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

1. Confirms the certificate issued by Medical Assessor Ian Cameron dated 13 April 2025.

1. Bilal El-Nabouch (the claimant) was involved in a motor accident on 27 November 2023. He says his van was stationary behind about 10-12 other vehicles when suddenly a truck approached at speed and collided with the rear of his van.
2. He claims to have suffered injuries to his head, neck, left shoulder, right knee and lower back.
3. He made a claim for statutory benefits with Allianz Australia Insurance Limited, the third-party insurer of the vehicle that he says caused the accident.
4. A medical dispute arose about whether the claimant's injuries were threshold or non-threshold injuries and the matter was referred to the Personal Injury Commission (Commission) for medical assessment.
5. On 13 April 2025, Medical Assessor Ian Cameron found all the claimant's injuries to be threshold injuries.
6. The claimant lodged an application with the Commission seeking review of the Medical Assessor's decision. This was allowed by the President's delegate (Mr Kenneth Ho) and this Review Panel was convened to conduct the review.[1]

1. Under the Motor Accident Injuries Act 2017 (the MAI Act), there is a scheme for statutory benefits (under Part 3) for persons injured in motor accidents in New South Wales. Such benefits can include treatment and care and weekly payments.
2. For injured persons who have "threshold injuries", they cannot receive statutory benefits beyond 52 weeks after the accident and cannot recover damages.[2]
3. For physical injuries, a threshold injury is defined as a "soft tissue injury".[3]
4. A "soft tissue injury" is defined as:

"An injury to tissue that connects, supports or surrounds other structures or organs of the body (such as muscles, tendons, ligaments, menisci, facia, fibrous tissues, fat, blood vessels and synovial membranes), but not an injury to nerves or a complete or partial rupture of tendons, ligaments, menisci or cartilage."[4]

1. A soft tissue injury includes an injury to a spinal nerve that manifests in neurological signs (other than radiculopathy).[5]
2. The Motor Accident Guidelines (the Guidelines)[6] defines radiculopathy as:

"Radiculopathy means the impairment caused by dysfunction of a spinal nerve root or nerve roots when two or more of the following clinical signs are found on examination when they are assessed in accordance with 'Part 6 of the Motor Accident Guidelines: Permanent Impairment'.

(a) loss or asymmetry of reflexes (see the definitions of clinical findings in Table 6.8 in these Guidelines)

(b) positive sciatic nerve root tension signs (see the

(c) muscle atrophy and/or decreased limb circumference

(d) muscle weakness that is anatomically localised to an appropriate spinal nerve root distribution

(e) reproducible sensory loss that is anatomically localised to an appropriate spinal nerve root distribution."[7]

1. Where the neurological symptoms associated with the injured person's injury of the neck or spine do not meet the assessment criteria for radiculopathy, the injury will be assessed as a threshold injury.[8]
2. Table 6.8 of the Guidelines provides definitions for the clinical signs in (a) to (e) above.

1. The provisions regarding causation of injury are contained in cls 6.5 to 6.7 of the Guidelines and apply to both permanent impairment and threshold injury disputes.[9]
2. Clauses 6.6 and 6.7 state:

"6.6 Causation means that a physical, chemical or biological factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following:

1. The alleged factor could have caused or contributed to the worsening of the impairment, which is a medical determination.
2. The alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination

This, therefore, involves a medical decision and a non-medical informed judgement.

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 s 5D and s 5E.

1. The injuries referred to Medical Assessor Cameron were worded as follows:
   • head injury - pain to occipital region and headaches;
   • cervical spine injury - neck pain radiating across the left shoulder and upper arm with intermittent numbness towards the left elbow, C3/4 disc protrusion with moderate central stenosis and C5/6 disc protrusion causing mild bilateral foraminal stenosis and possible C6 nerve irritation. Cervical discs desiccated with mild posterior annular bulges seen at C3/4. C5/6 and C6/7;
   • left shoulder injury - rotator cuff injury;
   • lumbar spine injury - lower back pain radiating down to the left leg, and
   • right knee injury.
2. Medical Assessor Cameron examined the claimant and found no evidence of cognitive impairment. Cervical spine and lumbar spine range of motion were symmetrically reduced. There was full range of motion at the left shoulder. The right knee range of motion was 0-130º with no crepitus or instability. There were no neurological abnormalities in the upper or lower extremities.
3. The Medical Assessor noted that the description of the cervical spine injury was copied from an imaging report. The Medical Assessor said it was not medically plausible for a cervical disc injury to have occurred in the motor accident. Had a disc injury occurred there would have been severe pain in a different pattern from that which occurred. In addition, the Medical Assessor stated that the imaging appearances are common in asymptomatic people. There was also no evidence that there had been a "rotator cuff injury" at the left shoulder.
4. The Medical Assessor concluded that the referred injuries were all soft tissue and threshold injuries.

Claimant's original application submissions dated 9 January 2025

1. The claimant's original submissions relate predominately to the claimant's alleged psychological injuries sustained as a result of the motor accident. The submissions with respect whether the claimant's physical injuries are threshold injuries are confined to the cervical spine.
2. The claimant says the findings of the MRI of the cervical spine dated 24 February 2024 include annular bulges at C3/4, C5/6 and C6 which, the claimant submits are non-threshold injuries.
3. The claimant further submits that neck pain is documented in the clinical note entries of Aya Medical Centre, the certificates of capacity from 10 January 2024 to 6 August 2024 and the certificates of capacity from 5 September 2024 to 8 November 2024.

Claimant's review application submissions dated 12 May 2025

1. The claimant submits that the Medical Assessor failed to make any mention of the MRI of the cervical spine dated 24 February 2024 in his certificate reasons.
2. The claimant takes issue with the Medical Assessor's reasoning that motor accident was unlikely to cause significant injury to the cervical spine. The claimant says this is an opinion that leans more towards an opinion from a biomechanical expert. The claimant refers to the seven photographs which were before the Medical Assessor and asserts that they show extensive damage to the rear of the claimant's vehicle.
3. The claimant also submits that the Medical Assessor was wrong to consider an unsigned statement of the insured driver at fault (Mr Turner).
4. It is further submitted that the Medical Assessor failed to bring inconsistencies in left shoulder range of motion between what was found at the medical assessment (full range of motion) to what was recorded in the Allied Health Recovery Request records.

Insurer's original reply submissions dated 3 February 2025

1. The insurer disputes that the claimant injured his shoulder, lumbar spine or right knee, as the contemporaneous complaints recorded at Campbelltown Hospital only referred to the head, neck and upper back.
2. The insurer's submissions with respect to each of the injuries are summarised below.

1. The claimant's treatment providers recorded headaches or an inability to concentrate which, without any evidence of brain imaging, should be considered a threshold injury.

1. The general practitioner's (GP) notes indicate that the claimant had neck issues with flare ups for the past four to five years before the motor accident. Any worsening of the neck symptoms or symptoms referred to the left arm are due to a flare and unrelated to the accident. The pathology seen in the MRI imaging are not acute but representative of longstanding degenerative changes.
2. In the alternative, the evidence does not support any diagnosis of radiculopathy nor the presence of any fracture or rupture in the cervical spine. The injury is therefore a threshold injury.

1. There were no complaints made to the left shoulder until 13 December 2023, 16 days after the accident, when a complaint was made to the GP. The certificate of capacity dated

5 September 2024 refers to "lt shoulder rotatoc" however it is disputed this is related to the motor accident in the absence of any imaging. 2. The injury is not related to the motor accident or, in the alternative, is a soft tissue injury only.

1. Complaint made to GP on 28 November 2023 is recorded as "upper back pain" which is in the cervicothoracic region - not lumbar. First record of lower back pain was by GP on

13 December 2023, 16 days after the accident. Subsequent mentions of "occasional stabbing pain sensation to the left lower back with radiating pain down the left leg" and "rare stabbing pain" do not satisfy the criteria for radiculopathy. 2. The injury is not related to the motor accident or, in the alternative, is a soft tissue injury only.

1. First record of right knee symptoms was by GP on 13 December 2023, 16 days after the accident. The complaints of "pain" are not evidence of an injury. In the alternative any injury to the right knee is a soft tissue injury only.

Insurer's review reply submissions dated 3 June 2025

1. The insurer submits that the Medical Assessor was open to find on the evidence that the cervical disc injuries were not causally related to the accident.
2. The balance of the submissions and the reference to authorities relate to the functions of the Medical Assessor or the medical assessment process. As the Panel conducts its assessment denovo or afresh, it is not necessary to refer specifically to these submissions.

1. On 16 June 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 1-231 and the insurer's bundle comprising of pages 1-80.
2. The Panel has read the documentation relied upon by the parties. The relevant material is referred to in the re-examination report and the Panel's findings below.

1. At the initial teleconference on 18 August 2025, the Panel determined that a re-examination of the claimant was required. This was conducted by Medical Assessor Oates on behalf of the Panel. Below is the re-examination report:

• Head injury - pain to occipital region and headaches
• Cervical spine injury - neck pain radiating across the left shoulder and upper arm with intermittent numbness towards the left elbow. C3/4 disc protrusion with moderate central stenosis and C5/6 disc protrusion causing mild bilateral foraminal stenosis and possibly C6 nerve irritation. Cervical discs desiccated with mild posterior annular bulges seen at C3/4, C5/6 and C6/7.
• Left shoulder injury - rotator cuff injury
• Lumbar spine injury - lower back pain radiating down to the left leg
• Right knee injury

Mr El-Nabouch attended and an Arabic interpreter (NAATI No. CPN0VK43G) was present for the duration of the assessment.

The claimant was assessed by Medical Assessor Oates on behalf of the Medical Review Panel on 27 August 2025 at the PIC Medical Suites as arranged.

Pre-accident medical history and relevant personal details

The claimant came from Lebanon to Australia in 2018.

He worked in plumbing and mechanical production in Lebanon. He then did a plumbing traineeship lasting six years when he came to Australia, consisting of four years training and then two years work experience. He had six months of the work experience to go at the time of the accident.

He had no prior accidents or injuries. He has had no serious illnesses and no operations. He was on no regular medications.

I asked the claimant about the Certificate accompanying the Claim Form dated 13 December 2023, which mentioned neck issues with flare-ups for the past 4 - 5 years. He said that these neck episodes of discomfort would be of gradual onset and there was no specific incident. He would see a chiropractor every few months for maintenance treatment with benefit. He didn't have to take medications and was able to continue normal duties in plumbing, mainly consisting of multi-resident single small unit blocks, which involved physical work, without difficulty.

After the accident, he broke up with his partner and she is no longer living with him. He then lived with a cousin for a while and subsequently became homeless and lived in his car. He now lives in a room alone in a building. He has one dependent son aged two who lives with the mother. Since the insurer recommenced his wages, he is looking for new lodgings.

Before the accident, he would walk on the beach and socialise with his partner and friends. They would go on drives on the weekends and he did running and jogging. He can't undertake these activities as easily as he could before the accident because of pain.

The claimant confirmed on 27 November 2023 at 4.00pm approximately, he was the driver of a van which he was using for work. There were no passengers. He had a seatbelt on. He was stationary in a row of cars at a red light and was hit from behind at speed by a small truck, such that his van was pushed to the left but did not hit the car in front. His van kept rolling, as it was in neutral gear at the time. Airbags did not deploy.

He said a metal plate with a wooden frame, which divided the driver's cabin from the back of the van, became loose and hit him on the back of his head. He was dazed and didn't know what happened, and can't recall how he got out of the van and came to be lying on a strip of grass on the left-hand side of the road.

He had left knee pain and low back pain, but is not sure how these were caused. He was taken by ambulance to Campbelltown Hospital. He was waiting a long time at the hospital and was not seen by a doctor after initial triage, so he called someone to come and pick him up.

History of symptoms and treatment following the motor accident

He then saw his GP, Dr Abdulsamad, Chester Hill, the next day. He was complaining of neck and upper back pain, and the doctor noted seatbelt marks on the right shoulder and chest. He was sent for x-rays of the cervical and thoracic spine and given painkillers. He also had analgesics. He was certified unfit for work.

At review with the GP, he was sent to the chiropractor for treatment to the neck and back, and was also given exercises.

He then saw his usual GP, Dr Ziadan Ali, at the same clinic as from 10 January 2024.

He had chiropractic treatment for three sessions, but it didn't help. He then went to physiotherapy twice a week for about eight weeks and this did not help. He was later given exercises. He remained off work.

Dr Ali sent him for MRI scans because of ongoing neck pain. There was constant pain radiating down the left arm to the hand, but he doesn't recall tingling or pins and needles in the arm. He would have to try and position his left arm with the hand tucked behind the head to relieve the pain in the arm, but it did not help. His sleep was disturbed.

The MRI scan showed desiccated discs with mild posterior annular bulges and C3/4, C5/6 and C6/7, with bilateral uncovertebral arthrosis at these levels. There was a moderate C5/6 bilateral exit foraminal stenosis with abutment on the bilateral exiting C6 nerve roots.

After the MRI scan of cervical spine, he was referred to Dr McKechnie, neurosurgeon, Bankstown whom he saw on 22 April 2024. He advised Lyrica for neuropathic pain in the arm.

At review on 19 June 2024, he had ongoing symptoms in the neck and left arm, and doctor suggested a left C6 injection, but the claimant did not agree to proceed with the injection.

He saw a psychiatrist because of concerns with driving and was placed on amitriptyline at night. He also saw a psychologist.

He had an ultrasound scan of the left shoulder on 22 July 2024 showing supraspinatus tendinosis with mild subdeltoid bursitis with impingement.

He says he saw Dr McKechnie four times in all and was told to continue conservative treatment.

He continued Lyrica (pregabalin) until about two months ago at 75mg 2 - 3 times a day. Dr Ali then changed him off Lyrica to a different medication, but he can't recall the name. However, the claimant feels that Lyrica was more helpful in reducing the pain than the new medication.

Financial constraints prevented him from continuing to attend the psychologist and psychiatrist.

He attended an exercise physiologist and physiotherapist, but could not afford to keep going because the insurer stopped paying for treatment.

Details of any relevant injuries or conditions sustained since the motor accident

The claimant said he has had no new accident, injury or condition develop.

The main problem is pain in the upper body and in the pelvis area, which come on with physical activity. He can't squat a lot because it hurts his knees.

He has not returned to work as a plumber and is no longer employed, as he was just a sub-contractor at the time of the accident.

He sold his car and shares and used his savings to support himself when insurance cut off all benefits. The insurer has now recommenced wages payment.

He is apprehensive when turning his head because he sometimes gets a painful catch in the left trapezial area. He no longer has any occipital headaches. He does feel some tightness at the side of the neck, over the sternomastoid muscles bilaterally.

He remains under the care of Dr Ali. He has a new medication in place of Lyrica but can't recall the name. He also takes Panadol as required.

He presented the history in a straightforward manner and there was no evidence of cognitive deficit. He needed frequent assistance from the interpreter and spoke mainly in Arabic but frequently using scattered English words in his speech.

He sat freely whilst relating the history and transferred freely out of a chair and on and off the couch.

No occipital or upper cervical tenderness. I note the GCS was 15/15 on three occasions when tested by paramedics at the accident scene.

He has not had any investigations of the head, as he no longer has symptoms in this part.

There was tightness and discomfort in the left upper trapezius but no guarding and no spasm. There were no non-verifiable radicular complaints.

Flexion and extension were full range, lateral flexion was three-quarters bilaterally and rotation was full range bilaterally. There was no dysmetria.

Sensation, power and reflexes in the upper limbs were normal.

Upper arm girth; right 30.5cm, left 31cm at 10cm above the elbow.

Forearm girth; right equals left equals 28cm at 10cm below the elbow.

There was no spasm. There was no guarding. There was no dysmetria, with flexion and extension three-quarters of normal, and lateral flexion three-quarters of normal bilaterally. Thoracic rotation was full range bilaterally.

Supine straight leg raising on the right was normal and on the left 60° with complaint of left groin pain, but there was a negative sciatic stretch test. Slump test negative bilaterally.

Reflexes symmetrical with plantar responses both flexor. Power and sensation in the lower limbs normal.

Thigh girth; right 51.5cm, left 51cm at 10cm above the patella.

Calf girth; right equals left equals 38.5cm at maximal circumference 14cm below the patella.

There was a full range of movement at the elbows, wrists and hands.

There was full range of movement of the right and left hips, apart from slight reduction of left internal rotation, but there was no associated complaint of hip or groin pain.

There was full range of movement from 0 - 130° of flexion measured with a goniometer bilaterally. There was no pain on patellar compression and no crepitus, and both knees were stable in anteroposterior and mediolateral directions.

As mentioned, he presented in a straightforward manner. There was some restriction of movement at the shoulder which the claimant indicated was because of associated pain.

The claimant did not bring any imaging to the Panel re-examination.

The damage to the vehicles involved in the accident have been noted."

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.[10]
2. The onus is on the claimant to prove, on the balance of probabilities, that the motor accident caused non-threshold injuries.[11]
3. The Panel may confirm the certificate of assessment or revoke that certificate and issue a new certificate as to the matters concerned.[12]
4. The Panel refers to the above re-examination report of Medical Assessor Oates. The Panel reconvened on 13 November 2025 and discussed the re-examination report findings before collectively making the below determinations.

1. The diagnosis is soft tissue injury. The criteria specified in cl 6.164 of the Guidelines for traumatic brain injury are not satisfied.
2. The accident was a cause of this injury, as it was mentioned on the Application for Personal Injury Benefits form (the APB form) dated 15 December 2023 and ambulance records refer to head injury, with no loss of consciousness and no amnesia.
3. The claimant indicated he was dazed but not unconscious. The Glascow Coma Scale score was 15/15 on three occasions when measured by paramedics.
4. There was no subsequent investigation taken of the head to determine if there were any intracranial lesion owing to his rapid recovery.

1. This is diagnosed as a soft tissue injury to conform with usual medical nomenclature.
2. The referral was made in terms of symptoms and findings on imaging. The accident was a cause of this injury, as it is mentioned on the APB form.
3. There was a past history of neck pain requiring conservative treatment, which was explored with the claimant. There was no evidence that this pre-existing condition was symptomatic immediately before the accident.
4. The ambulance indicated no neck tenderness at the time, however neck tenderness may not manifest immediately after the accident, but in the hours and days afterwards.
5. X-ray of the cervical spine was taken and the neck is referred to in the GP record of

28 November 2023 and 13 December 2023, and in the Medical Certificate accompanying the Claim Form. It is also referred to in the Allied Health Recovery Request (AHRR) dated

1. This is defined as soft tissue injury.
2. The accident was a cause of this injury, as it is mentioned on the APB form, in the GP record of 13 December 2023, the Medical Certificate accompanying the APB form, and in the AHRR dated 26 January 2024.
3. While the rotator cuff was mentioned in various certificates of capacity from September to November 2024, there was no evidence of partial or complete tear of tendon, ligament, meniscus or cartilage to indicate a non-threshold injury.

1. The diagnosis is soft tissue injury.
2. The accident was a cause of this injury, as it was mentioned in the APB form, in the GP record of 13 December 2023, the accompanying Medical Certificate, and in the AHRR dated 26 January 2024.

1. This is diagnosed as soft tissue injury.
2. The accident was a cause of this injury, as it is mentioned on the APB form, in the GP record of 13 December 2023, the Medical Certificate accompanying the APB form, and in the AHRR dated 26 January 2024.

1. The head injury, being a soft tissue injury, is a threshold injury.

1. The cervical spine soft tissue injury is a threshold injury. There were not two or more signs of radiculopathy on physical examination by the Panel, nor were there two or more signs of cervical radiculopathy indicated in any of the medical evidence.
2. The MRI scan of the cervical spine of 24 February 2024 noted desiccated cervical discs with posterior annular bulges indicating degenerative change, and bilateral uncovertebral arthrosis which is also a degenerative finding, and degenerative changes associated with some bilateral exit foraminal stenosis abutting the C6 nerve roots.
3. There was no mention of a breach of the intervertebral disc fibrocartilage (annulus fibrosus) which would qualify as a non-threshold injury.

1. This is a threshold injury.
2. An ultrasound scan of left shoulder dated 22 July 2024, performed because of left shoulder pain ongoing since the accident, showed supraspinatus tendinosis, mild subdeltoid bursitis and impingement, and the remainder of the rotator cuff tendons were intact.
3. There was no evidence of partial or complete tear of tendon, ligament, meniscus or cartilage to indicate a non-threshold injury.

1. The lumbar spine soft tissue injury is a threshold injury. There were not two or more signs of radiculopathy on physical examination by the Panel, nor were there two or more signs of lumbar radiculopathy indicated in any of the medical evidence.
2. There was no evidence presented of an injury to nerves, or partial or complete rupture of a lumbar intervertebral disc fibrocartilage (annulus fibrosus).

1. This is a threshold injury.
2. The medical evidence did not contain any imaging of the knee to indicate a partial or complete tear of tendon, ligament, cartilage or meniscus to justify the presence of a non-threshold injury at the right knee.

1. The following injuries were caused by the motor accident:
   • head - soft tissue injury;
   • cervical spine - soft tissue injury;
   • lumbar spine - soft tissue injury;
   • left shoulder - soft tissue injury, and
   • right knee - soft tissue injury.

1. The Panel is of the view that the claimant has not discharged his onus, on the balance of probabilities, that the above injuries fall outside the definition of a soft tissue injury as defined in s 1.6 of the MAI Act.
2. The claimant's injuries caused by the motor accident are therefore threshold injuries.
3. The certificate issued by Medical Assessor Ian Cameron dated 13 April 2025 is confirmed.

[1] Section 7.26(5) of the Motor Accident Injuries Act 2017 (MAI Act).

[2] The terminology for accidents that occurred before 1 April 2023 was "minor" injury and statutory benefits were only paid for up to 26 weeks.

[5] Section 4(1) of the Motor Accident Injuries Regulation 2017.

[6] The applicable version of the Guidelines is version 10.

[9] Briggs v IAG Limited Trading as NRMA Insurance [2022] NSWSC 372 per Wright J at [35].

[11] Briggs v IAG Limited Trading as NRMA Insurance [2022] NSWSC 372 per Wright J at [73].