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

1. The Review Panel revokes the certificate of Medical Assessor Ian Cameron dated

21 December 2024 and issues a new certificate as follows:

(a) The Review Panel certifies the following injuries were caused by the motor accident:

(i) cervical spine - soft tissue injury with secondary headaches.

(b) The Review Panel finds that the above injuries result in a whole person impairment of 1% which is not greater than 10%.

1. Francine Sanhard (the claimant) was involved in a motor accident on 31 May 2021. She was the front seat passenger in a vehicle driven by her husband. An oncoming vehicle was travelling fast and swerved into their direction causing a collision. Her husband managed to swerve to the left, thereby avoiding a head on collision, with the impact being to the side of their vehicle. Their vehicle then impacted the barrier at the side of the road.
2. The claimant says she sustained a head injury with ongoing headaches. She also alleges a cervical spine injury with occipital nerve neuritis and whiplash associated disorder Grade 2.
3. 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 she says caused the accident.
4. A medical dispute arose about whether the degree of the claimant's whole person impairment (WPI) is greater than 10% WPI. This is important because if there is a dispute about the degree of a claimant's WPI, damages for non-economic loss[1] cannot be awarded and disputes must be referred to a Medical Assessor/s for determination.
5. On 21 December 2024, Medical Assessor Ian Cameron found that as a result of the motor accident, the claimant suffered a soft tissue injury to her cervical spine which was assessed as 0% WPI. The claimed head injury was found to be not caused by the motor accident. The total degree of WPI was therefore assessed at 0% WPI which is not greater than 10% WPI.
6. The claimant lodged an application with the Personal Injury Commission (Commission) seeking a review of Medical Assessor Cameron's decision. This was allowed by the President's delegate (Ms Stephanie Wigan) and this Panel was convened to conduct the review.

1. Medical Assessor Cameron was asked to assess the following injuries:
   • head - ongoing headaches, and
   • cervical spine - occipital nerve neuritis; and whiplash associated disorder Grade 2.
2. The claimant told the Medical Assessor that while not physically injured, she was in shock following the motor accident. The following day, she attended her general practitioner (GP),

Dr Sheahan, who noted psychological symptoms after the accident. Subsequently, the claimant stated that she developed head pains and some neck symptoms. She had an MRI of her head and cervical spine on 3 September 2021. This showed non-specific brain white matter change and degenerative changes at the cervical spine. 3. The Medical Assessor found no evidence of a traumatic brain injury. The Medical Assessor stated that it is possible that the claimant hit her neck and sustained a whiplash-associated disorder, although based on the available records, this did not cause symptoms for a significant time after the motor accident. 4. There was also no evidence of "occipital nerve neuritis". 5. The claimant's ongoing headaches were found to be a component of whiplash associated disorder. The headaches were not separately assessable as being associated with permanent impairment. Reference was made to cl 6.162 of the Guidelines which states that "Headache or other pain potentially arising from the nervous system, including migraine, is assessed as part of the impairment related to a specific structure..." 6. The Medical Assessor accepted that the claimant suffered a soft tissue injury to her cervical spine which was assessed as DRE Cervicothoracic Category 1 or 0% WPI. 7. The Medical Assessor concluded that the degree of permanent impairment caused by the motor accident was 0% WPI.

1. The claimant submits that the claimant's symptoms associated with her whiplash associated disorder were not taken into consideration by the Medical Assessor. It is contended that the claimant's headaches satisfy the definition of non-verifiable radicular complaints.
2. The insurer says the Medical Assessor's history did not evidence any headaches on the day of the assessment nor any non-verifiable radicular complaints in the physical examination. The insurer submits that the Medical Assessor has made appropriate findings of fact and provided sufficient and consistent reasons.

1. On 28 February 2025, the Panel issued a direction to the parties requesting indexed and paginated bundles of the information they relied upon. The Panel advised that unless documents are uploaded to the review file, the Panel would not be able to read and consider those documents. The parties responded with the claimant's bundle comprising of pages 1-149 and the insurer's bundle comprising of pages 1-77.
2. In response to further Panel directions, the claimant provided GP records of First Light Healthcare for the period one year before the motor accident (31 May 2021) to two years after the motor accident.
3. The Panel has read and discussed the documentation with the relevant material referred to in the Panel's re-examination report and the Panel findings below.

1. At the preliminary conference on 12 May 2025, the Panel determined that the claimant be re-examined. The re-examination report of Medical Assessors Barnsley and Lahz is below:

"Medical Assessment of Mrs Francine Sanhard (Assessors Barnsley and Lahz) 25/7/25 PIC Suites - 75 minutes duration.

Mrs Sanhard aged 75 and right-handed attended the appointment punctually. She had flown down the previous day from home in Byron Bay. She and her husband have lived in Byron Bay since retirement approximately 10 years ago.

The purpose of the assessment (WPI determination) with respect to a motor accident 31/5/21 was explained to Mrs Sanhard at the commencement of the assessment. We explained that injuries of the neck and "headaches" had been referred for assessment.

The Panel started by asking Mrs Sanhard regarding her past medical history. She has a long history of anxiety and depression, commencing with an episode of post-natal depression 50 years ago with the birth of her first child.

She recalled an episode of left shoulder calcific tendonitis. She ascribed this to work duties requiring much typing whilst working as a medical secretary.

She has a diagnosis of hypothyroidism for which she takes medication.

She also has a diagnosis of psoriatic arthritis affecting the left ankle (but no other body parts) for which she has previously been treated with Humira and also Methotrexate although she is not presently prescribed any medication for this condition which fortunately has spontaneously settled.

She was asked specifically about any prior problems with neck pain, upper limb pain or headaches. She said she had occasional migraines but otherwise denied any complaints prior to the accident.

The medical assessors drew to her attention an entry in the GP records dated 7/8/20 referring to shooting pain in the left upper limb in a C6 pattern although there was no associated neck pain reported. Mrs Sanhard could not recall this episode.

The medical assessors then drew to her attention a GP entry in records dated 12/5/21 (i.e. 2.5 weeks before the subject motor accident) referring to a fall two months prior following which she had developed right-sided pain at the skull base. Her doctor ordered a CT scan of the neck.

She told the medical assessors about the fall which occurred whilst she had to separate a dog from her daughter's dog, causing her to fall backwards. So far as she could recall, she was not "laid up" and the neck symptoms had resolved by the time of the motor accident. She told the medical assessors that given her medical (vocational) background, she tended to have symptoms "checked out" more often than most people.

Her prescribed medications at the time of the accident 31/5/21, she thought, had been Thyroxine, Efexor (for depression) and Atacand for hypertension.

Mrs Sanhard confirmed her involvement in the May 2021 motor accident. She was a front seat passenger in a late model car which her husband had been driving and they were on the Bruxner Highway travelling behind a truck. An oncoming car was travelling quickly and erratically, which her husband swerved left to avoid. There was then a collision between the oncoming vehicle and the driver's side of the claimant's vehicle. The impact, she said "took out" the side of their vehicle before it then struck a wall alongside the highway.

She does not recall any direct impact to any part of her body including the head. There were no lacerations, bruises or bleeding.

The airbags did not deploy, and the ambulance/police did not attend. Although she was understandably distressed Mrs Sanhard was able to phone the towing company.

Within a week of the accident, she developed pain (akin to a heat sensation) commencing at the top of the head, spreading downwards on the right to the base of skull but generally not beyond. She also referred to some posterior neck discomfort although there has not been any upper limb pain, nor neurological symptoms.

She saw her doctor who referred her to an osteopath who suggested that the sensations at the head/skull were coming from the neck.

The GP referred her to a physiotherapist at the same practice whom she attended for so long as the insurer would fund treatment. Being on the Aged Pension, she could not afford to fund continuing treatment.

Her husband also helped by providing massages for tight muscles.

The medical assessors discussed the chronology of events per the GP records summarised immediately below. The first mention of neck and head pain in records is on 13/7/21, six weeks after the motor accident.

The GP records include a consultation on 1/6/21, the following day describing an "almost head on collision". Low mood was reported on account of her husband's illness and having to complete the work at home. There is a further consultation on 15/6/21 describing a flare of anxiety triggered by a motor accident two weeks before. There were also family stressors and the doctor suggested doubling the dose of Efexor. On 29/6/21, the GP refers to the car being a "write off". There were anxiety and depressive symptoms and CTP forms were completed. On 2/7/21, she was not dealing well with the motor accident, which had been a "near death experience". There was anger and the GP referred to PTSD.

It is not actually until 13/7/21 (six weeks post motor accident) that the doctor specifically records symptomatic complaints of head, neck and trapezial soreness. She had been "greatly affected" (sic" by the motor accident. Relaxation therapies were suggested for the head, neck and trapezial insertion pain.

Subsequent GP entries continue reference to low mood and anxiety with inability to travel in the front seat of a car. On 24/8/21, there is reference specifically to right occipital headache due to the motor accident. The doctor thought the headache "stressed based" although he recommended precautionary MRI of the cervical spine/brain.

On 3/9/21, the doctor referred to the MRI results (brain and neck) not demonstrating any traumatic findings although there were changes present consistent with small vessel disease. There is reference to "a few levels of anterolisthesis in the lowermost neck and upper thoracic spine" which according to the GP may be related to whiplash injury although seemed a bit low to account for the reported pain at the skull base. There was an ensuing discussion around vascular risk factor control such hypertension, cholesterol levels and healthy lifestyle changes with respect to diet. There was further reference to claimant's PTSD and negativity.

Mrs Sanhard could not shed light on the reasons for the delayed reporting of head and neck symptoms per the GP records.

Initially, there were activity restrictions due to pain and discomfort whereas now, she can undertake required daily activities despite persistent head/neck symptoms.

Even now, she reported that she cannot travel in the front seat. She has never held a licence.

Her doctor has recommended trauma counselling although she is not keen to pursue this.

Ongoing, she complains of peculiar sensations in the head/skull commencing at the skull vertex with spread down the right occipital region to the skull base/upper neck. She denied head pain as such, describing the head as mostly "sore" with a feeling akin to bruising. She reported too that it is generally easier to turn her neck towards the left than the right. The head and neck pain is non-radiating (no upper limb symptoms). She also does not report any numbness, tingling or shooting sensations at the skull.

Head and upper neck symptoms are generally worse at night. Prolonged sitting is also provocative for the neck, and she generally uses a pillow behind the neck for comfort when sitting.

She takes Nurofen 200 mg as required for symptomatic relief and uses symptomatic measures such as heat application.

There have been no spine/pain specialist consultations.

No further treatment is planned beyond symptomatic analgesia.

She completes daily chores, shopping and meal preparation as required, given there is no one else to do so.

On examination, she was well groomed, pleasant and cooperative.

The Panel observed that she is of relatively short stature with height 157 cm and weight 72.5 kg.

There was normal neck posture without focal tenderness. There was no muscle guarding or spasm.

Neck movements were uniformly restricted with rotation ¾ normal range to either side, flexion and extension ½ normal range and lateral flexion 1/3 normal range to either side. There was no dysmetria.

There were no non-verifiable upper limb radicular symptoms.

At the upper limbs, there were symmetrical reflexes, no abnormal sensory findings and normal power. There was no wasting of the right arm 10 cm above the lateral epicondyle, being 31cm on both sides nor at the forearms 10 cm below the lateral epicondyle 25 cm (left) and 25.5 cm right, consistent with right-sided dominance.

In summary, there were no findings to confirm the presence of upper limb radiculopathy.

Careful pinprick and light touch testing repeated to check for consistency over the skull indicated a subjective deficit in the right greater occipital nerve distribution."

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 (Guidelines).
2. Version 9.3 of the Guidelines, effective from 6 December 2024, applies to the review.
3. The Guidelines were issued pursuant to Division 10.2 of the MAI Act and adopt the American Medical Association's Guides to the Evaluation of Permanent Impairment, Fourth Edition (AMA 4 Guides). The Guidelines are definitive with regard to the matters they address but where they are silent on an issue, the AMA 4 Guides should be followed.
4. Permanent impairment is assessed in accordance with Part 6 of the Guidelines.

1. It is necessary for the Panel to consider whether the accident caused or contributed to the claimant's physical injuries.
2. The provisions regarding causation of injury are contained in cls 6.5 to 6.7 of the Guidelines.
3. The provisions state:

"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 (the 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 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, and
2. the alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination

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

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

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

1. The 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.[2]
2. The evaluation should only consider the impairment as it is at the time of the assessment.[3]
3. The Panel may confirm the certificate of assessment or revoke that certificate and issue a new certificate as to the matters concerned.[4]
4. The Panel refers to the above re-examination report of Medical Assessors Barnsley and Lahz. The Panel reconvened on 27 August 2025 and discussed the re-examination report findings before collectively making the below findings.

1. The claimant complains of headache and neck pain. The first issue is whether the headache was caused by the accident. The claimant was involved in a significant motor vehicle accident with multiple complex forces i.e. more than one impact at relatively high speed. The Panel considered that this incident could have caused injury to the cervical spine. There was no documented head strike. The Panel therefore considered that the accident could have caused an injury to the cervical spine, but there does not appear to have been a separate head injury. In particular, there was no history of a direct impact to the occipital region.
2. The Panel then considered whether the accident did cause the cervical spine injury and headaches. The Panel noted that there was a delay in the reporting of symptoms to the claimant's local doctor after the accident. The Panel accepted the claimant's explanation that she was initially shocked and distressed by the circumstances of the accident, as indicated by the contemporaneous GP's notes, and then became increasingly aware of her neck and head symptoms. The Panel therefore considered that, on the balance of probabilities, the motor accident did cause an injury to the cervical spine with secondary headaches.

1. In the cervical spine, the claimant has complaints of pain. She has no dysmetria, no non-verifiable radicular symptoms, and no radiculopathy in the upper limbs. The correct DRE classification is therefore DRE I which attracts a 0% WPI.
2. The Panel then carefully considered the appropriate means of assessing the headache symptoms. The Panel agreed with Medical Assessor Cameron that headaches alone are not separately assessable as being associated with permanent impairment pursuant to cl 6.162 of the Guidelines.
3. However, and as indicated above, the Panel found the claimant's headaches to be associated with an accident-related injury to the cervical spine.
4. The first consideration is whether there was evidence of greater occipital nerve compromise. This would be suggested by the presence of pain and sensory symptoms such as numbness or tingling. These symptoms would have to be in the appropriate distribution of one of the greater occipital nerves. The Medical Assessors considered that although her symptoms were not typical, in that she had no symptomatic sensory complaints, her pain followed the expected distribution of the right greater occipital nerve. She reported that her head symptoms, which she describes as "skull pain", and her neck pain always occurred together. The Panel therefore considered that her skull pain and occipital nerve symptoms were related to a cervical spine injury, rather than representing separate pathology.
5. The greater occipital nerve is a branch of the C2 nerve root. The means of assessing a C2 nerve root condition complicating a cervical spine condition are explicitly dealt with under cl 6.139 of the Guidelines,

"6.139 Spinal injury causing sensory loss at C2 or C3 must be assessed by first using Table 23 (page 152) of the AMA 4 Guides, rather than classifying the injury as DRE cervicothoracic category III (radiculopathy). The value must then be combined with the DRE rating for the cervical vertebral injury."

1. Table 23 of the AMA 4 Guides is further qualified by Table 20 (for sensory nerves, the greater occipital nerve has no motor function). The Medical Assessors noted that she had pain, reported no sensory symptoms, but had some decreased sensation on sensory testing. It was also noted that she had no interference with activity from her head symptoms. The Medical Assessors therefore considered that the correct classification of her peripheral nerve symptoms was class 2. This represents a 1-25% sensory impairment. Following the procedure outlined in Table 20b and section 4.4e of the AMA 4 Guides, the WPI is 25% (Table 20, highest value of range selected) of 5% (Table 23). This is 1.25% which rounds down to 1%.
2. The Panel noted the prior injury to the head and neck in the weeks preceding the subject motor vehicle accident. There are insufficient objective clinical details available to determine the pre-existing impairment, so its presence was ignored as per cl 6.31 of the Guidelines which states:

"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."

1. The Panel concludes that the claimant's injury caused by the motor accident results in a WPI of 1% which is not greater than 10%.
2. The certificate of Medical Assessor Cameron is revoked and a new certificate is issued at the front of these reasons.