MOTOR ACCIDENTS - Motor Accident Injuries Act 2017; medical assessment of whole person impairment (WPI) by Medical Assessor (MA); claimant injured in motor vehicle accident when she was inspecting her broken-down car when a vehicle hit the car and knocking her onto the road; dispute arose as to the claimant's WPI; Medical Assessor (MA) determined the claimant's WPI at 17%; insurer sought a review of the assessment under section 7.26; Held - Review Panel re-examined the claimant; Review Panel revoked certificate of the MA; substituted determination of 7% WPI.

1. The Medical Review Panel revokes the certificate of Medical Assessor Himanshu Singh of

15 August 2024 and substitutes the determination that as a result of the following psychiatric injuries caused by the motor vehicle accident, the claimant suffered a whole person permanent impairment of 7%: * post-traumatic stress disorder.

1. On 3 May 2022, the claimant, Jereena Jose (Ms Jose), was involved in a motor vehicle accident (the accident) when her car broke down and she pulled over to the side of the road to inspect the bonnet when another car hit her vehicle from behind, throwing her forward onto the road.
2. She alleged that she sustained physical and psychological injury as a result of the accident.
3. On 9 May 2022, Ms Jose lodged a Personal Injury Claim form in respect of the accident. Insurance Australia Group Limited t/as NRMA Insurance (the insurer) was the relevant third-party insurer.
4. On 7 June 2022, the insurer advised Ms Jose that it accepted liability for statutory benefits for 26 weeks after the date of the accident.
5. On 15 June 2023, Ms Jose made an application for damages under common law.
6. The claim is governed by the provisions of the Motor Accident Injuries Act 2017 (the MAI Act).
7. A medical dispute about the degree of Ms Jose's whole person impairment (WPI) in respect of the alleged psychological injuries has arisen in connection with her claim. This constitutes a medical assessment matter under Schedule 2, cl 2(a) of the MAI Act.
8. A medical assessment matter is determined in accordance with Division 7.5 of the MAI Act by a Medical Assessor: s 7.20 of the Act.
9. The dispute was referred to the Personal Injury Commission (Commission) which then assigned it to Medical Assessor Himanshu Singh for assessment. Medical Assessor Singh then assessed Ms Jose on 6 August 2024 and certified on 15 August 2024 that the following psychological injuries caused by the accident had given rise to a permanent impairment of 17%:
   • post-traumatic stress disorder, and
   • major depressive disorder.

1. The insurer sought a review of the medical assessment under s 7.26 of the MAI Act (the Review).
2. Clause 14F of Schedule 1 of the Personal Injury Commission Act 2020 (the PIC Act) provides that the new review provisions apply in relation to a decision of a new decision-maker. A "new decision maker" is defined in cl 14A(1) of Schedule 1 of the PIC Act. As the Medical Assessment which is the subject of the Review was made on or after 1 March 2021, the new review provisions apply.
3. On 30 October 2024, a delegate of the President of the Commission determined there was reasonable cause to suspect that the medical assessment was incorrect in a material respect and referred the matter to the Panel.
4. The review provisions provide that a review panel consists of two Medical Assessors and a Member assigned to the Motor Accidents Division of the Commission: s 7.26(5A) of the MAI Act. Accordingly, the President's delegate has convened this Panel to conduct the review of the Medical Assessment.
5. Part 5 of the PIC Act enables the Commission to make rules with respect to the practice and procedure before the Commission including proceedings before a panel reviewing a decision of a Medical Assessor: s 41(2) of the PIC Act.
6. 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. The Review is by way of a new assessment of all matters with which the medical assessment is concerned: s 7.26(6) of the MAI Act. However, s 7.25 of the MAI Act provides that the review of a medical assessment can be made on the basis of any agreement by the parties as to the degree of permanent impairment from a particular injury and whether a particular injury was caused by the accident, without those matters having to be the subject of assessment.
7. Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the PIC Act. A review panel determines how it conducts and determines the proceedings and may determine the proceedings solely based on the written application: Rule 128 of the PIC Rules.
8. On 25 July 2025, the Panel informed the parties that it considered a re-examination of

Ms Jose was required. Arrangements were made for her to be re-examined by Medical Assessor Alan Doris and Medical Assessor Gerald Chew by video link (MS Teams) on

1. Sections 5D and 5E of the Civil Liability Act 2002 (the CLA) apply to the MAI Act: s 3B(2) of the CLA.
2. Ms Jose's claim and entitlements to compensation are governed by the provisions of the MAI Act. An injured person can make a claim for both economic losses and non-economic loss damages.
3. However, s 4.11 of the MAI Act provides that no damages for non-economic loss may be awarded in respect of injury unless the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident is greater than 10%.

1. If there is a dispute about whether the degree of permanent impairment of an injured person is sufficient for an award of damages for non-economic loss, damages may not be awarded unless the degree of permanent impairment has been assessed by a Medical Assessor under Division 7.5: s 4.12(1) MAI Act.
2. The method of assessing the degree of impairment is dealt with in s 7.21, which is in the following terms:

(1) The assessment of the degree of permanent impairment of an injured person for the purposes of this Act is to be made in accordance with the Motor Accident Guidelines. The assessed degree of permanent impairment is to be expressed as a percentage.

(2) Impairments that result from more than one injury arising out of the same motor accident are to be assessed together to assess the degree of permanent impairment of the injured person.

(3) In assessing the degree of permanent impairment, regard must not be had to any psychiatric or psychological injury, impairment or symptoms, unless the assessment of the degree of permanent impairment is made solely with respect to the result of a psychiatric or psychological injury.

(4) A medical assessor may decline to make an assessment of the degree of permanent impairment of an injured person until the assessor is satisfied that the impairment caused by the injury has become permanent."

1. Clause 6.35 of the Guidelines states that psychiatric impairment is assessed in accordance with 'Mental and behavioural disorders', found in cls [6.201]-[6.228] of the Guidelines.

1. Pre-existing impairment is addressed in cls 6.31-6.33 as follows:

6.31 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.

6.32 The capacity of a medical assessor to determine a change in physical impairment will depend upon the reliability of clinical information on the pre-existing condition. To quote the AMA4 Guides (page 10): 'For example, in apportioning a spine impairment, first the current spine impairment would be estimated, and then impairment from any pre-existing spine problem would be estimated. The estimate for the pre-existing impairment would be subtracted from that for the present impairment to account for the effects of the former. Using this approach to apportionment would require accurate information and data on both impairments.' Refer to clause 6.218 for the approach to a pre-existing psychiatric impairment.

6.33 Pre-existing impairments should not be assessed if they are unrelated or not relevant to the impairment arising from the motor accident."

1. Clause 6.35 of the Guidelines states that psychiatric impairment is assessed in accordance with "Mental and behavioural disorders" within the Guidelines, namely cls [6.201]-[6.228] of the Guidelines.
2. In order to measure impairment caused by a specific event, a 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 the Guidelines, and subtract this value from the current impairment rating: cl 6.218.

1. The Guidelines state as follows with respect to causation of injury:

6.5 An assessment of the degree of permanent impairment is a medical assessment matter under clause 2(a) of Schedule 2 of the Act. The assessment must determine the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident. A determination as to whether the injured person's impairment is related to the accident in question is therefore implied in all such assessments. Medical assessors must be aware of the relevant provisions of the AMA4 Guides, as well as the common law principles that would be applied by a court (or the Personal Injury Commission) in considering such issues.

6.6 Causation is defined in the Glossary at page 316 of the AMA4 Guides as follows:

'Causation means that a physical, chemical or biologic 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 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. It is necessary for the Panel to consider whether the accident caused or contributed to the diagnosed psychiatric condition_: Briggs v IAG Limited t/a NRMA Insurance_ [2022] NSWSC 372 at [75]. The motor accident does not have to be the sole cause as long as it is a contributing cause, which is more than negligible: Owen v Motor Accidents Authority of NSW [2012] NSWSC 650 at [50]. Further, the provisions of the CLA apply, in particular s 5D and s 5E. possible presence should be ignored.

1. Medical Assessor Himanshu Singh examined Ms Jose on 6 August 2024 and certified on

15 August 2024 that the following psychiatric injuries caused by the accident gave rise to a WPI of 17%: * post-traumatic stress disorder, and * major depressive disorder 2. At [2]-[3] in his certificate, Medical Assessor Singh set out the submissions made by both parties. 3. The Medical Assessor recorded a psychosocial and pre-accident history at [7], setting out

Ms Jose's birth in Kerala in India, her early career at school as an elite athlete, her work in cardiac ICU for three-and-a-half years, her work in the ICU in Saudi Arabia, and then her career in nursing in Australia in an Emergency Department which she joined in April 2020. 4. At [8], the Medical Assessor took a comprehensive history of the accident of 3 May 2022. Her car had broken down and she pulled to the side of the road. Ms Jose and her husband got out of the car and inspected the bonnet to determine the cause of the car breaking down. At this time, another vehicle pulled up and parked in front of her to offer assistance with the broken car. Then, a third vehicle crashed into the back of Ms Jose's broken-down vehicle, which then knocked her down to the ground. 5. As a result of the accident, she ended up with major fractures to various parts of her body, including to the right-side of her pelvic bone, back side of the buttock bone, 5th, 7th and 8th ribs on the right, left hand, and nasal bone. She also sustained a pulmonary contusion, a head haematoma and swelling, a left maxillary cyst and both legs had abrasions, bruising and multiple wounds. Medical Assessor Singh recounts that Ms Jose stated to him that at the time of the accident, within seconds, she heard a screaming sound from an old man who was driving the other car. Ms Jose was lying on the road crying and screaming, and her husband felt helpless at the time and was asking for help. Ms Jose was conscious, and she could hear everyone screaming and crying. 6. She recounts that she was taken to Dubbo Base Hospital and was in the ICU for four days and in the surgical ward for three. She recounts how she could not go back to her previous job in the emergency department, so she relocated to Gosford. In her previous role she needed to be very active, and she could not manage that both physically and mentally. She later got a job in Gosford Hospital. 7. Medical Assessor Singh took a history of Ms Jose's symptoms and treatment following the accident at [9], reporting flashbacks of the accident, inability to drive, scared to touch the steering wheel, and that even while sitting in the passenger seat she gets anxious. She feels scared even if she is sitting in a taxi or Uber. 8. At [11], the Medical Assessor recorded current symptoms, including that she feels depressed most of the time and is not feeling happy. The accident comes to her mind all the time and everything is connected with the crash. She is in random accidents in her head in her dreams. She wakes up and cannot go back to sleep. If she is lucky, she may get two to three hours of sleep. She is working 0.5 shifts as a nurse at the hospital, and at the time of Medical Assessor Singh's assessment, was working 40 hours per week. She said to him that her nightmares still happen and her flashbacks as well, especially when she is sitting in the car. 9. Medical Assessor Singh covered current and proposed treatment at [12], reporting previous therapy sessions and natural remedies such as melatonin and ashwagandha. 10. At [13]-[15], the Medical Assessor undertook a clinical examination which the Panel reproduces below:

Ms Jose was seen over video conference. In terms of mental state, Ms Jose was dressed appropriately and appeared clean. She maintained good eye-to-eye contact and rapport was established. She had spontaneous speech with normal rate, tone and volume. Subjectively, she described her mood as being sad and getting upset very quickly. She described her sleep as disturbed and her appetite has been fine though she lost weight. She appeared to be distressed talking about the accident. She described her energy and motivation as low. She described low self-esteem and low levels of confidence. She described repeated thoughts about the accident, and it keeps coming to her head. She is not able to plan future. She wants to be better and tries to get better but soon everything falls apart. She said she has seen so many traumas at work and tries to be positive. She wants to be better and focus on her career. She described repeated memories of the motor vehicle accident along with flashbacks, nightmares, and avoidance towards anything that would remind her of the accident. She reported being hyper vigilant and anxious when she is in the car and is unable to drive. She denied having any active or passive suicidal thoughts, intents or plans and there were no thoughts of harming others. She did not describe any grandiosity, racing thoughts or increased energy levels. There was no evidence of formal thought disorder, no delusional pattern of thinking and no perceptual abnormalities. She described her attention and concentration as poor. Her judgement was intact and she had reasonable insight into her issues.

Ms Jose does attend all her personal care. However, it is not as her usual self. She is not looking after her skin care and not going out to attend the same. She does very basic things. She showers regularly, brushes her teeth, changes to clean clothes and pushes herself to do things. She looks after herself adequately. She relies on her husband for doing the house chores and also for cooking.

Her presentation was consistent during the assessment when history was taken and during mental state examination and to the documents provided."

1. The Medical Assessor then provided a summary of the documentation upon which he relied during his assessment of Ms Jose. The Panel notes that these documents are summarised below under the heading 'Evidence Available to the Panel'.
2. Medical Assessor Singh set out his diagnosis and reasons at [18] which is reproduced below by the Panel:

"In my opinion, Ms Jose has a current diagnosis of Post-Traumatic Stress Disorder and Major Depressive Disorder as per DSM-5 because of the psychological/psychiatric injury sustained in the motor vehicle accident. She has the below highlighted symptoms which meet the DSM-5 criteria of a diagnosis of Post-Traumatic Stress Disorder and Major Depressive Disorder. DSM-5 Diagnostic Criteria for PTSD:

1. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
   1. Directly experiencing the traumatic event(s).
2. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
   1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
   2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
   3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring.
   4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

1. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
   1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
   2. Avoidance of or efforts to avoid external reminders.

1. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
   1. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world.
   2. Persistent negative emotional state
   3. Markedly diminished interest or participation in significant activities.
   4. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
2. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
   1. Hypervigilance.
   2. Problems with concentration.
   3. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
3. Duration of the disturbance (Criteria B, C, D and E) is more than 1 month.
4. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
5. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

DSM-5 Diagnostic Criteria for Major Depressive Disorder Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure:

• Depressed most of the day, nearly every day as indicated by subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful)
• Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by subjective account or observation)
• Significant weight loss when not dieting or weight gain (e.g., change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day
• Insomnia or hypersomnia nearly every day
• Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive or inappropriate guilt
• Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
• Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
• The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The episode is not attributable to the physiological effects of a substance or to another medical condition."

1. At [19], the Medical Assessor then provided his causation and reasons, noting he opined that Ms Jose sustained a psychological/psychiatric injury because of the accident, and met the DSM-5 criteria of post-traumatic stress disorder and major depressive disorder.
2. Medical Assessor Singh noted at [20] that the following injuries referred by the Commission were caused by the accident:
   • post-traumatic stress disorder, and
   • major depressive disorder.
3. At [21], the Medical Assessor opined that the impairment was permanent as the impairment became static or well stabilised with or without medical treatment and was not likely to remit despite medical treatment. The impairment was considered permanent as it is unlikely to change substantially and by more than 3% in the next year with or without medical treatment.
4. Medical Assessor Singh then provided his psychiatric impairment rating scale (PIRS) table at [22] which is reproduced below:

GP follow-up and psychologist sessions. She has not been prescribed any medication apart from melatonin. She does not want to take medications as worried about side effects.

Ms Jose does attend all her personal care. However, it is not as her usual self. She is not looking after her skin care and not going out to attend the same. She does very basic things. She showers regularly, brushes her teeth, changes to clean clothes and pushes herself to do things. She looks after herself adequately. She relies on her husband for doing the house chores and also for cooking.

Ms Jose denied doing any social activity. She does not have any hobbies currently. She only goes for work and then comes back home. She cannot go to any social event as she feels overwhelmed and uncomfortable. If she has to travel anywhere, then she would avoid it. She is very anxious to travel and to be in places where other people are around

Ms Jose is not driving and has not driven since the accident. She stated even sitting in the passenger seat, she gets anxious. She goes for work and comes back. Her husband will drive her, or she may take an Uber or a taxi to go for work. She feels scared to be in the car. She is anxious and fearful when any big car or truck comes near her car or passes by at a high speed and gets worried about having another car accident.

Ms Jose described a good relationship with her husband. She has helped her to recover since the accident. He does all the cooking, laundry and all other work at home. They have known each other for 11 years and married for the last 3 years. However, she described the relationship is not as it should be and there is lack of intimacy. Her family is back in India and she has been in good relationship with them.

Ms Jose described poor focus and concentration. She was regular with yoga and meditation, but now she cannot do meditation and not able to do yoga as she cannot concentrate. Her mind cannot focus and tends to wander away. She cannot do studies as well as she cannot stay on task. She wanted to master's in nursing. However, she thinks she is far away from doing that. At work, she has also found herself low in concentration and focus and gets distracted after a few minutes. She can read but will lose track of what she was doing. She tries to do things quickly and is not able to study.

Ms Jose is currently working for 40 hours in a week at Gosford Hospital in the paediatric ward. She said she has to take some leaves at times as she feels uncomfortable or sick. She is able to work full-time but she is working in a different environment from that of the pre-injury job. She is working in a paediatric ward from being an ED nurse. Ms Jose cannot work at all in the same position which was in the emergency department. I note that she is currently working 40 hours in a week, but she reported that she is not regular to work and she often taking sick leave and personal leave and is not meeting the 40-hour requirement in the week.

1. The Medical Assessor then set out a PIRS table for pre-existing/subsequent impairment, which is not reproduced by the Panel as there was no assessable impairment for this section.
2. Medical Assessor Singh concluded at [26] that as a result of the injuries sustained in the accident, Ms Jose suffered a degree of permanent impairment of 17%.

1. In its assessment, the Panel relies on the following documentation and medical reports and summarises same below.

Report of Dr Hooi-Beng Teoh, consultant psychiatrist, dated 29 May 2024

1. Dr Teoh in his report stated Ms Jose presentation is consistent with the diagnosis of a major depressive disorder under (DSM-5 diagnostic criteria). Her prognosis is guarded as her condition has become chronic. Ms Jose current presentation is with significant anxiety and depressive symptoms. She has not been able to drive. She has managed to return to work full time. She has been socially withdrawn and irritable. She reported insomnia and nightmares. She has been able to return to full time work as a nurse at Gosford Public Hospital in the last 12 months. Ms Jose has reached maximum medical improvement and

Claimant's signed statement dated 22 November 2023

1. The Panel reproduces the relevant sections of Ms Jose's statement below:

"[6] On 3 May 2022 at approximately 6:30PM, I was involved in a motor vehicle accident. My husband and I were travelling along Dandaloo Road when our vehicle bearing registration BM2 5KN began to breakdown. We pulled over and parked the car on the side of the road with the hazard lights on. Another driver, Sharon Smith, stopped to assist, and parked their vehicle bearing registration DBB 03U, in front of ours, with their bonnet facing our bonnet and hazard lights on.

[7] I was standing in front of our vehicle when the defendant, Robert Whites, hit our car form behind in his vehicle bearing registration WPC 010. My car was pushed forward and collided into me. I was pushed into the middle of the road. The defendant did not stop and continued driving.

[8] NSW Police attended the scene of the accident and the event number E88973868 was created.

[12] I can no longer drive due to the psychological trauma caused by the accident. When in a vehicle I am hypervigilant and constantly fearful of another accident happening. I also suffer from anxiety and depression since the subject accident and often suffer from panic attacks.

[13] I struggle to sleep at night-time due to the physical discomfort I experience and frequent nightmares.

[14] Prior to the subject accident, I was a very active individual. My hobbies included physical outdoor activities such as hiking, biking, playing badminton and running. I have been unable to enjoy these activities since the accident due to my physical limitations.

[19] I have attended upon a psychologist for therapy and counselling.

[24] I would say that I was in generally good health at the time of the accident. I have not suffered from any prior injuries or medical conditions. I have not had any prior disabilities. I have not made any prior claims for compensation."

Application for Personal Injury Benefits Claim Form dated 9 May 2022

1. On her claim form, Ms Jose described the accident as follows:

"...After we reached 19k from Narromine, that is Dandaloo Road, at this road my car breakdown. So I parked my car to the side of the road and put my hazard lights on and came out of the car and checked my car for what's happening. At that time, one lady came from Tottenham towards Dubbo. So, we asked help from her and she parked her car in front of my car on the side ... At the same time another lady came towards Dubbo. She also parked her car with hazard lights on and both of them tried to help us. At this time, we all were checking the bonnet of my car. The person hit my car was coming from Narromine and he was rushing and hit on the rear of my car and moved forward and the car hit me and threw me forward to the middle of the road. At the same time the car move-forward and it hit on the front of the helping lady's car. She reported the following injuries: ...Major fractures on 5 parts of my body that is fracture on right side of pelvic bone, fracture on backside of buttocks bone, fracture on 5th, 6th, 7th and 8th rib right side bone, fractured left hand, fracture on nasal bone, and it extended with pulmonary contusion, head haematoma and swelling, left maxillary cyst, and both legs with abrasions, bruising, and multiple wounds. I can't weight bearing on my right hip and left hand until June 26th [2022] that is complete eight weeks...".

Dubbo Base Hospital discharge summary dated 9 May 2022

1. Admitted following polytrauma in a motor vehicle accident and the diagnosis of fracture of tip of nasal bone. Fracture of right 5th, 6th, 7th and 8th right ribs laterally with associated pulmonary contusion. Right S1 sacral segment non-displaced fracture. Fracture to the right inferior and superior pubic ramus undisplaced. Left distal radius fracture. She was admitted under the general surgical team and had inputs from both the orthopaedic team and acute pain service. She was managed conservatively with chest physiotherapy, incentive spiro and pain management. She was deemed safe for discharge with the following plan.

1. The Panel reproduces the submissions of Ms Jose dated 24 October 2024 by reference to paragraph numbers:

[1]-[2] Ms Jose sets out the background to the dispute.

[3]-[8] Ms Jose then sets out a procedural history, noting the accident on

3 May 2022, medical assessment with Medical Assessor Singh on

6 August 2024, and the insurer's application for review of 3 October 2024.

[9] The insurer submits a review is warranted because:

(a) Medical Assessor Singh allegedly erred in applying PIRS to Self-care and Personal Hygiene, Social & Recreational Activities, Travel, Concentration/Persistence/Pace, and Adaptation;

(b) the insurer submits the assessor wrongly concluded WPI exceeds 10% and failed to consider medical evidence, and

(c) the insurer alleges a failure to expose reasoning, relying on Wingfoot Australia Partners Pty Ltd v Kocak [2013] HCA 43; (2013) 252 CLR 480.

[10] Ms Jose submits these assertions are speculative, unsubstantiated and fall short of establishing material error.

[11]-[12] Medical Assessor Singh assessed Class 2, noting Ms Jose does basic self-care, looks after herself adequately, but relies on her husband for chores and cooking. The insurer submitted that she should fall within Class 1 because she attends work daily in a hospital environment with hygiene standards.

[13]-[14] Class 1 describes "no deficit or minor deficit" and Class 2 describes "mild impairment... may look unkempt occasionally... sometimes misses meals or relies on takeaway".

[15]-[16] Ms Jose submits that PIRS evaluates personal self-care, not standards enforced by an occupational environment. The insurer's assumption equating hospital hygiene requirements with personal hygiene is erroneous. The insurer argues she appeared clean and appropriately dressed at the assessment.

[17]-[19] Ms Jose submits that Class 2 expressly permits adequate presentation in formal settings while still experiencing deficits; her basic functioning and reduced motivation indicate Class 2 remains appropriate. She also reported reliance on her husband for meals, consistent with Class 2. The insurer relies on Dr Wallace's report regarding housework, but Ms Jose submits the PIRS domain concerns personal hygiene, not household chores.

[20]-[21] Ms Jose submits she properly fits Class 2 due to lack of motivation and reduced self-care. Ms Jose therefore rejects the insurer's assertion that the assessor's reasoning does not support Class 2.

[22]-[23] Medical Assessor Singh assessed Class 3, noting she does no social activities, only goes to work and back, feels overwhelmed, and avoids public places. Class 3 describes "moderate impairment... rarely goes to events... requires a support person... withdrawn".

[24] The insurer alleges no history of prior social activities was provided; however, Ms Jose refers to page 3 of the Certificate, which records previous athletics, academics, reading, yoga and meditation.

[25]-[27] The Medical Assessor also recorded that she previously video-called family, which she no longer can do. Ms Jose submits her social life primarily revolved around work (particularly the Emergency Department), which was disrupted after the accident. She stayed home for six months and later moved to a lower-pressure geriatric ward. Ms Jose submits that but for the accident she would have maintained social engagement and continued in the emergency department; her withdrawal and reduced involvement reflect Class 3 functioning.

[28] The psychological impact has restricted her ability to participate in work and social interactions.

[29]-[30] The insurer claims a lack of social history, but Ms Jose refers to Dr Teoh's report and her signed statement, both considered by Medical Assessor Singh. The insurer also argues she can travel independently, but Ms Jose submits she relies on taxis, Uber or her husband due to distress while travelling.

[31]-[33] The insurer submits she fits Class 2, which assumes occasional attendance without a support person. Ms Jose submits Class 3 is correct as she requires support and is not actively engaged socially since the accident. Therefore,

Ms Jose rejects the insurer's assertion that Class 2 is appropriate.

[34]-[35] Medical Assessor Singh assessed Class 4, noting she has not driven since the accident, becomes anxious even as a passenger, and fears another accident. Class 4 describes "severe impairment... extremely uncomfortable leaving home even with a trusted person".

[36]-[37] The insurer submits she is Class 1 because she goes to work via husband or Uber. Class 1 describes "no deficit" and ability to travel to unfamiliar environments without supervision.

[38] The Medical Assessor recorded flashbacks, hypervigilance and severe anxiety around cars, big vehicles and speed.

[39]-[40] Ms Jose submits that although she physically leaves the house, psychological trauma renders travel extremely uncomfortable. Ms Jose submits Class 4 recognises severe difficulty, not total inability, consistent with her symptoms.

[41]-[43] Her inability to drive at all and inability to travel independently shows this is not a minor deficit and Ms Jose submits she therefore fits Class 4, not Class 1. She rejects the insurer's submission that the assessor failed to provide a reasoning path.

[44]-[46] Medical Assessor Singh assessed Class 3, noting poor focus, inability to meditate or study, wandering thoughts, distractibility at work, and inability to complete study plans. The insurer submits that her work as a nurse indicates adequate concentration and that no evidence supports a Class 3 rating. Class 3 describes difficulty reading beyond short material and difficulty following complex instructions.

[47]-[48] The Medical Assessor recorded loss of planning ability, constant intrusive thoughts, irritability, sleep disturbance and persistent trauma symptoms.

Ms Jose submits the history clearly shows inability to study and inability to concentrate beyond short durations, consistent with Class 3.

[49] Her move from the Emergency Department to a slower-paced geriatric ward further indicates reduced pace and concentration.

[50]-[51] Ms Jose submits she cannot fall within Class 1 or 2 and properly sits in Class 3. Ms Jose rejects the insurer's assertion that the assessor failed to provide a path of reasoning.

[52]-[54] Medical Assessor Singh assessed Ms Jose as Class 3, noting she works 40 hours per week in the paediatric ward but must take leave when feeling uncomfortable or sick; she cannot work at all in her pre-injury ED role; and although rostered for 40 hours, she is not regular and often takes sick and personal leave. The insurer submits she does not fall within Class 3, which applies where a person cannot work in the same position as previously and can perform less than 20 hours per week in a different, less stressful position. The insurer further submits she falls within Class 1, which involves no deficit, full-time work, and coping with normal job demands.

[55]-[57] Ms Jose submits she does not fall within Class 1, as she was required to change duties from emergency department nursing. Ms Jose submits she properly falls within Class 3, as she no longer works in the ED and instead works in a less stressful paediatric ward. Ms Jose further submits Class 3 does not restrict individuals to only 20 hours; rather, it states they can perform less than 20 hours, which is consistent with her variable capacity depending on sickness or discomfort.

[58]-[59] Ms Jose rejects the insurer's assertion that the assessor failed to set out a reasoning path, submitting the assessor clearly used clinical judgment in assigning Class 3. Ms Jose submits there is no obligation on the assessor to comment on the degree to which paediatric ward duties require less skill or are qualitatively different.

[60]-[61] The insurer submits (per paragraph 5.1 of its review) that Medical Assessor Singh erred by not considering medical evidence or lack thereof when determining WPI. The insurer also submits the Medical Assessor failed to provide consistent findings in relation to Ms Jose's treating records.

[62] Ms Jose submits the assessor expressly noted at paragraph 5 of the certificate that he considered "the documents provided in the application and the reply," and he is not required to list each document individually.

[63] The Medical Assessor also confirmed he had considered all additional late documents lodged at the Commission.

[64]-[65] Ms Jose submits it is for the Medical Assessor to determine the weight to be given to medical evidence. She further submits there is therefore no error, and the review application ought to be dismissed.

Alleged Failure to Expose Reasoning (Wingfoot Argument)

[66] The insurer submits the assessor failed to expose his reasoning and relies on Wingfoot Australia Partners Pty Ltd v Kocak [2013] HCA 43; (2013) 252 CLR 480.

[67]-[69] Ms Jose notes the Medical Assessor recorded that she had no pre-existing mental health issues and found at paragraph 19 that she sustained a psychological injury due to the accident. Ms Jose submits the assessor clearly considered medical evidence, relied on clinical examination, and provided adequate reasoning regarding causation and assessment. At paragraphs 18 and 19, the assessor set out his "Diagnosis and Reasons" and "Causation and Reasons."

[70] Ms Jose submits there is no basis for review as no material error exists; even if any error were found (which is denied), it would not alter the outcome that WPI exceeds 10%.

1. The Panel summarises the submissions of the insurer dated 12 June 2024 by reference to paragraph numbers:

[1.1]-[1.7] The insurer sets out the background of the dispute and stating their reliance on Elliott v IAL t/as NRMA Insurance [2014] NSWSC 1848, noting Campbell J's statements that the proper officer need only hold a "state of unease" about correctness, and that the cumulative weight of complaints may justify review.

[2.1]-[2.9] The insurer sets out the relevant provisions upon which they rely in their submissions in the Act and the Guidelines.

[3.1] The insurer submits Medical Assessor Singh failed to comply with DSM-5, AMA4 and Part 6 of the Guidelines when applying the PIRS, particularly in the categories of Adaptation, Concentration/Persistence/Pace, Travel, Self-care and Personal Hygiene, and Social and Recreational Activities. The insurer submits these errors materially affect the WPI outcome.

[4.1] The insurer submits Medical Assessor Singh erred in determining PIRS class ratings for Self-care/Personal Hygiene, Social/Recreational Activities, Travel, Concentration/Persistence/Pace and Adaptation.

[4.2] The insurer relies on the following salient points.

[4.3]-[4.4] Medical Assessor Singh classified impairment as Class 2 based on reduced grooming, reliance on husband for chores, and "very basic" self-care. Class 2 describes "mild impairment...look unkempt occasionally...sometimes misses a meal".

[4.5]-[4.7] The insurer submits Ms Jose meets Class 1 as she attends all personal care, showers regularly, brushes teeth, changes clothes, and "looks after herself adequately". Class 1 describes "No deficit, or minor deficit...". The insurer submits Ms Jose attends work daily in a hospital and therefore maintains required cleanliness.

[4.8]-[4.12] The insurer notes the Medical Assessor recorded she was "dressed appropriately and appeared clean". Dr Wallace, on 30 March 2024, recorded "no difficulty dressing herself" and the Medical Assessor's "Current Functioning" notes confirm adequate self-care. Dr Wallace states she still completes housework tasks "at a slower pace". The insurer submits Class 1 is the appropriate category.

[4.13]-[4.14] The Medical Assessor classified as Class 3 based on no hobbies, avoidance of social events, overwhelm in public and anxiety in travel. Class 3 describes "Moderate impairment...rarely goes to social events...unable to go out without support person...".

[4.15]-[4.16] The insurer submits the assessor failed to specify pre-injury social/recreational activities. It further submits that the contemporaneous history taken in the hospital notes records no family in Australia and limited friends. The insurer submits no evidence demonstrates a change from pre-injury functioning.

[4.17]-[4.19] The insurer submits Ms Jose works full-time in a busy hospital and travels without a support person via Uber/taxi; the Medical Assessor failed to explain the reasoning for a Class 3 rating. Class 2 describes mild impairment: "able to occasionally go out...without support person". The insurer submits Class 2 is appropriate.

[4.20]-[4.21] The Medical Assessor rated travel as Class 4, citing anxiety in vehicles, not driving, and relying on husband/Uber/taxi. Class 4 requires "Severe impairment...extremely uncomfortable to leave own residence even with a trusted person".

[4.22]-[4.23] The insurer submits Ms Jose meets Class 1 as she uses Uber/taxis, travels to work daily, and does not need a trusted person. The insurer submits Class 4 is plainly inappropriate; Class 1 ("no deficit...able to travel without supervision") applies.

[4.24]-[4.25] The Medical Assessor rated Class 3 based on reported poor focus, inability to study, and distraction. The insurer submits a nurse working in a high-stress environment plainly requires concentration and that the history does not support Class 3.

[4.26]-[4.27] The insurer submits she can read more than newspaper articles, inconsistent with Class 3 and that the Medical Assessor ought to have clarified the information available at assessment.

[4.28]-[4.29] The insurer submits full-time employment at a hospital demonstrates capacity for complex tasks requiring attention and that Ms Jose's work demonstrates significant focus inconsistent with Class 3.

[4.30]-[4.32] The insurer submits the Medical Assessor misapplied PIRS and did not explain reliance on her statement that she is "far away" from further study. The insurer submits "distracted after a few minutes" may reflect normal variation and that Class 1 applies, as she works full-time and can function at her educational level.

[4.33]-[4.34] The Medical Assessor rated Class 3, noting she works 40 hours a week in paediatrics rather than ED, takes sick leave, and "cannot work at all" in previous ED role. The insurer submits Ms Jose clearly does not fall within Class 3 ("Moderate impairment...cannot work at all in same position...can perform <20 hours/week...") and that the evidence does not support this rating.

[4.35] The insurer refers to the Medical Assessor's notes that Ms Jose works 40 hours per week in the paediatric ward, takes leave when uncomfortable or sick, is able to work full-time, and cannot work in the ED role. The insurer submits the Medical Assessor erred by placing her in Class 3 when Class 1 ("No deficit... Able to work full-time... Duties and performance consistent with education and training... Able to cope with normal demands...") is more appropriate. The insurer submits the Medical Assessor failed to set out a path of reasoning for assessing Class 3 Adaptation and failed to consider that she is currently maintaining full-time employment. Taking some sick/personal leave is normal in the general population. Her ability to work full-time and perform duties consistent with her nursing training places her in Class 1.

[4.36] The insurer submits that Ms Jose clearly does not fall within Class 3 given her demonstrated capacity to work full-time (40 hours) in the paediatric ward.

[5.1]-[5.2] The insurer submits the Medical Assessor erred in determining WPI over 10% and failed to consider the medical evidence (or lack thereof) supporting psychological impairment. It further submits the Medical Assessor failed to provide consistent and reasonable findings when considering treating records.

[5.3] The insurer submits the Medical Assessor failed to set out a path of reasoning in assessing Class 2 for Self-care and Personal Hygiene, despite observing Ms Jose was clean, appropriately dressed, looked after herself adequately, and had a fine appetite. The insurer submits this is an error with material effect.

[5.4] The insurer submits the Medical Assessor failed to provide reasoning for assessing Class 3 for Social and Recreational Activities. The insurer submits the reasoning is illogical because Ms Jose has no close friends or family in Australia and the Medical Assessor does not describe pre-accident activities.

[5.5] The insurer submits the Medical Assessor's findings are inconsistent: he assessed Class 3 for Social and Recreational Activities but Class 1 for Social Functioning. The insurer submits this is illogical, as difficulty participating socially should correlate with difficulty maintaining relationships, yet the Medical Assessor recorded good marital relations. This inconsistency materially affects the determination.

[5.6] The insurer submits the Medical Assessor failed to explain his reasoning in assessing Class 4 for Travel and did not consider Ms Jose's capacity to regularly take Ubers and taxis to work without a support person, which contradicts Class 4 criteria ("extreme discomfort leaving residence even with trusted person").

[5.7] The insurer submits the Medical Assessor did not provide reasoning for assessing Class 3 for Concentration, Persistence and Pace, noting no evidence she engages in yoga/meditation and insufficient detail on reading activities. The insurer submits this lacks clear methodology and contradicts her ability to work full-time as a paediatric nurse, which requires high concentration. The insurer submits that this assessment is clearly incorrect.

[5.8] The insurer submits the Medical Assessor failed to provide reasoning for assessing Class 3 for Adaptation. Ms Jose works full-time with no restrictions; sick/personal leave accrues only with usual hours; and she continues to work as a registered nurse in a hospital setting. The insurer submits the Medical Assessor failed to explain how the paediatric ward requires less skill or is qualitatively different.

[5.9] The insurer submits the Medical Assessor erred in class ratings for:

• self-care and personal hygiene;
• social and recreational activities;
• travel;
• adaptation, and
• concentration, persistence and pace.

[5.10] The insurer submits the Medical Assessor did not comply with Part 6 of the Guidelines or consider causation as required.

[5.11] The insurer submits the Assessor failed to expose his reasoning and relies on Wingfoot Australia Partners Pty Ltd v Kocak.

[5.12] Accordingly, the insurer submits the certificate ought to be referred to a Review Panel.

1. On 9 September 2025, Medical Assessor Gerald Chew and Medical Assessor Alan Doris examined Ms Jose on behalf of the Panel. The findings of the Medical Members of the Panel are reproduced below.

1. Jereena Jose is a 32-year-old woman who was born in India. She currently lives with her husband and works full-time as a registered nurse on a geriatric ward in Gosford.

1. Ms Jose grew up with her parents, elder brother and elder sister. Her parents are professionals and are still working in their mid-sixties in India. There is no known family history of mental health problems. Ms Jose describes a positive upbringing. She did well academically and was encouraged to participate in sport at school. She had no social difficulties.
2. Ms Jose denied any serious health problems during her childhood or adolescence. She denied experiencing any traumatic events during these years.
3. After completing secondary education Ms Jose studied for a BSc in Nursing which she completed over four years. She excelled in her studies and obtained a position as a nurse in ICU at a new hospital after graduation. After three and a half years Ms Jose relocated to Saudi Arabia and worked there while applying to come to Australia. In 2019 Ms Jose came to Australia and completed a bridging course for nursing over six months in the Gold Coast. She then was sponsored to take a role as registered nurse in the Emergency Department at Tottenham Hospital in western NSW.
4. Ms Jose describes being successful in her work at Tottenham Hospital. She made friends locally and would socialise on her days off as well as going to a local gym and cycling. She would travel to Dubbo to socialise with the larger Indian community there. Ms Jose said that she previously enjoyed driving and would do this for recreation.
5. Ms Jose has known her husband since they were at school together. They married in 2021 though he remained in India until obtaining a visa in 2022. He arrived in Australia one week before the accident.
6. Ms Jose denied any significant injuries or accidents before the accident. She denied having any operations or serious illnesses. She denied any pre-existing chronic health problems.
7. Ms Jose denied consulting with a health professional about a mental health problem before the accident.
8. Ms Jose does not smoke and does not drink alcohol or use any illicit substances. She does not consume excessive quantities of alcohol or gamble.
9. Ms Jose is not taking any prescribed medication. She occasionally takes some Ashwagandha to assist sleep.

1. On 3 May 2022, Ms Jose was travelling by car with her husband between Narromine and their home in Tottenham having been shopping in Dubbo. Their car broke down and they exited the vehicle to check under the bonnet. Another motorist stopped to assist. A car travelling from the Narromine direction ran into Ms Jose's stationary vehicle at speed and striking her.
2. She sustained significant physical injuries in the accident including broken ribs, fractured nasal bone, fractured pelvis and left wrist. She was lying on the road in pain and immobile for approximately 40 minutes until emergency services arrived. She had no loss of consciousness. She was taken to Dubbo Base Hospital where she was initially treated in ICU for three days then the surgical ward for four days. Management was conservative with physiotherapy and analgesic medication. She had an assessment by a social worker while an inpatient who provide initial emotional support.

History of symptoms and treatment following the accident

1. Ms Jose remained in Dubbo Base Hospital until 9 May 2022. She recalls being easily emotionally upset during this time and worried for her husband who had recently arrived in the country and was unfamiliar with it. She was required to be on prolonged bed rest at home after discharge and attend appointments for physiotherapy.
2. Ms Jose had disturbed sleep with initial and middle insomnia. She had intrusive unpleasant images, memories and feelings associated with the accident. She did not return to driving and found being a passenger in a vehicle aversive with an increase in physiological and psychological symptoms of anxiety.
3. Ms Jose proceeded through a graduated return to work plan from September 2022. She returned to work in the Emergency Department at Tottenham Hospital though at 0.8 full-time equivalent rather than her pre-injury fulltime. In 2023 Ms Jose and her husband relocated to Gosford.

1. There have been no further injuries or conditions since the accident.

1. Ms Jose has not driven a car since the accident due to anxiety. When she is a passenger in a car she sits in the back, is hypervigilant for any threat and has an increased startle reflex. She will take an Uber or taxi to work most days if her husband cannot drive her. She will cancel the car if it is a Toyota Camry as this was the vehicle she was driving at the time of the accident.
2. Ms Jose has typical physiological symptoms of anxiety such as palpitations and sweating when she hears emergency sirens. She has distressing intrusive recollections of the accident, particularly when exposed to a situation that reminds her of it. Ms Jose avoids thinking about the accident if possible and will avoid people who may ask her about it. She has avoided telling some of her family and friends about the accident.
3. Ms Jose continues to have poor sleep with initial and middle insomnia. She occasionally has unpleasant dreams relating to the accident.
4. Her persistent mood state is "not happy" and she gets little enjoyment from previously enjoyable activities.
5. Ms Jose has reduced concentration for activities such as reading and now reads magazine articles rather than longer pieces of text.
6. Ms Jose has a reduced desire to socialise and so sees friends less often. She will go for walks with her husband and rarely participates in community events.
7. Ms Jose enjoys her work and believes that she is doing well in her role. On days off she spends most of her time at home doing chores. She will go shopping with her husband.
8. Ms Jose travelled to India with her husband last in February 2024 and stayed there for a month. This was to attend the wedding of her brother-in-law.

1. Ms Jose has joined her husband to meet with a psychologist based in India by telehealth on two occasions. Otherwise, she has not had treatment for her psychological condition.

1. Ms Jose joined the video assessment from her home in Gosford. Her self-care appeared good; she was neatly dressed and had painted fingernails. She gave a comprehensive and spontaneous history with normal speech. Her affect was reduced in range and reactivity. Her mood was objectively and subjectively moderately low with increased anxiety. She was future focussed. Her thought form was normal. There were no abnormal beliefs in the form of delusions or over-valued ideas and no abnormal perceptions. Ms Jose was fully alert and orientated. She attended adequately for the purpose of the interview and her recall appeared good. A formal cognitive assessment was not carried out.

1. Ms Jose lives with her husband in Gosford. She is able to attend to her self-care adequately and showers daily. She cooks usually on two days per week, which is less than before the accident. Ms Jose goes for walks regularly with her husband in the local area.
2. Ms Jose rarely participates in social and recreational activities and mostly when prompted by a close friend or family member. She no longer attends a gym as she did before the accident. She has participated in Indian community activities twice in the last year which is significantly less than before the accident. She attended her brother-in-law's wedding in early 2024.
3. Ms Jose no longer drives. She is able to be a passenger in a car driven by her husband, a taxi or Uber, though experiences unpleasant symptoms. She is able to walk to work on occasion. She travelled to India with her husband last year.
4. There are some strains in the relationship between Ms Jose and her husband and they have jointly met with a psychologist in India by telehealth for assistance with these. The relationship remains mutually supportive and there have been no periods of separation of domestic violence. There has been loss of some friendships. Ms Jose maintains contact with family and some friends overseas each week.
5. Ms Jose is able to focus on work-related tasks requiring concentration such as administering medication. She reads magazine articles rather than books since the injury due to a reduction in her ability to sustain concentration for long periods. She is able to watch movies.
6. Ms Jose is working full-time in a geriatric ward at Gosford Base Hospital. She is able to work full-time though the work is qualitatively different with less exposure to trauma, including motor accidents.

1. Ms Jose's history and presentation was internally consistent on examination and in keeping with information in the documents.

1. On 3 May 2022 Ms Jose sustained serious physical injuries when she was struck by another vehicle after her car had broken down.
2. Ms Jose developed typical post-trauma symptoms in the weeks following the accident and these have persisted. She has some functional impairment due to her psychological condition.

1. Following the DSM 5TR diagnostic system, Ms Jose has developed post-traumatic stress disorder due to the accident.
2. The Panel considered whether Ms Jose had also developed a major depressive disorder as found by Medical Assessor Singh. The opinion of the medical members of the Panel is that the mood-related symptoms experienced by Ms Jose are most appropriately diagnosed as part of post-traumatic stress disorder rather than a separate disorder.
3. Ms Jose was exposed serious injury in the accident (criterion A). Since the accident Ms Jose has experienced intrusive, distressing, memories of the accident. She has prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event (criterion B).
4. Ms Jose avoids thinking or talking about the traumatic event, and external reminders, such as particular cars, that arouse distressing recollections (criterion C).
5. Ms Jose has a persistently negative emotional state saying, "I am not happy" and "this is not me; it is not normal" since the accident. She has a marked diminished interest in significant activities such as cultural activities in the community and going to the gym.
6. Ms Jose has a hypervigilance for threat when in a motor vehicle and an exaggerated startle response. She has sleep disturbance and some reduction in her concentration (criterion E).
7. Ms Jose's symptoms have persisted for more than one month (criterion F).
8. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (criterion G).
9. The disturbance is not attributable to the physiological effects of a substance or another medical condition (criterion H).

1. Before the accident of 3 May 2022 Ms Jose had no psychological condition and no impairment. She developed symptoms consistent with post-traumatic stress disorder following the accident, and these have become persistent. She has not sustained any other injury or developed any other relevant condition. The accident has caused the development of Ms Jose's psychological condition.

Ms Jose is able to attend to her self-care adequately and showers daily. She cooks usually on two days per week, which is less than before the accident. Ms Jose goes for walks regularly with her husband.

Ms Jose rarely participates in social and recreational activities and mostly when prompted by a close friend or family member. She no longer attends a gym. She has participated in Indian community activities twice in the last year. She attended her brother-in-law's wedding in early 2024.

Ms Jose no longer drives. She is able to be a passenger in a car driven by her husband, a taxi or Uber, though experiences unpleasant symptoms. She is able to walk to work on occasion. She travelled to India with her husband last year.

There are some strains in the relationship between Ms Jose and her husband and they have jointly met with a psychologist in India by telehealth for assistance with these. The relationship remains mutually supportive and there have been no periods of separation of domestic violence. There has been loss of some friendships. Ms Jose maintains contact with family and some friends overseas each week.

Ms Jose is able to focus on work-related tasks requiring concentration such as administering medication. She reads magazine articles rather than books since the injury. She is able to watch movies.

Ms Jose is working full-time in a geriatric ward at Gosford Base Hospital. She is able to work full-time though the work is qualitatively different with less exposure to trauma, including motor accidents.

List Classes in Ascending Order Median Class Value

Pre-existing Impairment (If yes, determine % as above) Median Class Value

Apportionment - pre-existing/subsequent impairment

1. There is no pre-exiting condition or impairment. There are no subsequent conditions or injuries leading to psychological impairment.

1. As a result of injuries caused by the accident, Ms Jose sustained a degree of permanent psychiatric impairment of 7%.

1. Ms Jose made submissions in respect of each of the PIRS categories.

1. Medical Assessor Singh assessed Ms Jose at class 2 and so does the Review Panel.

1. Both the Review Panel and Medical Assessor Singh assessed Ms Jose at Class 3.

1. Medical Assessor Singh put Ms Jose at Class 4, noting that she had not driven since the accident and that she becomes anxious even as a passenger.
2. Ms Jose's submission points out that Class 4 describes "severe impairment". The Members of the Review Panel discussed whether the appropriate classification was 2 or 3.
3. For all relevant purposes travel is not referring to an overseas trip, which is a one-off, but to everyday activities. Ms Jose has a job and must travel to work every day. It is a significant impost and inconvenience for her to rely on her husband to take her to work or even to rely on an Uber which involves difficulties of possible unreliability. Even if she takes a taxi or Uber, she experiences unpleasant symptoms which is a difficult way to start a working day.
4. The Panel discussed whether it would be more reasonable to assign a Class 3 - moderate impairment for Travel. After further discussion, the Medical Members of the Panel assigned a Class 2. Ms Jose is able to travel without a support person, such as by taxi or Uber when going to and from work.

1. The Medical Members of the Panel assigned a Class 3 for Social Functioning on the basis that she does not participate in social activities, but only goes to work and back, feels overwhelmed, and avoids public places.
2. Class 3 describes "moderate impairment". She rarely goes to events and requires a support person.
3. The Review Panel discussed whether the appropriate class for Social Functioning is Class 2 or Class 3.
4. In addition to the problems identified by Medical Assessor Singh, there have been strains in Ms Jose and her husband's relationship, and they have jointly consulted with a psychologist in India via Telehealth.
5. The Review Panel further noted that there has been a loss of some friendship, although she does maintain contact with her family and some friends overseas each week.
6. The Review Panel discussed whether there was a good argument that the impairment should be rated as moderate rather than mild, giving a category of 3.
7. Despite the strain in the relationship between Ms Jose and her husband, the relationship remains mutually supportive and there have been no periods of separation of domestic violence. There has been loss of some friendships. Ms Jose maintains contact with family and some friends overseas each week. This is consistent with a category 2.

1. Medical Assessor Singh assessed Class 3, noting poor focus, inability to meditate or study, wandering thoughts, distractibility at work, and inability to complete study plans.
2. The Review Panel notes that Ms Jose has gone through a highly accomplished specialist nurse in an emergency department, to working in a geriatric ward where there is far less responsibility compared with an emergency ward.
3. The Review Panel discussed whether a more appropriate classification would be moderate impairment Class 3.
4. Medical Assessor Singh assessed Class 3 for Concentration, Persistence and Pace.

Ms Jose argues that she is no longer able to work as a nurse in the emergency room, a high stress environment which requires concentration and exposure to pressure and difficulty, and that working in a geriatric ward is a totally different situation. 5. There is an argument that the appropriate classification is Class 3. 6. Working as a registered nurse requires concentration, persistence and pace for tasks such as checking and administering medications without error. Ms Jose is able to focus on such work-related tasks and reports no concerns about her ability to do these being brough to her attention. There is some reduction in this area consistent with a mild impairment.

1. The Medical Review Panel revokes the certificate of Medical Assessor Himanshu Singh of

15 August 2024 and substitutes the determination that as a result of the following psychiatric injuries caused by the motor vehicle accident, Ms Jose suffered WPI of 7%: * post-traumatic stress disorder.