. The claimant lodged an application with the Personal Injury Commission (Commission) seeking a review of Medical Assessor Canaris' assessment. This was allowed by the President's delegate (Ms Stephanie Wigan) and this Panel was convened to conduct the review.

1. Medical Assessor Canaris was referred the following injuries for assessment:
   • psychological injury - anxiety disorder, chronic adjustment disorder with depressed mood.
2. The Medical Assessor was given a pre-accident psychiatric history of the claimant feeling sad and spent months not going out after the death of his brother in 2017. Around this time his mother also had cancer and the claimant closed his demolition business because of this. There were no other relevant pre-existing physical or psychiatric conditions.
3. Following the motor accident, the claimant gave a history of ongoing back and shoulder pain. He is currently on both pain and anti-depressant medication and sees a psychiatrist, Dr Eddie So, every two or three months, and a psychologist, Dr Hamid, every four months.
4. The Medical Assessor diagnosed the claimant with persistent depressive disorder with anxious distress. In addition, the claimant's strong concerns relating to pain warranted a diagnosis of somatic symptom disorder with predominant pain. This diagnosis was considered causally related to the motor accident because while there was evidence of other events resulting in psychological symptoms, it was the motor accident that was the predominate driver of the claimant's current psychological disturbance.
5. The claimant's impairment was assessed under the psychiatric impairment rating scale (PIRS) at 7% (1,2,2,2,3,3 - median class 2). There was a 1% WPI uplift for a modest treatment effect. The total WPI was therefore assessed at 8%.

1. The claimant's review submissions concern the Medical Assessor's assessment under the PIRS in the following categories:
   • self-care and personal hygiene;
   • social and recreational activities;
   • travel;
   • social functioning, and
   • adaptation.
2. The claimant says a higher rating was justified, based on the Medical Assessor's own findings and from the clinical notes of psychiatrist Dr Eddie So.
3. The insurer says that Medical Assessor Canaris has provided his reasoning for each of the disputed PIRS categories without any material error. It is contended the Medical Assessor was entitled to use their own clinical judgement when determining the appropriate impairment class rating that arose from the claimant's psychiatric injuries.
4. In its original submissions, the insurer says the claimant's WPI for his psychiatric injuries should not exceed the 10% threshold and relies on the reports of psychiatrist Dr George and orthopaedic surgeon Dr Harrington.

1. On 7 February 2025, the Panel issued a direction to the parties requesting indexed and paginated bundles of the information they relied upon. The Panel advised that unless documents are uploaded to the review file, the Panel would not be able to read and consider those documents. The parties responded with the claimant's bundle comprising of pages

1-49 and the insurer's bundle comprising of pages 1-465. 2. A summary of the bundle documents relevant to the issues in dispute is provided below. 3. A2Z Medical Centre consultation entries - detailed clinical notes spanning 2010 to 2023. Past-medical history does not indicate any psychological or psychiatric disorders. Motor vehicle accident noted in 2018 with depression noted in 2019. 4. Pre-accident entries: May 2013 - some mention of depression. January 2015 - poor sleep, lethargy, low self-esteem, irrational fear, panic attacks, compulsive behaviour, delusions, hallucinations without suicidal thoughts. Symptoms repeated in October 2025 with diagnosis of depressive anxiety disorder. December 2015 - changes in sleep, early morning wakening, depressed mood, low self-esteem, irrational fear, panic attacks. February 2016 - notation of "Depressed". June 2016 - "Depressed", similar description of symptoms to that in December 2015. November 2017 - similar descriptions of symptoms, "patient reported a history of the following symptoms which are coming in different times...tiredness or fatigue, sleep disturbances, irritability, poor sleep, early morning wakening, depressed mood - insomnia". 5. Post accident entries: 10 September 2018 - difficulty concentrating, remembering details and making decisions; fatigue and decreased energy; feelings of guilt, worthlessness and/or helplessness; feelings of hopelessness and/or pessimism; insomnia, early morning wakefulness, or excessive sleeping; irritability, restlessness; loss of interest in activities or hobbies; persistent aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment; persistent sad, anxious or "empty feelings". 18 September 2018. Multiple entries in September, October, November 2018 of pain in neck, back and right shoulder with psychological symptoms including notations of depression. Similar themes persisting to 2023. 6. Report of Dr Eddie So dated 17 May 2019: Motor vehicle accident head and neck pain with reduction in range of motion in right shoulder. Unable to return to previous level of occupation (electrician) since injury. Provisional diagnosis of anxiety disorder, complicated by pain and loss of function of right arm. 7. Report of Dr Chris Harrington dated 6 August 2020: Strange presentation with inconsistencies observed at examination. No impairment evaluation made. 8. Report of Dr Graham George dated 24 August 2020: Diagnosed accident-related chronic adjustment disorder with depressed mood. Alternative diagnosis of post-traumatic stress disorder as claimant was in life threatening situation in the motor accident. Claimant on anti-depressant medication but not considered to have substantive psychological treatment. Not working from time of accident with pain from physical injuries being indicated as the limiting factor. WPI rated under the PIRS as 5% (1,2,2,2,2,2 - median class 2). 9. Commission Certificate of Medical Assessor Sally Preston dated 19 August 2023: Found accident-related soft tissue injuries to the three spinal regions with WPI assessed at 0%. 10. Report of Dr Chris Harrington dated 20 March 2024: Found accident-related soft tissues injuries to the cervical spine and lumbar spine which have settled. Ongoing pain and restricted movement of dominant right shoulder related to the motor accident. Claimant keen to have capsular release and therefore injury not considered stabilised.

1. At the initial preliminary conference on 20 March 2025, the Panel determined that the claimant be re-examined on 12 June 2025. Unfortunately, due to an interpreter issue, this did not proceed which has led to delay. The re-examination was rescheduled to 21 August 2025.
2. The re-examination report of Medical Assessors Chew and Gill is below:

Background and History of the Presenting Complaint (YOB: 1969)

Mr Adel El Dirany is a 55-year-old male. He was in his lawyer's office in Burwood, for the assessment process. He lives in Bankstown with his wife and son (8 years old). He has been married since 2010.

Before the accident, he was employed full-time, doing electrical and demolition work, but he has not worked since.

He is currently on disability payments but was not sure about the condition which makes him entitled to the payments.

On 3 September 2018, Mr El Dirany was driving a Station Wagon near Botany in rainy weather, heading to Bunnings. While driving at about 50 km/h, another car (possibly a Holden sedan) suddenly swerved onto his side of the road, causing a head-on collision. It was early afternoon.

His airbags deployed, and he was wearing a seatbelt. He saw the smoke coming out of the car. At that time, he was fearful and said at interview, 'I was seeing death'.

He was helped from his car by people nearby. He notices that his right hand was swollen. Ambulance and Police were in attendance.

An ambulance took him to St George Hospital. He was assessed and discharged the same day. At the hospital, he was assessed, provided medication for pain and was discharged into the care of his general practitioner (GP).

His vehicle could not be salvaged and was subsequently written off.

The following day, he saw his GP. He was referred to a specialist for pain management. He complained of pain, initially in the right upper limb.

After first week, the pain got worse and has involved his neck, lower back, and both shoulders.

He had surgery to his right shoulder 18 months ago, however the pain did not resolve and his movement was limited.

A few months after the accident he wanted to return to work, and look for work, but noted his mental state was not optimal. He was struggling to hold his son.

He started to feel useless. He continues to feel like this, stating that his life has no meaning. He recounted that he likes to shoot, but his weapon and licence were taken away, because of the medications he was taking.

He said that prior to surgery 18 months ago, he had a glimmer of hope, however now states that his movements have decreased. He feels less hopeful now. He said that he has to be strong for his son.

He said that he has been trying to cope with alcohol. Whenever he feels better, he said that he explores employment opportunities. He said that he is trying improve his psychosocial functioning.

He has been looking for work and courses to upskill him and increase his vocational abilities. He said he had hoped that with his improving physical functioning, he would be able to return to his pre-injury work.

He socialises with his family members. He visits family members and friends every three or so days and says that he does not spend much time at home.

He describes himself as a religious person who 'is not an extremist'.

He disclosed that he visited Lebanon in 2023, before his surgery. He visited there with his wife and son.

He said that he is an optimistic person and that one day things will improve. He recounted his current low level of functioning, however, wants to focus on his hope.

He is fearful of the future and what it entails for him. However, this has no impact on his pain. He said that when he is depressed his pain is worse.

Mr El Dirany has no history of psychosis, mania, or hypomania.

Mr El Dirany does not have active suicidal ideation, intent or plan. He had suicidal ideation on one occasion nine months ago with no plans. There is no family history of suicide. His family appears to be a protective factor for him.

Mr Dirany's sleep is described as sub-optimal. He said that pain has an impact on the quality of his sleep. He has early, middle, and delayed insomnia.

He feels tired and lethargic because of the poor quality of sleep.

His memory is said to be forgetful. He attributed this to the medication pregabalin. He tends to struggle with organising himself.

His concentration and attention are said to be relatively fair, as he can concentrate for a considerable period, however, must move about to manage.

He said that he likes to keep updated in the world of electronics.

Mr El Dirany's motivation and energy levels are fluctuating and depends on the task requiring attention.

He said that he engages in household chores if small. He said that his wife does most of the cleaning at home. He tries to assist in little things around the house.

His self-care and hygiene is tended to every second day. He at times needs assistance from his wife. He said that he does not want to trouble his wife and said, 'I don't want her to divorce me', in a jovial manner.

After the accident, he was dependent on his brother-in-law to assist with driving and drove him for three years. He now mostly drives locally and can do so by himself. With slightly longer distances, he rests part way and then continues for the remainder of the journey. No major concerns with driving were reported. He attends the mosque and to festivals (like Eid) or funerals.

Mr El Dirany's appetite is 'average'. He recounts that there may have been some weight loss following the accident but at present, his weight has increased.

Mr Dirany has accrued diagnoses of depression, anxiety disorder, adjustment disorder, a persistent depressive disorder with anxious distress, post-traumatic stress disorder, and somatic symptom disorder with predominant pain. The Panel noted that there was no clear diagnosis or loss of functioning from the clinical notes.

He claimed that he spent four months in his house after the death of his brother in 2017. Around this time, his mother had also been diagnosed with cancer, his father had an open-heart surgery and his own children was born.

He said that he has no diagnosed history of mental illness before the injury.

He has engaged with a psychiatrist, Dr Eddie So. He could not recall exactly when he started to see Dr So. He started to see Dr So after he engaged with a psychologist. He sees Dr So every three months.

Mr El Dirany has engaged with psychological support. He sees Dr Ayman Hamid. He has participated in cognitive behavioural therapy, skills training, and interpersonal therapy. He sees Dr Hamid every two to four months.

There is no history of hospital presentation or admissions for psychiatric reasons.

He is currently seeing a shoulder specialist and has engaged with a pain related specialist.

He has an history of asthma, hepatomegaly, and GORD. He has no history of head trauma or seizures.

Mr El Dirany is taking pain medications (Panadeine forte, Tramadol, Pregabalin) and other medications Nexium, and Ventolin.

He is prescribed Temazepam 5-10 mg as needed at night which in practice he takes it every night, Olanzapine 5 mg at night, Vortioxetine 10 mg in the morning. He admits to variable compliance.

Historically, he has been tried Temazepam, Duloxetine, Mirtazapine, and Citalopram.

Mr El Dirany occasionally consumes alcohol weekly 1-2 glasses. He said that he smokes between 6-7 cigarettes per day. He denied illicit substance use. He denied gambling.

Salient Features of Psychosocial and Developmental History

Mr El Dirany's primary emotional support comes from his wife and sister-in-law. The relationship with his wife is described as being strong and supportive.

He had three brothers living in Lebanon, one deceased. His parents are alive and live in Lebanon. He is the youngest in his family.

Mr El Dirany was born and grew up in Lebanon. No childhood trauma was reported. He described his childhood as 'beautiful'.

He came to Australia in 2011. He stated that he immigrated because of the war and in hope of a better future.

Mr El Dirany finished university. He also completed short courses in demolition in Australia, to aid with his electrical work.

Mr El Dirany lost his driving licence in 2017, due to being under the influence of alcohol. There is no history of incarceration.

Mr El Dirany is a male of stated age. He was appropriately dressed and groomed. He was easy to engage with, was cooperative and rapport was readily established. There was no psychomotor agitation or retardation. His body demeanour was showing underlying anxiety and irritability. He kept moving about in the chair and at times was standing, which he attributed to his shoulder and back pain. He was using his left hand more compared to the right. Speech was of regular rate, volume, and tone. Thought processes were coherent, logical, and goal directed. At times circumstantial thought stream was noted. The content of thought revolved around his injuries, ongoing pain, psychological distress, and their impact on daily functioning. He was able to use humour in the conversation. There was no evidence of hallucinations or other perceptual disturbances. His affect showed a mild restriction in range. His mood was subjectively described as 'down' and was congruent with the observed affect. He was alert and fully orientated to person, place, and time. Concentration and memory appeared intact during the interview. Insight into his psychological difficulties was fair; he recognised he was unwell but tended to attribute symptoms primarily to pain. Judgement at the time of review was reasonable.

1. Section 7.21 of the MAI Act provides that the degree of permanent impairment of an injured person is to be assessed in accordance with the Motor Accident Guidelines (Guidelines).
2. Version 10 of the Guidelines applies to the review.
3. The Guidelines were issued pursuant to Division 10.2 of the MAI Act and adopt the American Medical Association's Guides to the Evaluation of Permanent Impairment, Fourth Edition (AMA 4 Guides). The Guidelines are definitive with regard to the matters they address but where they are silent on an issue, the AMA 4 Guides should be followed.
4. Permanent impairment is assessed in accordance with Chapter 6 of the Guidelines. Specifically, the assessment of psychiatric impairment draws from the chapter "Mental and behavioural disorders" which commence at cl 6.201 of the Guidelines.

1. It is necessary for the Panel to consider whether the accident caused or contributed to the diagnosed psychological or psychiatric condition.
2. Causation is dealt with at cls 6.5-6.7 of the Guidelines. An abridged form of the requirements is contained in cl 6.7 which states:

"6.7 There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be a sole cause as long as it is a contributing cause, which is more than negligible. Considering the question 'Would this injury (or impairment) have occurred if not for the accident?' may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes."

1. Further, the provisions of the Civil Liability Act 2002 apply, in particular ss 5D and 5E.

1. The review of the medical assessment is not limited to a review of only that aspect of the assessment that is alleged to be incorrect and is to be by way of a new assessment of all the matters with which the medical assessment is concerned.[2]
2. The evaluation should only consider the impairment as it is at the time of the assessment.[3]
3. The Panel may confirm the certificate of assessment or revoke that certificate and issue a new certificate as to the matters concerned.[4]
4. The Panel refers to the above re-examination report of Medical Assessors Chew and Gill. The Panel reconvened on 18 September 2025 and discussed the re-examination report findings before collectively making the below determinations.

1. Mr El Dirany presents with a persistent depressive disorder. He meets DSM-5-TR criteria as follows:
   • he has had a consistently persistent depressed mood for at least two years;
   • along with the depressed mood, he has experienced sleep, appetite, energy and concentration difficulties;
   • there has never been a manic or hypomanic disorder;
   • the disturbance is not better explained by a psychotic disorder or attributable to substances or a medical condition, and
   • the symptoms cause clinically significant distress.
2. With respect to causation, the Panel noted the circumstances of the accident involved a car from the opposite side of the road swerving into the direction of the claimant's vehicle. This caused a head on collision with the deployment of airbags and the claimant "seeing death".
3. At the time of the accident, the Panel felt that the claimant likely qualified for the diagnosis of post-traumatic stress disorder, however much time has passed since the motor accident and his presentation is now more consistent with a persistent depressive disorder as described above.
4. On 10 September 2018, a week after the motor accident, the claimant reported psychological symptoms in the A2Z Medical Centre clinical notes. These symptoms persisted with the claimant regularly presenting to his GP in the ensuing months.
5. The Panel noted that the claimant had pre-accident psychological symptoms as detailed in the pre-accident clinical note entries from A2Z Medical Centre. The word "depressed" was mentioned sporadically in the years spanning 2013 to 2017. There were also other associated psychological symptoms, however the aetiology of those symptoms was not mentioned. The Panel could infer that there was some contribution from the death of his brother in 2017 or the stresses associated with his unwell mother. However, of particular note was the absence was any diagnosis of a psychiatric disorder or condition that was related to a particular event or accident.
6. The Panel viewed the claimant's pre-accident symptoms could have made him more susceptible of suffering psychological damage as a result of the motor accident. There is some overlap of his symptoms, for example the depressed mood and the sleeping difficulties, however the Panel was of the view the increased regularity and intensity of the post-accident symptoms recorded in the A2Z Medical Centre notes satisfied the Panel that the motor accident contributed to the development and persistence of Mr El Dirany's persistent depressive disorder.
7. The Panel was therefore satisfied that the persistent depressive disorder was causally related to the motor accident.

1. The claimant's symptoms have been continuously present since September 2018. Over this time, he has been referred to psychologists, psychiatrists with regular visits to his GP. The claimant has been taking medication since the accident and continues to do so. The Panel considers the claimant's condition to have reached a state of permanency for an assessment of permanent impairment to be made.

Degree of permanent impairment - Psychiatric Impairment Rating Scale

Mr El Dirany has some limitations because of his physical status however from a psychological perspective he is able to live independently and look after himself regularly. There has been some difficulty with appetite and meals at times however he reports that his weight has in fact increased.

Mr El Dirany maintains excellent function. He goes out daily with friends and meets them for coffee, or visits them at their mechanic shop or restaurant. The Panel noted Dr Eddie So's reference to irritability, sleep disturbance and poor concentration, however this has not affected the claimant's functioning as he is today.

The Panel acknowledges that Mr El Dirany functioning with respect to travel was limited soon after the accident with his brother acting as his driver. However, the history given to the Panel is that he is able to travel independently without a support person, although he does prefer familiar areas.

Mr El Dirany maintains good relationships with his family and friends. There is past documentation of some irritability at times and some arguments with family however presently, his family is supportive of his emotional needs and his relationship with his wife is strong.

Mr El Dirany reported subjectively some difficulty with his memory and concentration. He however is able to concentrate to keep up to date on the internet on his field of interest electronics. He was able to concentrate for an 85-minute interview.

Mr El Dirany has struggled as he is unable to work in his previous roles because of the physical injury. While he continues to want to work or to try and find a way back to some work he has struggled because of psychological issues compounding this, namely a reduction in motivation and drive. There is an element of the pain from his physical injuries contributing to this reduction in drive, which the Panel has accounted for in this rating of class 3. From a psychiatric perspective his psychiatric injury has affected only his motivation and his concentration mildly. If not for his physical injury the clinical assessment is that he would be able to perform in a less stressful position than previously but would likely be only able to perform for less than 20 hours.

1. The GP notes have isolated entries spanning from 2013 to 2017 of Mr El Dirany feeling depressed with other associated psychological symptoms. However, the Panel was not satisfied that these symptoms amounted to a diagnosable psychiatric condition in order for the Panel to provide an estimate for any pre-existing impairment.
2. Hence, the Panel has not made any apportionment for pre-existing impairment.

1. There has been a modest but incomplete improvement from treatment, thus an adjustment for the effects of treatment is indicated by the addition of 1%.

1. The Panel concludes that the claimant's injury caused by the motor accident results in a WPI of 6% which is not greater than 10%. Although the psychiatric diagnosis is similar to that found by Medical Assessor Canaris, the Panel's assessment of the degree of permanent impairment is different.
2. Accordingly, the certificate issued by Medical Assessor Canaris dated 27 March 2024 is revoked. A new certificate is issued at the front of this determination.