Issued under Division 7.5 of the Motor Accident Injuries Act 2017

1. Revokes the certificate of Medical Assessor Rikard-Bell.
2. Certifies that the degree of the claimant's permanent impairment resulting from the injuries caused by the motor accident on 15 September 2019 is not greater than 10%.

A statement setting out the Panel's reasons for the assessment is included with this certificate.

1. Houda El Jassem was involved in a motor accident on 15 September 2019.
2. The claimant says she injured her neck, left arm and lower back in the accident. She made a claim for statutory benefits and then damages against GIO, the third-party insurer of the vehicle that she says caused her accident.
3. A medical dispute about the degree of the claimant's whole person impairment (WPI) has arisen in connection with that claim and Ms El Jassem referred that dispute to the Personal Injury Commission (the Commission) for assessment.
4. On 5 June 2024 Medical Assessor Rikard-Bell determined Ms El Jassem had a chronic adjustment disorder secondary to a chronic pain condition and her whole person impairment (WPI) was 5%.
5. The claimant has lodged an application with the Commission seeking a review of the Medical Assessor's decision. On 9 August 2024, Ms Baba, a delegate of the President determined there was reasonable cause to suspect a material error in the assessment and allowed the Review and on 5 May 2025 the President's delegate convened this Panel to conduct the Review.
6. The Panel notes an assessment of the claimant's physical injuries was undertaken by Medical Assessor Home, and an application for Review of that decision was made. That Panel determined the claimant had a WPI of 7%.[1]

1. Ms El Jassem's claim and entitlements to compensation are governed by the provisions of the Motor Accident Injuries Act 2017 (the MAI Act).
2. In a claim for lump sum compensation, damages are assessed in accordance with common law principles as modified by the MAI Act. Under Part 4 of the Act, an injured person can make a claim for damages for both certain types of economic (pecuniary) losses and damages for non-economic (or non-pecuniary) loss.
3. Damages for non-economic loss are limited and restricted by the provisions in Division 4.3 of the MAI Act. For example, non-economic loss damages are limited to a maximum amount in accordance with s 4.13[2] and entitlement to those damages is restricted by s 4.11 to persons who have a greater than 10% WPI as a result of the injuries sustained in the accident.
4. If there is a dispute about the degree of the claimant's permanent impairment, damages for non-economic loss cannot be awarded and the dispute must be referred to a Medical Assessor for determination.[3]
5. Impairment from psychological or psychiatric injury cannot be combined with any physical assessment and therefore to be entitled to non-economic loss a claimant must have a greater than 10% WPI for either her physical injuries or her psychological injuries (or both) but cannot add or combine say 5% for one with 6% for the other to achieve the threshold degree of WPI.[4]

1. Division 7.5 of the MAI Act provides for medical assessments by the Commission including provisions relevant to original medical assessments such as Medical Assessor Home's and Medical Assessor Ricard-Bell's, further medical assessments and the review of medical assessments by this Panel.[5]
2. Applications for review of a medical assessment are made to the President of the Commission on grounds that the assessment "was incorrect in a material respect" (s 7.26(1)). If the President, or his delegate is satisfied "there is a reasonable cause to suspect that the medical assessment was incorrect in a material respect" then the President arranges for the application to be referred to a review panel consisting of a Member of the Commission and two Medical Assessors (s 7.26(2) and (2B)).
3. The review is not an appeal looking for error and is not confined to the issues raised in the application (or the reply) but is "a new assessment of all the matters with which the medical assessment is concerned" (s 7.263A).
4. Rule 128 of the Personal Injury Commission Rules 2021 (the Rules) permits the Panel to determine its own proceedings and the Panel is not bound by the rules of evidence and may inquire into relevant matters as it thinks fit.

1. Permanent impairment is to be assessed in accordance with Chapter 6 of the Motor Accident Guidelines (the Guidelines)[6] which are largely based on the American Medical Association's Guides to the Evaluation of Permanent Impairment, Fourth Edition (AMA 4 Guides).
2. Due to the nature of the injuries sustained by the claimant, Chapter 13, the mental and behavioural chapter of the AMA 4 Guides is relevant.

1. The Medical Assessor examined the claimant on 15 May 2024 and issued his certificate on

5 June 2024. Medical Assessor Rikard-Bell confirms at [2][7] that he was asked to assess the claimant's "psychiatric condition - anxiety, depression, posttraumatic stress disorder." 2. The claimant was, at the time 63 years of ages living with her husband (she is his carer). He had been injured at work and has not worked since. The claimant and her husband have five adult children. 3. The claimant reported lower back pain for 20 years before the accident but says otherwise she was functioning well, caring for her husband and driving without restrictions. 4. The claimant denied any previous serious illnesses but had been treated for diabetes, high cholesterol, high blood pressure and reflux. Medical Assessor Rikard-Bell refers to a possible motor accident in the 1990s. 5. The claimant was depressed in 2004 after the death of her mother, and she had counselling and was prescribed medication which continued until the accident, but she says the dosage was increased after the accident. 6. The claimant recounts a history of the accident saying there was an intersection collision and that her airbags deployed and she was shocked and had difficulty orientating herself. 7. The claimant says she has ongoing neck, left arm and lower back pain and the worse aspect of the accident was her ongoing pain. She had bad dreams, but they subsided, she continues to drive and slows down close to the accident scene. 8. The claimant said that because the pain is always there, her blood pressure has increased, and her medication has increased. She reported no major avoidance behaviours and no intrusive recollections or nightmares. 9. The claimant's routine involved getting up and calling her daughter to assist with housework or cooking. She can do some tasks around the home but spaces them out. Her sleep is interrupted due to neck pain. 10. Medical Assessor Rikard-Bell diagnosed an adjustment disorder secondary to chronic pain caused by the accident. 11. He assessed WPI as follows:

(a) Self-care and personal hygiene Class 1;

(b) Social and recreational activities Class 3;

(c) Travel Class 2;

(d) Social functioning Class 2;

(e) Concentration persistence and pace Class 2, and

(f) Adaptation Class 1.

1. The Medical Assessor did not adjust the impairment for any pre-existing disorder or for the effect of treatment noting there was no current counselling treatment being provided to the claimant.
2. The aggregate score was 11, the median class value was 2 and the WPI 5%.

1. The claimant takes issue with each psychiatric impairment rating scale (PIRS) category, and the class of impairment chosen by the Medical Assessor for each category.
2. The claimant also submitted she has had treatment from a psychologist and is currently taking medication to treat her psychological condition.

1. The insurer submits that the claimant was taking medication before the accident and had a pre-existing condition.
2. The insurer submits that the Medical Assessor is not to assess the claimant's physical injuries and pain and that he has undertaken an assessment of her impairment from a psychological perspective.

1. The Panel issued directions on 20 May 2025 seeking bundles of documents from both parties. The claimant provided a bundle of documents on comprising 477 pages of documents on 6 June 2025. The insurer provided a bundle with 163 pages on 27 June 2025.
2. The Panel met on 15 July 2025 and reported to the parties the next day. The Panel advised:

(a) an assessment de novo was being undertaken which would require the Medical Assessors to make a diagnosis in accordance with the DSM-5-TR and the Panel may, in their clinical judgment diagnose a different disorder to any disorder diagnosed by other Assessors and examiners;

(b) the Panel had no medico-legal reports from the claimant;

(c) the Panel required copies of records from Dr Younan and details of any psychologist or psychiatrist the claimant had consulted to date and the Centrelink history in respect of the carer's payment received by the claimant, and

(d) the date for the re-examination was provided.

1. The claimant responded with an additional bundle of 298 pages of documents which will be included in the evidence review below. The claimant advised:

(a) multiple attempts had been made to obtain Dr Younan's records. He is no longer a registered psychiatrist;

(b) no further records were available about the litigation following her mother's death;

(c) the claimant has seen Dr Tran, Zen Psychology and Dr Assaad;

(d) Medicare records have been requested but there is a delay, and

(e) Centrelink records have been provided.

1. The claimant submits that the records indicate that there is no objective evidence of a pre-existing impairment at the time of the accident. The claimant also submitted in respect of the test of causation. The insurer relayed a message to the Panel advising it had no further evidence or submissions.

1. There are handwritten notes from Dr Assaad which date back to 1985.[8] These are hard to read. Of significance to this Panel, it is noted that:

(a) the claimant's mother died suddenly after a fall from a train in 2004. Litigation was contemplated or commenced (possibly by the claimant's brother) and

Dr Assaad provided a report to the claimant's lawyers in October 2005[9] noting the claimant had been prescribed an antidepressant since 2002 due to depression and anxiety, the dose was increased in 2003 due to a worsening of her condition, and her condition further worsened after the death of her mother and Tryptanol was added. The depression was not well controlled, and the claimant was referred to Dr Younan. By September 2005 the depression was considered to be under control. He diagnosed "chronic major depression" and he considered the claimant unfit to work due to a "lack of concentration and loss of motivation";

(b) Dr Younan first saw her on 21 October 2004 at which stage the claimant was "deeply depressed" and suicidal. She wanted to sue the State Rail Authority;[10]

(c) Dr Younan's first report referred to the death of the claimant's father when she was 12 and her mother had brought her up alone and they were "deeply attached". The claimant's mother had been staying with the claimant for five months at the time of the accident. The claimant had been prescribed Zoloft (an antidepressant) 50 mgs per day;

(d) a further short report was written in 2006 by Dr Younan and another report from Dr Assem to the claimant's solicitor was provided on 17 August 2007. He noted the claimant continued to see him "on a regular basis" for depression aggravated due to her mother's death. He considered the depression "fairly controlled" on a prescription of 10 mg of Lexapro. He said, "regarding her prognosis, it will be one of chronic major depression requiring the use of Lexapro for as long as this drug controls her depression.";

(e) the claimant saw a neurologist in July 2008 due to numbness in the medial three fingers of both her hands and had a CT scan showing spondylosis in particular at C4-5;

(f) she had left shoulder investigations in March 2010 with bursitis and tendonitis reported;

(g) on 31 January 2012 she saw another neurologist, Dr Ell due to episodes of dizziness, numbness in the right hand and leg and heaviness in the head "when she is upset or nervous". She had recently had a normal MRI but had lost the report. He requested further tests and afterwards reported to Dr Assaad that he considered her symptoms "anxiety related" and he noted the claimant agreed with this diagnosis,[11] and

(h) on 13 February 2012 the claimant was referred to a physiotherapist under an existing care plan.

1. Records from Busby First Care Medical Centre have been provided.[12] These commenced in 2002 with limited detail provided. Lexapro, an antidepressant was prescribed for the first time in April 2006 (10 mg daily), December 2008, February 2009, August 2011, June 2012, October 2012, December 2013, December 2014, December 2015, May 2016, July 2017, December 2017, June 2018, January 2019 and August 2019 (same dose).
2. Celebrex was prescribed on 16 October 2016 for lower back pain radiating to the left hip with "normal range of motion". Mobic and Voltaren Gel were prescribed on 22 December 2016 again for nonspecific lower back pain.
3. On 10 May 2017 the claimant attended Dr Gouder at Busby with pain in her left hand and left wrist with tenderness and mild swelling. The claimant was still being prescribed Lexapro at this time. There were reports of dizziness and tiredness (August 2017) and back pain (December 2017).
4. On 16 April 2019 there is an entry by Dr Tran of "lef sid3d neck pain" and 400 mg of Brufen was prescribed three times a day.

1. The claimant's claim form was signed and dated 25 September 2019.[13] Ms El Jassem discloses a previous CTP claim about 20 years ago but gave no further details.
2. Ms El Jassem gives a consistent history of the accident and lists her injuries as follows:

(a) discal injury to neck with radiculopathy into left upper limb;

(b) injury to left shoulder;

(c) left side of head feels heavy;

(d) discal injury to lower back with radiculopathy into right leg;

(e) injury to pelvis, and

(f) injury to chest.

1. The claimant also says in the claim form she had some back pain and depression at the time of the accident.
2. The claimant and the insurer have both provided photographs of the claimant's vehicle.[14]There is significant damage to the driver's side door, and the front panel. The tyre is "blown", and the front part of the bonnet and bumper is destroyed with headlights smashed. Both driver and passenger frontal airbags can be seen as deployed.

1. The ambulance report notes the claimant was seated in the car when they arrived (nine minutes after the first call). The claimant was complaining of front left sided neck pain and chest pain (airbag deployment). She denied any radiating pain. The claimant was also feeling dizzy but was able to stand and transfer to stretcher. On examination the claimant had no seatbelt bruising or obvious trauma.
2. Vital signs were taken at 9.20am and 9.55am and all was normal. In particular the claimant's Glasgow coma scale was 15 out of 15 and her pain levels were 3 out of 10 on both readings.
3. The claimant attended Liverpool Hospital on the day of the accident. She reported feeling dizzy but was said to have been walking around the department. There was no obvious external injury but chest and left shoulder pain. There was midline tenderness in the neck. While there was slight pain on deep breathing there was a good deep breath.
4. The claimant first attended Dr Tran on 17 September 2019. The claimant complained of "all body ache and pain". On examination there were no neurological signs, reduced range of motion in the left shoulder, left sided neck pain and low back pain. The claimant was prescribed Norgesic and Endone.
5. On 18 September 2019 the claimant was seen again, and the claimant was reassured about the tests from the hospital. The claimant was said to be taking Norgesic and Endone "with good result." On 26 September 2019 however the claimant could not sleep at night due to pain when turning, the Endone was no longer effective and she complained of left shoulder pain radiating to the left arm, left chest wall and left neck pain. There was no abnormality recorded in neck range of motion, but shoulder flexion and abduction were limited.
6. The claimant's medication was adjusted on 3 October 2019. Repeat scripts for other unrelated matters were provided and a script for 10 mg of Lexapro was also given to the claimant. On 30 October 2019 the claimant expressed concerned about her injuries and who would take care of her, and the dose of Lexapro was increased by Dr Tran to 20 mg daily.
7. On 28 November 2019, Dr Tran, completed a certificate of fitness. She diagnosed "soft tissue pain left shoulder: bursitis and posttraumatic stress disorder." She says the claimant first attended on 17 September 2019. Her management plan was for pain relief, referral to a psychologist, cortisone injection into the left shoulder, MRI of the left shoulder and physiotherapy. She imposed a 5kg lifting limit and said the claimant had capacity for eight hours of work a day for five days a week from 22 November 2019 to 19 December 2019. The corresponding notation records mainly left sided neck, shoulder and left arm pain and lower back pain after doing household chores for a while. Also noted was the lower back pain slowly getting more stiff and it was hard to bend down. There was a normal range of motion and no pain down the legs. Dr Tran also notes "now mainly? PTSD: stress, anxious, insomnia, scared of driving again." A referral to a psychologist was given.
8. Dr Tran wrote a further certificate of capacity on 8 December 2019. In very similar terms but with this annotation "She has complained of having lower back pain now (not at the time of the accident)." An MRI of the lumbosacral spine was suggested.
9. On 12 December 2019 the claimant's doctor, Dr Al-Shelh (Liverpool Healthcare Medical Centre) completed a certificate of fitness[15] noting "soft tissue injuries - PTSD". The management plan for the injuries were rest, analgesia and steroid injection along with physiotherapy and counselling. He certified the claimant as having no fitness for any work from the date of the accident to 15 December 2019.
10. Dr Al-Sheih's notes have been provided,[16] and they show two attendances on 12 and

30 December 2019 only. A referral to Dr Carlos El-Haddad, rheumatologist was provided on 12 December 2019 for "left shoulder pain, neck pain, mid back and lower back pain". A referral to Mr Moutasallem was given on 30 December 2019 for physiotherapy for neck and left shoulder pain only. The clinical note for 30 December 2019 refers to "still in pain, shoulders both, with numbness, neck pain discogenic derangement". 11. A later bundle of notes includes attendances on 15 January 2020 with a note "stay same well controlled". On 20 February 2020 the claimant attended for review of her pains, and the claimant reported troubles sleeping with left neck, left shoulder and lower back pain "with radiation to both legs now, no sciatica". A further referral to Dr El-Haddad was given. 12. Ms Boutros of Zen Psychology Solutions completed a questionnaire for the insurer on

17 February 2020[17] stating the claimant was displaying symptoms of major depressive disorder. These were said to be "severe" and she had requested a psychiatric assessment. In a letter dated 6 February 2020 addressed to Dr Al-Shelh, Ms Boutros says that the claimant's depression and anxiety levels were high, and she was having ruminations about death, was socially withdrawn and her sleep was impacted. The claimant was taking the antidepressant Lexapro. 13. Ms Lama, physiotherapist wrote to Dr Al-Shelh on 24 March 2020[18] having taken a history that the claimant was not able to breathe, talk or move her arms after the accident. Ms El Jassem complained of pain and numbness in her left shoulder and three lateral fingers and had increased lumbar and cervical spine pain. There is no complaint of symptoms in the head, right shoulder, chest or pelvis. 14. On 20 April 2020 the claimant was reviewed by Dr Al-Shelh with "left arm pain numb and heavy" and reduced range of motion in the neck. Lyrica was provided in addition to other medication. On 12 June 2020 left shoulder and cervical pain was the subject of complaints and radiology was requested. On 26 June 2020, Dr Al-Shelh referred the claimant to

Dr Abrazsko and Dr Dave following complaints of neck and left shoulder pain. 15. Dr Dave wrote to Dr Al-Shelh on 28 July 2020[19] advising that the claimant's shoulder problems appeared to be related to a C6/7 radiculopathy, and he suggested she see a spine surgeon and in the meantime have some posterior capsule and rotator cuff strengthening. 16. Dr Abrazsko wrote to Dr Al-Shelh on 20 August 2020.[20] Dr Abrazsko had a history of immediate neck pain and left shoulder pain and severe neck pain radiating to the left arm and left hand with swelling in the forearm. Dr Abrazsko reports "power, tone, reflexes and sensations are normal". There was spasm of paraspinal muscles and limited left shoulder motion and an MRI and bone scan were requested. There is no complaint of symptoms in the head, thoracic spine, lower back, right shoulder, chest or pelvis. Dr Abrazsko ordered scans of the neck, shoulder and left wrist only. 17. On 17 September 2020, Dr Al-Shelh records complaints of a painful left hand, mid back pain and aches and on 30 December 2020 there were further complaints of pain in the shoulder and neck "with LBP". 18. On 27 March 2022 the claimant attended on Dr Tran at First Care Medical Centre and was referred for a chest X-ray of her left ribs on 29 March 2022 the claimant attended noting her pain was better and no abnormality was detected on the radiology. 19. There were several attendances in 2023 and others in 2024 and two in 2025, but none appear related to the accident or the claimant's physical injuries or psychological state.

1. Two sets of documents from Ms Boutros have been provided with the following clinical notes handwritten:[21]

(a) on 10 January 2020 the claimant appears to have seen Ms Boutros for the first time. Ms Boutros has a history of the accident and the claimant's previous depression after her mother's death which she noted as "resolved" however she also notes the claimant's increase in Lexapro as a result of the accident. She reported her back hurt and she had nightmares and panic attacks;

(b) on 6 February 2020 Ms El Jassem reported her back was painful all the time and she was not sleeping well, cannot do housework and dislikes driving. She is bored with life and feels "death is close";

(c) on 20 February 2020 the claimant was reporting arm pain, and she was struggling with day-to-day tasks and "feels she has reached the end of her life";

(d) on 14 May 2020 the claimant returned to Ms Boutros and was unable to leave the house and was completely unmotivated. She was avoiding driving due to increased anxiety and was arguing with her family. Her stomach was hurting from her medications, and she was sleeping poorly. She reported being unable to do her housework. She had asked her doctor not to give her more medications, her depression was high, and her life was not worth living. She was incapacitated by pain;

(e) on 22 May 2020 the claimant was said to be in bed and could not get out due to ongoing pain in her left arm. This was waking her. She struggled to pick things up and the weather was affecting her mobility;

(f) on 17 December 2020 the claimant was tired, her body ached, she was unmotivated and could not do anything. She relies on her daughters. She says her pain feels like knives are digging into her shoulders and she is "like the living dead";

(g) on 7 February 2021 the claimant reported being "tired - pain constant". She was avoiding her children as she had no energy and had not spoken to her husband for four weeks. She was anxious and having difficulty sleeping. She reported no joy in life and was given suicide counselling as she was "avoiding all forms of communication" and "feels life is darkness". She had no emotions and could not do her housework which made her feel useless;

(h) on 11 March 2021 the claimant had a cortisone injection but felt no difference in her pain. She ruminated over the impact of the injury and had flashbacks to the accident. She complained about the pain which impacted her motivation for cooking and housework;

(i) on 1 October 2021 Ms El Jassem reported pain and feeling sad. Her husband was in hospital, and she was not allowed to visit him. Her stomach hurt and she was not sleeping at all;

(j) on 22 July 2022 the claimant reported feeling like she had not improved, and she no longer did any housework or cooked. She depended on others. Her pain is ongoing and "so heightened feels like she may die." She was waking at night due to shar pain in neck and radiating pain;

(k) on 26 August 2022, the claimant reported an increase in pain, and her arms hurt all the time even when carrying a single chopping bag. She had no motivation to go to the doctors and was dizzy all the time. She reported a poor memory, lack of focus and her medication was not working, and

(l) on 12 January 2023 the claimant said her situation was getting worse. She had no happiness and refused to go out with her children and does not go anywhere. She had shooting pain in her neck.

1. In the last note on 7 February 2023 the claimant's pain had increased, she was relying on pain medications and could not sleep at night due to pain and ruminating. Neck pain was said to be "severe". Despite this she was scared to have surgery. She had pain while walking and it was impacting the way she walks.
2. A second set of notes was provided[22] which includes one further clinical note of an attendance on 29 March 2023. The claimant was said to be depressed with "pain impacting her ability to function. Can't cook or fast for Ramadan. Upsets her."

1. There are no medico-legal reports provided by the claimant in support of her medical assessment or this Review.
2. The claimant was examined by Dr Vickery for the insurer on 23 November 2021. She disclosed a previous psychiatric condition in 2004 and treatment following the sudden death of her mother.
3. Ms El Jassem reported physical symptoms of pain in her neck, left shoulder, arm and fingers of her left hand. She said she had lower back pain since December 2019 but "I have had that for a long time before the accident".
4. In relation to her psychiatric symptoms, she told Dr Vickery she had restricted socialising due to COVID-19 but:

"Now I'd rather just stay at home and I think about how I thought I was going to die in the accident and I think about the death of my mother and I just want to keep to myself now."

1. The claimant reported increased frustration with her husband (who has a cardiac condition) and she tells him to stay with their daughter (who lives over the road). She regularly visits her daughter, and her daughter regularly visits her. The claimant has conflict with her husband but is close to her children and grandchildren.
2. Dr Vickery notes the claimant drives, although notes she has difficulty turning her head and using her right arm. She says she restricts her domestic duties due to pain. He records "no impairment in hygiene or grooming."
3. He notes the claimant has been her husband's carer for the last 20 years.
4. Dr Vickery has a history of the claimant having counselling and talking about her pain because she cannot talk about her pain with her family. He notes her "behaviour and mood were focussed on her incapacitating pain."
5. Dr Vickery diagnosed a somatic symptom disorder which did not attract a WPI in accordance with cl 6.215 of the Guidelines.
6. The insurer relies on a report from Dr Powell, orthopaedic surgeon dated 18 June 2021 following an examination on 26 March 2021.
7. The claimant reported to Dr Powell that she had pain in her neck and left upper limb. The neck pain radiated to the left shoulder and down to the upper limb. It was sharp and constant, and she had pins and needles in the ulnar three digits. She is aware of restriction of left shoulder motion.
8. The claimant denied previous injuries although acknowledged lower back pain after an earlier motor accident.
9. Neck movements were restricted but equally so. There was tenderness but no spasm and no guarding reported. There was some reduced left-hand sensation but no other neurological abnormalities.
10. There was some restriction of motion in both the left and right shoulder with no extension at all in both.
11. Dr Powell diagnosed a musculoligamentous injury of the cervical spine and aggravation of underlying degenerative disc disease. He also diagnosed a soft tissue injury to the left shoulder with aggravation of underlying rotator cuff tendinopathy. Dr Powell assessed WPI at 5% for the neck and 2% for restricted range of motion of the left shoulder.

1. On 21 June 2023, Medical Assessor Herald determined a dispute about treatment (nerve conduction studies, MRI of the cervical spine and a whole-body bone scan) in favour of the claimant. He found evidence of radiculopathy including weakness in a C7 dermatome and altered sensation over a C6 dermatome and reduced biceps jerk on the left when compared to the right.
2. While he acknowledged pre-existing degenerative changes in the cervical spine, he found the claimant was asymptomatic before the accident and that therefore her radiculopathic symptoms were caused by the accident.
3. He found the treatment reasonable and necessary as they are investigations which "will help guide treatment".
4. Medical Assessor Home examined the claimant on 30 September 2024 and issued his certificate on 4 October 2024. The Medical Assessor states at [2] that he was asked to assess the following injuries:

(a) head - soft tissue injury (due to impact);

(b) cervical spine - disc bulge C5-C6 impinging on the exiting C6 and C7 nerve root/soft tissue injury with radiculopathy into the upper limbs;

(c) thoracic spine - discal/ soft tissue injury with radiculopathy;

(d) lumbar spine - discal/ soft tissue injury with radiculopathy;

(e) left shoulder - Injury to left shoulder/arm/hand - bursitis/ rotator cuff injury/ referred paid from the cervical spine;

(f) right shoulder - referred paid from the cervical spine;

(g) chest - soft tissue injury, and

(h) pelvis - soft tissue injury/symphysitis.

1. The claimant could not recall neck pain and imaging in 2008 or left shoulder pain and imaging in 2010. She said she had no neck or left shoulder pain leading up to the accident. She did concede chronic lower back pain before the accident managed with analgesic medication.
2. Ms El Jassem gave a consistent history of the accident. She said her airbags deployed and she was shocked and could not get out of the vehicle. She recalled neck and left shoulder pain. She was taken to hospital, discharged and she saw her doctor. She was referred to

Dr Dave for her shoulder and Dr Abraszko for her neck. 3. The claimant was not working at the time of the accident, was said to be independent in self-care, could do light household tasks but had not resumed gardening. She has five children. 4. On examination there was dysmetria but no muscle guarding and reduced sensation in three fingers. Some right shoulder movements were restricted and there was more restriction in the left. The chest was normal on examination. There was no guarding or dysmetria in the lumbar spine and no neurological abnormalities in the lower limbs. There was no abnormality in the head. 5. Medical Assessor Home found a cervical spine injury and left shoulder injury but no injury to the head, thoracic spine, lumbar spine, pelvis or right shoulder. He noted the chest injury had resolved. 6. Medical Assessor Home assessed WPI as follows:

(a) cervical spine - DRE category II = 5%, and

(b) left shoulder - range of motion = 5%.

1. He made no deduction for any pre-existing impairment or to account for the contralateral uninjured joint.
2. Medical Assessor Home's certificate was the subject of an application for Review. The Panel found all of the areas of the claimant's body were injured in the accident other than the right shoulder. All areas other than the neck and left shoulder were found to have recovered leaving no ongoing impairment. The Panel came to the same conclusion as Medical Assessor Home (WPI not greater than 10%) but a different degree of WPI (7% not 10%) and his certificate was revoked.

RE-EXAMINATION FINDINGS - MEDICAL ASSESSORS ANDREWS AND HONG

1. Ms El Jassem attended the 70-minute re-examination by way of an audiovisual link from her home. The re-examination was conducted by Medical Assessors Andrews and Hong, assisted by an Arabic interpreter and the interview was conducted entirely through the interpreter. Ms El Jassem gave no indication that she could communicate effectively in the English language.

Psychosocial history and pre-accident history

1. Ms El Jassem is a 64-year-old woman who lives in Liverpool with her 71-year-old husband. She came to Australia in the early 1980s with her husband. He worked for nine years in a metal factory until he was injured in an accident and has not been able to work since. Ms El Jassem has been in receipt of a carer's pension for the last 20 years in order to assist him. She has been a homemaker and has not worked outside the home.
2. The claimant and her husband have two daughters, three sons, and at least 10 grandchildren. Her children all live in the suburbs of Sydney.
3. Ms El Jassem had been a carer for her husband and was actively involved in the life of her children. She had a small group of friends with whom she socialised.

1. Ms El Jassem has a history of diabetes, hypercholesterolaemia, hypertension and gastro-oesophageal reflux disease. The records reveal and she confirmed a history of low back pain before the motor vehicle accident.
2. Ms El Jassem's mother died in a train accident in 2004. She had been visiting Ms El Jassem, who then felt responsible for the accident. She developed depression in the context of her grief and was treated with counselling and an antidepressant medication. Ms El Jassem was commenced on escitalopram 10 mg daily in 2004. She was still on this medication when the motor accident occurred, and the dose was later increased, after 2020, to 20 mg daily. Ms El Jassem said that she made a full recovery but that her doctor had recommended that she stay on the medication for life, a suggestion that she has complied with. This is why she indicated in the claim form that she suffered from depression at the time of the accident.
3. Ms El Jassem says she was functioning well before the motor accident and the depression she had did not impact on her ability to care for herself or her husband or otherwise engage with family and friends.
4. There is no relevant forensic history evident from the claimant's history of the records.

1. Ms El Jassem said she was injured in the motor accident on 15 September 2019 when she collided with a vehicle that failed to give way at an intersection. Her airbags deployed, and police and ambulance attended. Ms El Jassem recalls being distressed at the accident scene. She had trouble moving and breathing.
2. She was taken to the hospital and discharged after three or four hours. She recalls having pain in her right shoulder and neck. Emotionally she said she felt like she was "in shock."
3. Ms El Jassem denied any subsequent accident, injuries or relevant conditions.

History of symptoms and treatment of physical symptoms following the motor accident

1. Following the motor vehicle accident, Ms El Jassem has had treatment for her physical injuries with her general practitioner and a physiotherapist.
2. Ms El Jassem has a history of diabetes, hyperlipidaemia, hypertension and gastro-oesophageal reflux. The Panel notes the records indicate she takes medication for these conditions. The claimant conceded she had back pain before the accident and the Panel also notes she had issues with her neck and shoulder before the motor vehicle accident.
3. Since the accident, she has continuing orthopaedic problems and pain, specifically in her neck and right shoulder. She described pain on average being about 8.5/10 on a scale where 10/10 is the maximum pain possible. This indicates a severe level of ongoing pain. Her pain and physical injuries limit her activities and make doing household chores, caring for her husband, and caring for herself challenging.

History of symptoms and treatment following the motor accident

1. In the days and weeks following the accident, Ms El Jassem recalls feeling "shock" and being too anxious to "get behind the wheel."
2. She was diagnosed with depression and anxiety by Dr Nabil Assad and commenced on antidepressant medication (sertraline) in 2002, before the death of her mother. She had her medication changed to escitalopram after her mother's death and continued to take this medication (10 mgs) up until and after the motor accident. The dose was modified after the accident and increased to 20 mg. She also had psychological therapy with Ms Zeina Boutros, but this has ceased.

1. Ms El Jassem described having a flat mood with reduced enjoyment of daily activities. She is irritable. She said, "I can't cope with one word, I don't want to go anywhere, I want to stay home."
2. She feels isolated and hopeless. She said, "I feel like it is the end of me; no one would help me."
3. She worries about her current situation and her future.
4. She says she has problems with concentration and memory.
5. She has had thoughts of wanting to die and, on one occasion, after a conflict with her son she took a knife and threatened to harm herself.
6. She has disturbed sleep that she attributed to pain from her physical injuries.
7. She eats a simple diet, but her appetite has reduced. She says her weight has decreased from 83 kg pre-accident to 72 kg now.

1. Ms El Jassem presented as woman who looked her stated age, interviewed in her own home.
2. She was neatly and casually attired, wearing a headscarf, a denim jacket and a dark top.
3. She was cooperative throughout the interview, interacting well with the interpreter and the examiners.
4. She had a restricted affect, consistent with a depressed mood and congruent with the interview content.
5. There was no evidence of any disorder perception. She appeared to speak fluently, although it was challenging to assess thought form given the language barrier.
6. At the end of the interview, she agreed that we had covered everything necessary and added, "Honestly, what I told you was true. I am done with all the doctors and medications."

1. She continues to live in Liverpool with her husband. She is less tolerant of him and feels less able to care for his needs. She thinks that he is uncaring about her ongoing pain and distress.
2. She has five children and at least 10 grandchildren who live within the Sydney catchment.
3. She wakes at about 6.00am but will lie in bed for 60 to 90 minutes. When she rises, she does some housework, either cleaning chores or meal preparation, but rarely both on the same day. She said that she received no help from family members or others with household chores.
4. She neglects her own hygiene and says she showers and cleans her teeth about every three days without prompting.
5. She usually skips either breakfast or lunch and tends to prepare simple meals for herself and her husband.
6. She no longer sees friends and has no structured activities outside of her home. She visits her daughter at Yagoona about once a month and otherwise has visits from her children at her home. She said that on days such as birthdays, "we do nothing."
7. Last summer, she travelled with her daughter to The Entrance, about two hours from her home by car, where she stayed a week. She had a holiday with her daughter and Josh's family, but otherwise, "we didn't do anything."
8. She drives herself to see her daughter, a 30-minute drive, choosing to go early to avoid traffic.
9. She described a strained relationship with her husband, saying, "It's not good, we always quarrel; I tell him I can't stand him; he is always asking me for things." Despite this strain, there have been no separations or domestic violence. Ms El Jassem has good relationships with her children and grandchildren.
10. She is not interested in reading and has no hobbies or projects. She does enjoy watching documentaries about nature and animals.
11. Ms El Jassem has never worked outside the home. She continues in the caring role for her husband she has had for the last 20 years.

1. Ms El Jassem's presentation today was similar to how she presented to the Medical Assessor in June.
2. Her narrative was generally consistent with the documents provided although there were some variations from that recorded by Medical Assessor Rikard-Bell and Dr Vickery such as:

(a) the claimant told us that she injured her right shoulder in the accident when the records suggest it was her left. We note that there have been both left and right shoulder complaints in the records;

(b) while the claimant complained to us about her relationship with her husband saying he did not care about her difficulties, Dr Vickery records (in 2021) what appears to be a much more strained relationship with her husband, and

(c) the claimant reported to Dr Vickery (four years ago) and Medical Assessor Ricard-Bell (over a year ago) more significant impairment in her ability to undertake the household chores relying on her family and her daughter who lived over the road. Ms El Jassem told us that she did all the household duties for herself and her husband, albeit pacing herself because of her physical injuries and reduced motivation.

1. The Panel notes that it is required to determine the degree of impairment resulting from the injuries caused by the accident. Therefore, before assessing the degree of impairment, the Panel must first determine whether an injury was caused by the accident and if so, what the diagnosis of that injury is.

1. The insurer's submissions both before the original Medical Assessor and before the Panel do not clearly raise an issue of causation of injury, although there is reference to a pre-existing condition in the context of impairment assessment.
2. The test for causation of injury is whether the accident could have caused or materially contributed to the development of a psychiatric injury and whether the accident did in fact cause or materially contribute to the development of a psychiatric injury.
3. The claimant was involved in a serious accident with another car at an intersection. Her airbags deployed and her car significantly damaged (as shown in the photographs). She was taken to hospital by ambulance. She sustained multiple soft tissue injuries most of which the Panel in the related proceedings found had recovered but two of which left the claimant with permanent impairment. It is the clinical judgment of the Medical Assessors that these circumstances could cause or contribute to the development of a psychiatric disorder.
4. It remains to be determined whether the claimant's accident did in fact cause or materially contribute to the development of a psychiatric disorder. The claimant's accident occurred on 15 September 2019. Five weeks later the claimant's dosage of Lexapro was increased and on 28 November 2019 the claimant's GP recorded symptoms of post-traumatic stress and referred the claimant to a psychologist. The Panel is satisfied that this history supports a finding that the claimant did develop psychiatric symptoms caused by the accident.

1. It is the clinical judgment of the Medical Assessors that, with reference to the DSM-5-TR criteria Ms El Jassem has a major depressive disorder with anxious distress.
2. Criterion A in the DSM-5-TR that must be satisfied is that of the symptom threshold. This requires there to be five (or more) of a number of listed symptoms present during the same two-week period, representing a change from previous functioning:

(a) depressed mood most of the day, nearly every day (subjective or observed);

(b) markedly diminished interest or pleasure in almost all activities;

(c) significant weight change or appetite disturbance (±5% body weight in a month);

(d) insomnia or hypersomnia nearly every day;

(e) psychomotor agitation or retardation, observable by others;

(f) fatigue or loss of energy nearly every day;

(g) feelings of worthlessness or excessive/inappropriate guilt;

(h) diminished ability to think or concentrate, or indecisiveness, and

(i) recurrent thoughts of death, suicidal ideation, or suicide attempt.

(a) depressed mood, or

(b) loss of interest or pleasure (anhedonia).

1. Ms El Jassem has a pervasively low mood (a) with loss of interest and pleasure in usual activities (b). She describes a significant weight loss although this cannot be corroborated by her medical records[23]. She suffers from insomnia (c), which is in part due to pain, but insomnia is a core symptom of depression, and it is not possible to disentangle one cause from the other. She has reduced energy and motivation (f), possibly psychomotor retardation. She has feelings of hopelessness and worthlessness (g). She has a subjective reduction in her ability to think or concentrate (h) and has had thoughts of suicide (i) although she has not acted upon these thoughts.
2. The symptoms reported by Ms El Jassem establish Criterion A for a diagnosis of major depressive disorder.
3. Criterion B of DSM-5-TR - functional impairment - the symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Ms El Jassem's depressive symptoms are constant and have persisted longer than two weeks. While the Medical Assessors acknowledge the claimant has physical injuries which and have caused physical impairments, the claimant's depression has caused psychiatric related distress and impairment, in particular her motivation to socialise and care for herself and her husband as she used to.
4. There are three criteria which require consideration of alternative diagnoses and conditions. Criterion C states that the episode is not attributable to the physiological effects of a substance or another medical condition; Criterion D provides that the episode is not better explained by schizophrenia spectrum or other psychotic disorders, and Criterion E excludes the diagnosis if there has been a manic or hypomanic episode (unless substance-induced or due to a medical condition). Ms El Jassem's disorder is not due to a general medical condition or substance use disorder, and are not better explained by another psychiatric diagnosis, and she has not had mania or Bipolar disorder.
5. Ms El Jassem asserts that her symptoms have not changed appreciably since the motor accident and that she has obtained no benefit from psychotherapy or increases in her medication.
6. The Panel notes that the application for medical assessment lodged by the claimant listed the injury to be assessed as "psychiatric condition - anxiety, depression, posttraumatic stress disorder". The Panel notes that there is no medico-legal report from the claimant and the insurer's expert diagnosed a somatic symptom disorder.
7. In relation to these other diagnoses, it is the clinical judgment of the Medical Assessors that:

(a) although Ms El Jassem was involved in a significant motor vehicle accident and sustained physical injuries, she does not meet the criteria for post-traumatic stress disorder. She does not have continuing intrusion symptoms and is not avoidant of driving or travelling;

(b) Ms El Jassem's mental state examination was predominantly of a depressive state with associated anxiety;

(c) Medical Assessor Rikard-Bell had diagnosed an adjustment disorder secondary to chronic pain caused by the accident. The medical members of this Panel do not support a diagnosis of adjustment disorder primarily because a mood disorder diagnosis supersedes that of an adjustment disorder after this period of time, and

(d) a somatic symptom disorder (SSD) requires that the person has disproportionate and persistent thoughts about the seriousness of symptoms, persistently high anxiety about health or symptoms, and excessive time and energy is devoted to symptoms or health concerns. Ms El Jassem suffers pain due to her musculo-skeletal injuries. Her response to this appears proportionate and appropriate.

1. Six years have passed since Ms El Jassem's motor accident. She continues to have symptoms and associated impairment. Her condition is stable and entrenched. She has had treatment with escitalopram, the medication was started before her motor accident, and she had psychotherapy with a psychologist. Despite these treatments, she asserts that her condition has not improved.
2. It is the clinical judgment of the Medical Assessors that Ms El Jassem's condition and associated impairment will not change significantly over the next 12 months, with or without further medical treatment. She has reached maximum medical improvement.

1. The Guidelines include a chapter entitled "Mental and behavioural disorders" and require the assessment to be undertaken in accordance with the PIRS. The Guidelines also say that the mental and behavioural chapter of the AMA4 Guides are to be used as "background or reference only".[24]
2. The PIRS requires a psychiatric diagnosis to be undertaken first in accordance with the current edition of either the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Statistical Classification of Diseases and Related Health Problems (ICD).[25]
3. The PIRS provides in cl 6.219 for six areas of function:
   • 1.219.1 self-care and personal hygiene;
   • 1.219.2 social and recreational activities;
   • 1.219.3 travel;
   • 1.219.4 social functioning (relationships);
   • 1.219.5 concentration persistence and pace, and
   • 1.219.6 adaptation.
4. The PIRS then provides at cl 6.220 for five classes with a descriptor for each which is "illustrative rather than literal criteria" and which is based on:

"... a history of the injured person's pre-accident lifestyle, activities and habits, and then [an assessment of] the extent to which these have changed as a result of the psychiatric injury".

1. Once all six areas of function have been categorised into a particular class, the median class score is determined, the aggregate score is determined and the median and aggregate is converted to provide a WPI percentage.[26]
2. The impairment may be adjusted for treatment[27] that is treatment such as medication being taken to treat the psychiatric condition.
3. The PIRS provides[28] for the consideration of any psychiatric condition present before the accident in question as follows:

"In order to measure impairment caused by a specific event, the medical assessor must, in the case of an injured person with a pre-existing psychiatric diagnosis or diagnosable condition, estimate the overall pre-existing impairment using precisely the method set out in this part of the Guidelines, and subtract this value from the current impairment rating."

1. Clause 6.34 of the Guidelines provides for subsequent conditions and impairments.
2. The Panel is aware of cl 6.215 and the requirement for PIRS to be administered without regard to somatic symptoms or pain. Some of Ms El Jassem's functional impairment is related to pain and her physical limitations. While the Panel is aware of this, care was taken to identify the impairments due to her psychiatric condition, excluding the impairment due to non-psychiatric causes. In other words, the impairments referred to in the attached PIRS table are due to her psychiatric condition only.

1. At Table 6.11 of the Guidelines, the following classes of impairment are provided:

(a) Class 1 - No deficit, or minor deficit attributable to normal variation in the general population;

(b) Class 2 - Mild impairment. Able to live independently and look after self adequately, although may look unkempt occasionally. Sometimes misses a meal or relies on takeaway food;

(c) Class 3 - Moderate impairment. Cannot live independently without regular support. Needs prompting to shower daily and wear clean clothes. Cannot prepare own meals, frequently misses meals. Family member or community nurse visits (or should visit) two to three times per week to ensure minimum level of hygiene and nutrition;

(d) Class 4 - Severe impairment. Needs supervised residential care. If unsupervised, may accidentally or purposefully hurt self, and

(e) Class 5 - Totally impaired. Needs assistance with basic functions, such as feeding and toileting.

1. Ms El Jassem lives independently without significant practical support from her family or her husband or external services. She receives a carer's payment for looking after her husband who has a serious and significant heart condition. She does household chores, including cleaning and meal preparation, but struggles with motivation and says she maintains a lower standard than before her accident. She showers and cleans her teeth about every three days without prompting which she says is a lower degree of personal hygiene than before (she uses a shower chair now because of her pain from her physical injuries). Some of Ms El Jassem's functional impairment is related to pain and her physical limitations however the impairments assessed are due to her psychiatric condition only.
2. It is the clinical judgment of the Medical Assessors that the claimant is functioning with a mild (class 2) impairment.

1. The PIRS at Table 6.12 provides for the following:

(a) Class 1 - No deficit or minor deficit attributable to normal variation in the general population. Able to go out regularly to cinemas, restaurants or other recreational venues. Belongs to clubs or associations and is actively involved with these;

(b) Class 2 - Mild impairment. Able to occasionally go out to social events without needing a support person, but does not become actively involved; for example, in dancing, cheering favourite team;

(c) Class 3 - Moderate impairment. Rarely goes to social events, and mostly when prompted by family or close friend. Unable to go out without a support person. Not actively involved, remains quiet and withdrawn;

(d) Class 4 - Severe impairment. Never leaves place of residence. Tolerates the company of family member or close friend, but will go to a different room or the garden when others visit family or flatmate, and

(e) Class 5 - Totally impaired. Cannot tolerate living with anybody, extremely uncomfortable when visited by close family member.

1. Ms El Jassem no longer socialises with friends and does not go out to a venue such as restaurants or cafés. Although she had responsibility for her husband's care before the accident, she used to go out to see friends and engaged in family activities and celebrations. She reports that she does not attend family celebrations as she used to. She visits her daughter in Yagoona once a month and has family visit her at home. Last summer, she went on a family vacation to The Entrance but did not actively engage in activities.
2. While the Panel accepts the claimant's physical restrictions affect this area of her functioning, it is the clinical judgment of the Medical Assessors that the claimant has a moderate, class 3 functional impairment in this area because of her psychological state and her lack of motivation.

1. Table 6.13 of the PIRS provides the following categories of impairment:

(a) Class 1 - No deficit, or minor deficit attributable to normal variation in the general population. Able to travel to new environments without supervision;

(b) Class 2 - Mild impairment. Able to travel without support person, but only in a familiar area such as local shops or visiting a neighbour;

(c) Class 3 - Moderate impairment. Unable to travel away from own residence without support person. Problems may be due to excessive anxiety or cognitive impairment;

(d) Class 4 - Severe impairment. Finds it extremely uncomfortable to leave own residence even with a trusted person, and

(e) Class 5 - Totally impaired. Cannot be left unsupervised, even at home. May require two or more persons to supervise when travelling.

1. She is independent with local travel in her local area but says she has no need to travel beyond this familiar area. On her one trip out of the area in the last year, she was taken by family as part of a family holiday. It is the clinical judgment of the Medical Assessors that

Ms El Jassem has a mild (class 2) impairment in this area of functioning.

1. Clause 6.208 says that "Social functioning refers to the capacity to get along with others and communicate effectively." Table 6.14 provides the following impairment classes:

(a) Class 1 - No deficit, or minor deficit attributable to normal variation in the general population. No difficulty in forming and sustaining relationships; for example, a partner or close friendships lasting years;

(b) Class 2 - Mild impairment. Existing relationships strained. Tension and arguments with partner or close family member, loss of some friendships;

(c) Class 3 - Moderate impairment. Previously established relationships severely strained; evidenced, for example, by periods of separation or domestic violence. Partner, relatives or community services looking after children;

(d) Class 4 - Severe impairment. Unable to form or sustain long-term relationships. Pre-existing relationships ended; for example, lost partner, close friends. Unable to care for dependants; for example, own children, elderly parent, and

(e) Class 5 - Totally impaired. Unable to function within society. Living away from populated areas, actively avoids social contact.

1. Her relationship with her husband is strained but they remain living together and she remains as his full-time carer. She has maintained good relationships with her five children and grandchildren and sees them regularly. She says she no longer sees friends. It is the clinical judgment of the Medical Assessors that the claimant is functioning with a class 2, mild impairment.

1. In accordance with Table 6.15 there are the following classes of impairment:

(a) Class 1 - No deficit, or minor deficit attributable to normal variation in the general population. Able to operate at previous educational level; for example, pass a TAFE or university course within normal timeframe;

(b) Class 2 - Mild impairment. Can undertake a basic retraining course, or a standard course at a slower pace. Can focus on intellectually demanding tasks for up to 30 minutes, for example, then feels fatigued or develops headache;

(c) Class 3 - Moderate impairment. Unable to read more than newspaper articles. Finds it difficult to follow complex instructions; for example, operating manuals, building plans, make significant repairs to motor vehicle, type detailed documents, follow a pattern for making clothes, tapestry or knitting;

(d) Class 4 - Severe impairment. Can only read a few lines before losing concentration. Difficulties following simple instructions. Concentration deficits obvious even during brief conversation. Unable to live alone, or needs regular assistance from relatives or community services, and

(e) Class 5 - Totally impaired. Needs constant supervision and assistance within an institutional setting.

1. Ms El Jassem has subjective problems with concentration and memory. She reports being forgetful and often loses track of plans and household care activities at home. She no longer reads stories as she used to and she continues to enjoy watching one-hour documentaries on nature subjects about once a week. She has no projects or hobbies. Ms El Jassem engaged with the Medical Assessors (and the interpreter) for more than one hour and during that time gave a coherent history without needing questions restated or redirection. She did not at any stage lose focus or concentration.
2. It is the clinical judgment of the Medical Assessors that Ms El Jassem is functioning with a mild impairment (class 2).

1. The Panel notes that Table 6.16 in the Guidelines provides the following classes of impairment:

(a) Class 1 - No deficit, or minor deficit attributable to normal variation in the general population. Able to work full time. Duties and performance are consistent with injured person's education and training. The injured person is able to cope with the normal demands of the job;

(b) Class 2 - Mild impairment. Able to work full time in a different environment. The duties require comparable skill and intellect. Can work in the same position, but no more than 20 hours per week; for example, no longer happy to work with specific persons, work in a specific location due to travel required;

(c) Class 3 - Moderate impairment. Cannot work at all in same position as previously. Can perform less than 20 hours per week in a different position, which requires less skill or is qualitatively different; for example, less stressful;

(d) Class 4 - Severe impairment. Cannot work more than one or two days at a time, less than 20 hours per fortnight. Pace is reduced, attendance is erratic, and

(e) Class 5 - Totally impaired. Cannot work at all.

1. Clause 6.221 of the Guidelines is relevant here as Ms El Jassem has not ever worked. This clause says:

"Where adaptation cannot be assessed by reference to work or a work-like setting, consideration must be given to the injured person's usual pre-injury roles and functions such as caring for others, housekeeping, managing personal/family finances, voluntary work, education/study or the discharge of other obligations and responsibilities."

1. Ms El Jassem has always attended to home duties and has not worked outside the home. For 20 years, she has been a carer for her husband. She continues in this role in some areas with no change for example she manages her husband's medication as well as her own. In other activities she is less able than she was before her motor accident. For example, she says she undertakes the cleaning and the laundry "but to a lesser standard" than before the accident.
2. It is the clinical judgment of the Medical Assessors that Ms El Jassem is functioning with a mild impairment (class 2).

1. The six impairment classes are arranged in numerical order as follows: 2, 2, 2, 2, 2 and 3. The median of those is 2, the aggregate is 13. In accordance with Table 6.17, this converts to a 7% WPI.
2. A summary of the impairment findings of the Panel is provided as annexure A.

1. Clause 6.31 of the Guidelines provides as follows:

"The evaluation of the permanent impairment may be complicated by the presence of an impairment in the same region that existed before the relevant motor accident. If there is objective evidence of a pre-existing symptomatic permanent impairment in the same region at the time of the accident, then its value must be calculated and subtracted from the current WPI value. If there is no objective evidence of the pre-existing symptomatic permanent impairment, then its possible presence should be ignored."

1. It is the clinical judgment of the Medical Assessors that no deduction should be made for a pre-existing condition. While the claimant was taking an antidepressant medication at the time of the accident and conceded in her claim form that she was a bit depressed at the time of the accident, there is no objective evidence of any impairment. The history given by Ms El Jassem at the re-examination was that she was caring for her husband and caring for herself, socialising and driving with no issues.
2. If the Panel had been satisfied the claimant had a symptomatic pre-existing condition of depression, then the Panel would have assessed the claimant as class 1 for each of the areas of functionality (1, 1, 1, ,1 ,1 ,1) which would produce a median of 1 and an aggregate of 6. The Panel would have been minded to then add 1% for the effects of the treatment the claimant was having at the time of the accident (medication). This would have resulted in a score of 7 which in accordance with Table 6.17 would have resulted in a 0% WPI for that condition.
3. Clause 6.22 provides for the adjustment of impairment for the effects of treatment if all of the following requirements are met:

(a) there is research evidence demonstrating that the treatment prescribed is effective for the injured person's diagnosed psychiatric condition;

(b) the treatment has been appropriate, for example, medication has been taken in the appropriate dose and duration;

(c) the treatment has been effective, that is, the injured person's symptoms have improved, or her functioning has improved, and

(d) ceasing treatment will result in a deterioration of symptoms or worsening in function.

1. The Medical Assessors are of the view that the claimant's medication regime and her psychological treatment are appropriate treatments however the claimant's treatment has not been effective because Ms El Jassem gave the Medical Assessors a clear history that she obtained no benefit from either the medication or the counselling.
2. Therefore, no adjustment can be made for the effect of treatment.

1. The Panel's determination of impairment is 7%. Although the Panel has arrived at the same outcome as Medical Assessor Rikard-Bell, the Panel has found a different percentage. As the Medical Assessor included that percentage in the certificate, the Panel has to revoke the certificate and issue a fresh one.

[1] El Jassem v AAI Limited t/as GIO [2025] NSWPICMP 500 (PIC Bulletin 221).

[2] The current maximum as of October 2024 is $654,000.

[5] Sections 7.20, 7.24 and 7.26 of the MAI Act.

[6] Section 7.21. The current version of the Guidelines is Version 9.3.

[7] The numbers in square brackets are a reference to the section number in the Medical Assessor's reasons.

[10] Dr Younan was asked by the insurer for a copy of his clinical notes but said he had none in a letter dated 20 August 2020 at page 234 of the insurer's bundle.

[11] Reports are found at pages 138 and 139.

[13] At page 54 of the claimant's bundle and page 1 of the insurer's bundle.

[14] Page 70 of the claimant's bundle and page 6 of the insurer's bundle.

[17] Pages 33 and 34 of the insurer's bundle.

[20] Page 238 of the insurer's bundle. The referral is found at page 248 of the insurer's bundle.

[21] Page 238 and 450 of the claimant's bundle.

[22] Page 450 of the claimant's bundle.

[23] The Panel notes that Ms El Jassem's weight recorded in her GP notes in 2009 was 74 kg, her weight in May 2023 when examined by Medical Assessor Herald was 73 and when examined by Medical Assessor Home in September 2024 was 74 kg. While her weight has stabilised over the last two years there is no detail of her weight in the records between 2009 - 2023.

[26] See cls 6.225 - 6.228 and table 17.

[27] See cls 6.222 - 6.223 of the guidelines.