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

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

1. Jamil Rababi (the claimant) was involved in a motor accident on 10 November 2022. He was the driver of a vehicle in the middle lane of a road when another vehicle exited a service station and collided with the left passenger side of his vehicle. He says he suffered physical and psychological injuries as a result of the motor accident.
2. The claimant made a claim for statutory benefits with Insurance Australia Limited t/as NRMA (the insurer), the third-party insurer of the vehicle that he says caused the accident.
3. A medical dispute arose about whether the claimant's injuries were threshold or non-threshold injuries and the matter was referred to the Personal Injury Commission (Commission) for medical assessment.
4. On 13 April 2025, Medical Assessor Ian Cameron found the claimant's injury to be not a threshold injury.
5. The insurer lodged an application with the Commission seeking review of the Medical Assessor's decision. This was allowed by the President's delegate (Ms Ratula Gupta) and this Review Panel was convened to conduct the review.[1]

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

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

1. The provisions regarding causation of injury are contained in cls 6.5 to 6.7 of the Guidelines and apply to both permanent impairment and threshold injury disputes.[5]
2. Clauses 6.6 and 6.7 state:

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

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

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

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

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

1. The injuries referred to Medical Assessor Cameron were worded as follows:
   • head concussion;
   • ribs fractured rib;
   • right hip torn ligaments;
   • right arm and wrist, and
   • lumbar spine.
2. Medical Assessor Cameron examined the claimant and observed that he walked with a walking stick. There was no evidence of cognitive impairment. There was atrophy of the right arm with limited movement in the right hand consistent with Erb's palsy which the claimant has had since birth. The lumbar spine had symmetrically reduced range of motion (to 70% normal) and there was pain on movement of the right hip. There were no neurological abnormalities in the lower extremities.
3. The Medical Assessor referred to the discharge summary from St George Hospital which stated that there was a possible 11th rib fracture. An X-ray of the chest and left ribs stated "there is a possible fracture of the left 10th rib, please correlate the site of bony tenderness..."
4. There was no brain imaging abnormality. Imaging of the right wrist showed no fracture.
5. The Medical Assessor concluded that the claimant suffered multiple soft tissue injuries and a fractured rib or ribs as a result of the motor accident.
6. The rib fracture was not considered to be a threshold injury because there has been a broken bone.

1. In response to Panel Directions issued on 25 June 2025, the insurer agreed that the only issue in dispute was with respect to whether the "Chest- fractured left rib" is a threshold injury.
2. The Panel will proceed to conduct the review on the threshold injury dispute with respect to the injury "Chest- fractured left rib".

Insurer's original reply submissions dated 16 January 2025

1. The insurer provided a comprehensive summary of the medical documentation, including the contemporaneous ambulance / hospital records, the relevant consultation notes from the clinical records and the relevant imaging reports. The insurer made no reference to any pre-existing injuries other than the claimant right brachial plexus palsy which was a condition affecting the claimant's upper limbs from birth.
2. The insurer concedes that while the claimant sustained injuries to his pelvis/hip, right arm, right wrist, lumbar spine, chest and left ribs, these were all soft tissue and threshold injuries as defined in the Act.

Insurer's review application submissions dated 8 May 2025

1. The insurer submits that the possible fracture of the 10th rib described in the chest X-ray dated 10 November 2022 was clarified in chest CT scan of the same date which described no fractures in the thorax, lumbar vertebra or pelvic bones.
2. It is submitted that the Medical Assessor failed to reveal why he favoured the X-ray over the CT scan when concluding that the alleged fracture rib injury was not a threshold injury.

Claimant's review reply submissions dated 4 June 2025

1. The claimant submits that the contemporaneous medical evidence suggests that the claimant's rib injuries were more than simply soft tissue injuries. These are:

(a) Ambulance records - travelling approximately 55kmph with front impact. Vehicles have significant damage to front of vehicle, all airbags deployed. Patient complaining of pain to the left anterior lower ribs...slight swelling noted to area of pain, and

(b) St George hospital records - Dr Langcake noted left upper quadrant pain as well as being administered Ibuprofen, oxycodone and paracetamol for management of severe pain levels. Query 10th rib fracture following chest X-ray "tender over the left lateral chest wall rib 5-9...unable to cough".

1. It is contended that it was open for the Medical Assessor, having considered the overall circumstances following the motor accident, to conclude that the claimant suffered a rib fracture as a result of the motor accident.

1. On 25 June 2025, the Panel issued a direction to the parties requesting indexed and paginated bundles of the information they relied upon. The Panel advised that unless documents are uploaded to the review file, the Panel would not be able to read and consider those documents. The parties responded with the insurer's bundle comprising of pages 1-286 and the claimant's bundle comprising of pages 1-8.
2. In compliance with Panel Directions, the insurer provided the following further documents:
   • X-ray and CT scan of St George Hospital;
   • clinical notes of MyHealth Oran Park, and
   • clinical notes of Hussien Hamad (physiotherapist).
3. The Panel has read the documentation relied upon by the parties. The relevant material is summarised below.
4. Ambulance report dated 10 November 2022 - travelling approximately 55kmph with front impact. Vehicle has significant damage to front of vehicle, all airbags deployed, seatbelt worn. Had headstrike on pillar, denies loss of consciousness. Complaints of pain to left lower ribs. Nil obvious deformity/flail segment to chest, slight swelling noted to area of pain.
5. St George Hospital - Travelling 55kmph, someone pulled out and head on collision. All airbags deployed, significant deformity to car. L anterior rib pain. **"**X-ray chest initial concern re ? left 11th rib #". Primary survey: tender over Lt lateral chest wall rib 5-9. Unable to cough. Secondary survey: left 10-12 rib tenderness. Tertiary study: tenderness on L chest wall to palpation.
6. X-ray chest and ribs left (verified) dated 10 November 2022 - there is a possible fracture of the left 10th rib. Please correlate with the site of bony tenderness.
7. CT chest abdomen pelvis with contrast (unverified) dated 10 November 2022 - no fractures are identified and [sic] the thorax. No acute intra-thoracic pathology identified. Panel comment: The "and" is a typographical error and should be "in".

1. At a further teleconference on 23 October 2025, the Panel determined that the claimant be re-examined by Panel Medical Assessor Oates. This was to occur at the Commission's Medical Suites on 27 November 2025 at 12.00pm.
2. On 31 October 2025, the Commission was advised that Brydens Lawyers no longer represented the claimant.
3. As there was an upcoming re-examination, the Commission attempted to contact the claimant. Despite numerous attempts to contact the claimant by phone and emails, the Commission case manager advised the Panel that all avenues to contact the claimant were exhausted.
4. The re-examination date for 27 November 2025 at 12.00pm remained open and Panel Medical Assessor Oates attended on the day. The claimant failed to attend the re-examination.
5. The Commission's case manager again attempted contact with the claimant on numerous occasions by phone to no avail. This was to ascertain the reasons behind the claimant's non-attendance and to obtain information for the Panel to decide whether to provide a further re-examination date.
6. Given that the claimant remained uncontactable and was no longer represented, the Panel issued Directions on 30 January 2026. The Directions noted that the insurer's application for review remained on foot and that the issue in dispute primarily concerned the interpretation of the available radiological reports about whether the alleged injury "ribs fractured rib" is a threshold injury.
7. In the circumstances, it was the Panel's view that in the interests of a quick, just and cost-effective resolution of the Panel proceedings, it was proposed that the matter be dealt with "on the papers". The Panel sought submissions from both parties as to this proposed course.
8. In correspondence dated 5 February 2025, the insurer agreed that there was sufficient evidence for an assessment on the papers and accordingly did not object to the Panel's proposed assessment. The claimant did not respond to the Panel's Directions.
9. In accordance with clause 53 of Procedural Direction No 7, which states that the review proceedings must be conducted in the way that best supports the objects of the enabling legislation and the Personal Injury Commission Act 2020, the Panel determined that the assessment will proceed on the papers.

1. The review of the medical assessment is not limited to a review of only that aspect of the assessment that is alleged to be incorrect and is to be by way of a new assessment of all the matters with which the medical assessment is concerned.[6]
2. This new assessment will be confined to whether there was a left lower rib fracture caused by the motor accident. The Panel noted that while Mr Rababi was uncontactable, his submissions concern only the alleged left lower rib fracture and the insurer confirmed that this was the only issue to be determined by the Panel.
3. The Panel may confirm the certificate of assessment or revoke that certificate and issue a new certificate as to the matters concerned.[7]

Did the motor accident cause a left lower rib fracture?

1. The Panel was of the view that the imaging was inconclusive - the X-ray suggested a possible fracture of the left 10th rib while the CT scan did not. Neither X-ray or CT scan are, in the Panel's view, infallible with respect to visualising rib fractures. In the Panel Medical Assessors' experience, X-ray has approximately a 50% missed diagnosis rate for rib fractures, and CT scan has a 70 - 90% accuracy rate for identifying rib fractures. This means at least 10% of rib fractures will not be identified on CT scan particularly if the fracture is limited in size and undisplaced. The 'gold' standard is a nuclear bone scan, which however, is not performed in the acute trauma setting and which was not subsequently performed here as a rib fracture heals and the condition is self-limiting.
2. The Panel notes the early treatment records between the date of hospital discharge until

5 May 2023 were not forwarded by the parties in compliance with the Directions dated

19 August 2025. The Panel specifically requested the notes for this period because early GP records would likely reveal symptoms to the rib area consistent with a rib fracture. 3. There is no reference to a rib injury in the later GP records supplied dating from 5 May 2023 which is as expected because a rib fracture would have resolved by that time, six months after the accident. 4. Turning to the motor accident itself, the Panel considered that the crash caused significant damage to the vehicles involved, the crash being a head on collision at 55kmph with all air bags deploying. The claimant driver was also noted to be wearing a seatbelt which was likely to be fastened over his right shoulder and across the left side of his body. The ambulance report noted pain to the lower left ribs with slight swelling in the area of pain. In the Panel's view, these are all factors that lend weight towards a significant injury to the chest area which could cause a fracture in the lower left ribs. 5. Clinically, when presented at St George Hospital, the claimant reported left rib pain with all surveys (primary, secondary and tertiary) pointing towards an injury to the left rib area. The medical personnel were concerned about a left lower rib fracture and accordingly, an X-ray and CT scan was performed. Of particular note was the claimant's reported left anterior rib pain and an inability to cough and localised left sided chest wall tenderness was found on the three physical surveys (clinical examinations) of this region performed in the hospital which, in the Panel's view, were clinical indicators consistent with a rib fracture. 6. While the Panel accepts the insurer's submission that the CT scan (when compared with X-ray) is a better diagnostic tool for identifying rib fractures, there are still a small proportion of cases that are missed. While imaging may assist medical practitioners in making a diagnosis, and may be useful to confirm a diagnosis, the absence of a pathological change does not invalidate a clinical diagnosis. To be of diagnostic value, imaging studies must be concordant with clinical symptoms and signs.[8] 7. The Panel attributes greater weight to the mechanism of the motor accident and the clinical picture provided in the ambulance and St George Hospital notes which supports a finding that the motor accident could have caused a fracture to the 10th left rib and did cause a fracture to the 10th left rib. The Panel considers a fracture to a bone to fall outside the definition of a soft tissue injury and is therefore not a threshold injury.

1. The following injury caused by the motor accident is not a threshold injury:
   • left 10th rib fracture.
2. The certificate issued by Medical Assessor Ian Cameron dated 13 April 2025 is confirmed.

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

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

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