MOTOR ACCIDENTS - Motor Accident Injuries Act 2017; review of medical assessment of single medical assessor by Review Panel; whether the injuries caused by the motor accident is greater than 10% whole person impairment (WPI); claimant's right foot and ankle ran over by a motor vehicle; consideration as to impairment related to metatarsal fractures; fractures not displaced on viewing of plain x-rays therefore no WPI; question of whether correct table (48 of American Medical Association's Guides to the Evaluation of Permanent Impairment (AMA 4)) referred to; Held - found that the correct table referred to noting clause 6.106 of the Motor Accident Guidelines; also found that clinical diagnosis required to determine functional weakness and cannot occur on imaging alone; original medical assessment certifying 7% WPI confirmed.

Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017

1. Confirms the certificate of Medical Assessor Ian Cameron dated 31 March 2025.

1. Mrs Milka Munjas, (the claimant) is a 76-year-old female who suffered injury on

15 February 2021 as a result of a motor vehicle accident. 2. A claim was lodged upon Insurance Australia Group Limited t/as NRMA Insurance (the insurer) who is the compulsory third party insurer of the vehicle considered to be at fault. The insurer has a liability to pay statutory benefits and/or damages under the Motor Accident Injuries Act 2017 (MAI Act). 3. The issue in dispute between the parties is whether the "degree of permanent impairment as a result of the injury caused by the motor accident is greater than 10%."[1] 4. This is a review of a medical assessment pursuant to s 7.26 of the MAI Act. The medical assessment the subject of this review was conducted by Medical Assessor Ian Cameron. He issued a certificate dated 31 March 2025. The Medical Assessor certified that injuries caused by the motor accident give rise to a permanent impairment of 7% which is not greater than 10%.

1. The claimant sought a review of the medical assessment in accordance with s 7.26 of the MAI Act (review). On 10 June 2025, the President's delegate determined that there was reasonable cause to suspect the medical assessment was incorrect in a material respect. As such the review application was accepted and referred to a Review Panel (the Panel).
2. A review panel consists of two Medical Assessors and a Member assigned to the Motor Accidents Division of the Personal Injury Commission (Commission).[2]
3. 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: s 7.26(6).
4. Rules 127 to 130 of the Personal Injury Commission Rules 2021 (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 Rules.
5. The Panel issued interim directions dated 12 June 2025 requiring the parties to lodge paginated and indexed bundles of all documents relied upon. The parties lodged bundles in compliance with those directions.
6. Following an initial preliminary conference, the Panel issued directions dated 11 August 2025 advising that it required the claimant to attend a re-examination with Medical Assessor Maloney on 8 October 2025. The claimant attended the examination, and details are set out below.
7. The Panel reconvened via teleconference on 20 October 2025 to discuss the clinical examination findings of Medical Assessor Maloney, and the material relied upon by the parties. These reasons have been prepared by all three Panel members as a collective adopting the clinical examination findings of Medical Assessor Maloney.

1. Section 7.21 of the MAI Act provides that the degree of permanent impairment of an injured person is to be assessed in accordance with the Motor Accident Guidelines (the Guidelines).
2. The Guidelines are issued pursuant to s 10.2 of the MAI Act. The Guidelines adopt the fourth edition of the American Medical Association's Guides to the Evaluation of Permanent Impairment (AMA 4). Where there is any difference between AMA 4 and the Guidelines, the Guidelines are definitive.[3]

1. Causation of injury is addressed from cl 6.5 of the Guidelines. Whilst the clauses are set out in respect of permanent impairment they are relevant to a dispute as to threshold injury.[4] Clauses 6.6 and 6.7 provide:

"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. In determining the issue of causation, the Panel is to also have regard to s 5D of the Civil Liability Act 2002 (CL Act):[5]

(1) A determination that negligence caused particular harm comprises the following elements;

(a) that the negligence was a necessary condition of the occurrence of the harm (factual causation), and

(b) that it is appropriate for the scope of the negligent person's liability to extend to the harm so caused (scope of liability).

(2) In determining in an exceptional case, in accordance with established principles, whether negligence that cannot be established as a necessary condition of the occurrence of harm should be accepted as establishing factual causation, the court is to consider (amongst other relevant things) whether or not and why responsibility for the harm should be imposed on the negligent party.

(3) If it is relevant to the determination of factual causation to determine what the person who suffered harm would have done if the negligent person had not been negligent -

(a) the matter is to be determined subjectively in the light of all relevant circumstances, subject to paragraph (b), and

(b) any statement made by the person after suffering the harm about what he or she would have done is inadmissible except to the extent (if any) that the statement is against his or her interest.

(4) For the purpose of determining the scope of liability, the court is to consider (amongst other relevant things) whether or not and why responsibility for the harm should be imposed on the negligent party."

1. Medical Assessor Cameron examined the claimant on 21 March 2025. He concluded that the following injuries caused by the motor accident gave rise to a 7% whole person impairment (WPI):
   • right foot - crush injury with fractures and soft tissue injures;
   • right lower extremity - scarring, and
   • right knee - avulsion fracture and soft tissue injury.
2. The Medical Assessor found that as a result of the motor accident, where the claimant's right lower leg and foot were ran over by a vehicle, the claimant sustained a crush injury to the foot with metatarsal fractures, skin injury (with scarring), partial nerve injury and an injury to the right knee. A 2% WPI was found in respect of scarring using the TEMSKI scale and a 5% WPI was found in respect of the right foot.

Claimant's review submissions dated 15 February 2021

1. The submissions indicate the claimant's agreement with the assessment of WPI by Medical Assessor Cameron for the following injuries:
   • right ankle restricted range of motion - dorsiflexion: 3% WPI;
   • right ankle restricted range of motion - inversion or eversion: 1% WPI;
   • right great tow interphalangeal joint range: 0% WPI, and
   • right lower extremity - scarring: 2% WPI.
2. However, it is submitted that the Medical Assessor failed to assess the metatarsal fractures to the first, third and fourth metatarsals of the right foot and incorrectly assessed the sensory/nerve impairment to the medial and lateral plantar nerves of the right foot.
3. It is submitted that the Medical Assessor did not use Table 64 to assess the crush fractures to each of the first, third and fourth metatarsals. The submissions refer to a report of

Dr Dixon dated 13 December 2024 that the claimant submits correctly assesses the fractures utilising Table 64. He assessed a 4% WPI in respect of the first metatarsal and 1% in respect of the third and fourth metatarsals. 4. It is submitted that the Medical Assessor did not assess the metatarsal fractures and did not provide any explanation for not doing so. 5. It is further submitted that the Medical Assessor used the incorrect methodology to assess the nerve dysfunction in the right foot. It is stated that the Medical Assessor refers to Table 48 of the AMA4 Guides in assessing the right foot, yet that table refers to sensory deficit to the upper extremity. 6. Further the Medical Assessor is noted to make reference to cls 1.58 and 1.60 of the Guidelines, when these clauses related to insurance premiums.

1. The insurer submits that the Medical Assessor did assess the fractures to the first, third and fourth metatarsals of the right foot. In this regard, the certificate refers to metatarsal fractures.
2. It is submitted that the claimant fails to explain why the Medical Assessor ought to have assessed the claimant under Table 64 other than that is the table used by Dr Dixon. The insurer notes the Medical Assessor assessed the metatarsal fractures using Table 45 that relates to toe impairments.
3. The insurer concedes that the Medical Assessor appears to refer to the incorrect table in his reasons, however, it is unclear from the reasons which table was used. In this regard, the Medical Assessor refers to both table 11 and table 68. With table 11 relating to upper extremity and table 68 to the lower extremity.

Claimant's submissions in reply dated 6 August 2025.

1. These submissions were prepared and lodged as an application to admit late documents by the claimant. The submissions are in response to the insurer's submissions of 16 May 2025. Apparently, the insurer does not consent to the inclusion of the submissions in the material to be considered by the Panel.
2. The Panel notes that the submissions were prepared and served well before the re-examination of the claimant and are satisfied that it is in the interests of justice that the submissions be considered. The Panel is satisfied that they are relevant to the dispute to which it is to determine.
3. The claimant submits that the insurer's assertion that the Medical Assessor assessed the metatarsal fractures of the foot is incorrect, and that instead he found that they occurred but he did not assess them.
4. The claimant refers to the assessment of Medical Assessor Woo who identified metatarsal fractures. It is noted that Medical Assessor Woo and Dr Dixon both utilise table 64, page 86 of the AMA4 Guides.

1. The Panel has considered all documentation that was provided by the parties in compliance with Panel directions. This includes a bundle lodged by the claimant on 14 July 2025 consisting of 81 pages - "20250714 bundle of docs for review panel (Ian Cameron)." Also considered is a bundle lodged by the insurer on 31 July 2025 consisting of 281 pages - "DISP - Munjas - 2025.07.31 - Insurer's Review Panel List of Docs (Assessor Cameron) (bookmarked)".
2. Whilst not every document has been specifically referred to within these reasons, the certificate and reasons have been provided in the context of all material having been considered.

Application for personal injury benefits dated 24 February 2021

1. In this claim form the claimant describes having her foot ran over, causing her to fall to her knee. The claimant lists injuries to her toes including fractures, open wounds and a right knee injury including swelling.

1. The report documents the claimant having had her ankle ran over on acceleration and then the vehicle reversed back over the claimant's ankle. The claimant was transported to hospital.

1. The clinical records of Health Check Family Medical Practice are provided which document the claimant having been a long term patient of Dr Tomasevic.
2. On 3 June 2021 Dr Tomasevic takes a history of the motor accident. He notes the claimant was initially treated at Blacktown Hospital then transferred to Westmead Hospital then Blacktown Hospital then Mt Druitt Hospital and then Holroyd Rehabilitation Hospital. The claimant was discharged home on 11 May 2021.
3. The claimant was noted to no longer be using a cam boot and had no further plaster on the right foot. The wound dressing was cared for by a community nurse at the claimant's home. The claimant was noted to be mobilising with a right foot dressing in situ.

1. An X-ray report of the right foot of 29 March 2021 (investigation taken on 26 March 2021). The findings include no acute or healing fracture, the foot was normally aligned, no features of a destructive osseous lesion and no significant cartilage space reduction. In respect of the right ankle it is reported to be normal alignment with minor soft tissue oedema. Generalised osteopenia present and no acute fracture detected.
2. An X-ray report of the right knee of 21 April 2021 noted small linear osseous foci adjacent to the medial epicondyle of the femur suggesting avulsion fractures in the setting of trauma. An overlying soft tissue oedema was noted. There was no knee joint effusion and knee joint alignment was maintained.
3. An MRI report dated 28 August 2024 of the right ankle-mid and forefoot concludes as follows:

• Evidence of chronic denervation atrophy of the intrinsic muscles of the foot, likely to reflect an underlying peripheral neuropathy. Is the patient a diabetic?
• Mild nonspecific subcutaneous oedema
• Small subchondral cyst deep to the distal cuboid articular facet for the base 4th metatarsal, without discernible overlying articular cartilage abnormality, of doubtful significance
• Intact Lisfranc ligament complex
• NO evidence of midfoot OA.
• Uncomplicated os trigonum.
• NO features to suggest an infective process.
• NO evidence of insufficiency bone stress."

Dr Ramawat, orthopaedic surgeon, foot and ankle and trauma

1. Dr Ramawat reported to the claimant's GP on 29 March 2021. He noted the claimant presented with no pain in the foot. Five areas of skin were noted to be still healing. At that time the claimant was receiving twice weekly dressing changes by a community nurse. He recommended the dressings continue for a few weeks and it may take a further four to five weeks to heal completely. He also advised the claimant to come out of the boot and she was also able to fully weight bear while working without issue.
2. In a report dated 10 May 2021 the doctor noted the claimant walked into his rooms in normal shoes with no issues. Some dry scab was noted on the wound. X-rays performed demonstrated a healed fracture. The doctor discharged the claimant from his care.

Dr Alice Change, orthopaedic surgeon foot and ankle surgery and trauma surgery

1. In a report dated 13 August 2024 Dr Chang stated the claimant gave a history of the motor accident and that she suffered wounds to the right ankle and foot and also had three toe fractures. It is noted the claimant apparently did not require surgery. The claimant is reported to have persistent ankle and foot pain worsened with activities and can only walk for 5-10 minutes at most.
2. On examination, the doctor noted normal hindfoot alignment and no gross deformity. Marked venous varicosities below the knee were noted significantly worse than the left. The doctor noted the scars. The claimant was referred for an MRI.

1. Dr Dixon provided a report to the claimant's legal representatives dated 24 October 2022. Following examination he found a 12% WPI, including a 3% for scarring, 4% for the right ankle and a 4% WPI for the fracture of the first metatarsal, and 1% for the remaining two metatarsal fractures.
2. The insure obtained a report of Dr Wallace dated 2 March 2023. He found a 2% WPI due to the scarring.

Medical assessment certificate and reasons of Medical Assessor Woo dated 17 June 2024

1. Medical Assessor Woo provided a certificate in respect of the WPI dispute following examination of the claimant on 5 June 2024. It is noted that a further application for assessment of WPI was subsequently lodged and accepted which culminated in the assessment of Medical Assessor Cameron, the subject of this dispute.
2. Medical Assessor Woo found an 8% WPI which is not greater than 10%. This included a 4% WPI in respect of the first metatarsal and 1% each in respect of the third and fourth metatarsals, in addition to a 2% WPI for the scarring.

1. The below are the clinical examination findings of Medical Assessor Maloney.
2. Mrs Munjas attended the medical suites at the Commission on 8 October 2025. She was accompanied by her husband and a Serbian interpreter, Marina Pinter NAATI no. CPN1QQ77F who was present for the interview and examination.
3. The plain X-ray film of the foot and ankle of 26 March 2021, and the plain X-ray film of the right knee of 19 April 2021 were brought to the examination by Mrs Munjas. Medical Assessor Maloney viewed the films during the examination.

1. Mrs Munjas lives with her husband and is on an age pension. She states that there have been no previous injuries to the right leg. Prior to the accident she was taking medication for hypertension and hypercholesterolaemia.

1. Mrs Munjas was walking on the footpath with her husband when a car came out of a parking area and ran over her right leg and foot. She states that the wheel of the car hit her right leg and reversed over it. Police and ambulance attended the scene of the accident and she was transported to Blacktown Hospital and then to Westmead Hospital for further assessment and back to Blacktown Hospital.

History of symptoms and treatment following the motor accident

1. At the hospital, the wounds were cleaned and initially a plaster cast was applied and then changed to a boot on the right foot. After treatment at Blacktown Hospital, she went to Mount Druitt Hospital and then a private hospital for rehabilitation. The cam boot was worn for about three months and she was using a stick in the right hand.
2. After about three months of hospital treatment, she was discharged home without the boot but continue to use a walking stick. Physiotherapy was organised but she continued to have difficulty with walking.
3. There have been no further injuries sustained since the accident.

1. Mrs Munjas gets a sharp pain in the right ankle and knee which is variable and increases in cold weather. There is occasional swelling of the right ankle with numbness over the right anterior shin and toes. There is a poor sleep pattern due to pain.
2. She finds walking difficult and relies on the walking stick. The pain in the right ankle and knee continues without any improvement. She is mainly confined to the house and her husband does the shopping.

1. Present medication is Panadeine Forte about one per day and another analgesic. She takes Zoloft for depression and other medication for hypertension and hypercholesterolaemia.
2. No manual therapy is being undertaken at present.

1. Mrs Munjas walked into the room reliant on the walking stick and sat comfortably during the interview. The height was measured at 162 cm and weight 74 kg.

1. On palpation of the knees, no tenderness was noted and no effusion was present. There was no ligament laxity on testing and on passive movement no crepitus was detected. The circumference of the calves was 36 cm bilaterally at the maximum level. Prominent varicose veins were present in both legs.

1. There was no crepitus on passive movement of the ankles.

1. The right big toe had some restriction in range of movement. Extension of the metatarsophalangeal joint was 20° and flexion of the interphalangeal joint was 10°.
2. Flexion and extension of the other toes was 20°.

1. There are several areas of scarring over the right lower leg. There was a large irregular scar over the medial side of the right ankle of approximately 4 cm in diameter with pigment changes and tenderness on palpation. There are smaller scars over the dorsum of the right foot. Mrs Munjas can easily locate these scars and they are visible when wearing sandals or thongs. There is no adherence to the underlying structures with minor effect on ADLs and trophic changes to touch. No suture marks are visible.

1. The above clinical examination findings of Medical Assessor Maloney were discussed at the post re-examination teleconference on 20 October 2025. The Panel collectively agreed to incorporate the findings into these reasons.

1. There is documentation that Mrs Munjas sustained an avulsion fracture to the medial femoral condyle of the right femur in the subject accident. The knee is assessed using range of movement and table 41 which is 0% WPI. There was no patellofemoral pain at the time of the examination by Medical Assessor Maloney with no crepitus palpated and no ligament laxity.

1. There was a direct injury to the right ankle and foot in the subject accident with resulting metatarsal fractures. This is assessed using range of movement with tables 42 and 43 of AMA 4. This gives a total of 7% lower extremity impairment +2% Lei (the maximum range of movement in each compartment). This is a total of 9% lower extremity impairment.

1. The toes are assessed using range of movement and table 45 of AMA 4. Extension of 20° of the big toe is 2% Lei. There is no measurable impairment of the other toes. The metatarsal fractures are also assessed using table 64. However, on the x-rays (viewed by Medical Assessor Maloney) there is no dorsal displacement of the metatarsal heads greater than

5 mm with no plantar angulation. Therefore, there is no impairment of the metatarsal fractures apart from assessing range of movement.

1. This is assessed using the TEMSKI chart. Mrs Munjas was conscious of the scars and there are pigmentary changes compared to surrounding skin, and she is easily able to locate the scars. Trophic changes noted to touch with no suture marks. The scar is visible when wearing sandals or thongs. There is no contour defect and minor limitation on any ADLs (such as wearing closed shoes) with no treatment required and no adherence. Classification of best fit is 2% WPI.

1. On testing the toes and foot there was no obvious motor weakness. There was decreased sensation to light touch over the sole of the right foot which is a partial sensory deficit of the medial and lateral plantar nerves.
2. The MRI of the right forefoot dated 28 August 2024 reported fatty infiltration of the intrinsic muscles of the forefoot consistent with denervation, but this is not a clinical diagnosis to determine functional weakness. Using table 68, sensory loss in the medial and lateral plantar nerves is 5% LEI (lower extremity impairment) each.
3. Under the guidance of the Guidelines, peripheral nerve injury is assessed using table 11 and 12 of AMA 4. This is a grade 2 which is 25% of the maximum. 25% of 5% is 1.25%, rounded down to 1% lower extremity impairment which adds to 2% LEI in total.

1. Total WPI is calculated is 9% lower extremity impairment for the right ankle range of movement, 2% for the right big toe and 2% for loss of sensation in the medial and lateral plantar nerves. This gives a total of 13% lower extremity impairment. 13% LEI is 5% WPI using table 6.4 of the Guidelines. This is added to 2% WPI for scarring and gives a total of 7% WPI.
2. The Panel notes the claimant's submissions regarding Medical Assessor Cameron utilising table 48 of the AMA 4 which refer to upper extremity impairment. The Panel notes that this is the correct methodology as required by cl 6.106 of the Guidelines.
3. The Panel also acknowledges the submissions that refer to the findings of Dr Dixon.

Dr Dixon found impairment based on the fatty infiltration of the intrinsic muscles of the forefoot demonstrated on MRI of the foot. However, as noted above, this is not a clinical diagnosis to determine functional weakness. In other words, impairment due to nerve injury requires demonstrable clinical signs of motor weakness or sensory deficit - not imaging alone.

1. The finding of 7% WPI by the Panel accords with the findings of Medical Assessor Cameron of 7% WPI. Accordingly, the certificate is confirmed.

[4] See Briggs v IAG Limited t/as NRMA Insurance [2022] NSWSC 372 at [35].