MOTOR ACCIDENTS - Motor Accident Injuries Act 2017; assessment of permanent impairment; claimant was a front seat passenger; at-fault driver was travelling behind in the same lane at about 140 km/h; claimant's vehicle hit a metal crash barrier; claimant was conveyed by ambulance to the hospital where she underwent diagnostic scans; claimant began to experience flashbacks and nightmares; claimant has been prescribed anti-depressant medication and has been under psychological treatment for the last five years; claimant was involved in a subsequent motor vehicle accident in October 2018 when her vehicle was struck on the left side by the at-fault vehicle which ran a red light (the second accident); Held - certificate revoked.

REVIEW PANEL ASSESSMENT OF DEGREE OF PERMANENT IMPAIRMENT

Certificate issued under s 7.26(7) of the Motor Accident Injuries Act 2017 (the Act)

1. The Review Panel revokes the certificate of Medical Assessor Christopher Canaris dated

21 February 2024 and issues a new certificate determining that:

(a) the following injuries caused by the motor accident give rise to a permanent impairment of 7% and IS NOT GREATER THAN 10%:

• major depressive disorder - moderate severity.

1. Yosra Semawy (the claimant) was a front seat passenger in a car driven by her husband, together with their three children, returning from Wollongong to Sydney. They were travelling about 100 km/h as they entered the freeway. The at-fault driver was travelling behind in the same lane at about 140 km/h. Her vehicle tapped the back right of the vehicle in which the claimant was travelling, causing it to slide to the left and hit the metal crash barrier. The car spun out of control ending up in the middle traffic island. The other car flipped on its side. Ambulance, Fire Brigade and Police Officers attended. The claimant was conveyed by ambulance to Wollongong Hospital where she underwent diagnostic scans. The claimant discharged herself in the early hours of the morning due to the need to care for her baby. The family vehicle was written off.
2. The claimant began to experience flashbacks and nightmares. The claimant has been prescribed anti-depressant medication and has been under psychological treatment for the last five years.
3. The claimant was involved in a subsequent motor vehicle accident in October 2018 when her vehicle was struck on the left side by the at-fault vehicle which ran a red light (the second accident). Notwithstanding that her vehicle was caused to spin around, the claimant says that the second accident was much less severe than the first (subject) motor accident.
4. Allianz (the insurer) indemnifies the owner and/or the driver of the at-fault vehicle for liability to pay to the claimant any damages under the Motor Accident Injuries Act 2017 (the Act). The insurer declined liability for payment of statutory benefits beyond twenty-six (26) weeks on the basis that all of the claimant's accident-related injuries relevantly are threshold injuries for the purposes of the Act. The insurer also declined to concede that the 10% whole person impairment (WPI) threshold is exceeded.

1. As there is a dispute between the parties about the degree of permanent impairment under Schedule 2, cl 2(a) of the Act, the claimant was referred to Medical Assessor Christopher Canaris for assessment. Medical Assessor Canaris certified on 21 February 2024 as follows:

The following injuries caused by the motor accident give rise to a permanent impairment of 9% and IS NOT GREATER THAN 10%:

Medical Assessor Canaris found 7% on the psychiatric impairment rating scale (PIRS) to which he added 2% to adjust for treatment effects. Medical Assessor Canaris stated that, while there is evidence of self-limiting symptoms of anxiety and depression in the past, these appear to have resolved completely prior to the subject accident. There is consequently no apportionment.

1. Medical Assessor Canaris issued a certificate for the second accident which was in the same terms as the certificate for the subject accident.

1. Medical Assessor Garvey certified on 25 November 2018 as follows:

C4/C5 and C5/C6 mild disc bulging without annular tear or disc protrusion is a minor injury. There is no evidence of radiculopathy on physical examination, so it is considered a minor injury under the definition

L4/L5 and L5/S1 early disc bulging without focal disc protrusion or annual tear is a soft tissue injury. There is no evidence of radiculopathy on physical examination. This is a minor injury under the definition.

Right shoulder - subacromial/sub-deltoid bursitis is a soft tissue injury of synovial membrane and is a minor injury.

Left shoulder - subacromial/sub-deltoid bursitis, Biceps tenosynovitis are soft tissue injuries of synovial membranes and are considered minor injury under the definition

are MINOR INJURIES for the purposes of the Act.

1. Medical Assessor Thomas Newlyn certified on 18 March 2019 as follows:

is not a MINOR INJURY for the purposes of the Act.

The Panel assumes there was no application for a review of that certificate.

1. The claimant sought a review of Medical Assessor Canaris' certificate, on the grounds that the medical assessment was incorrect in a material respect, under s 7.26 of the Act. The claimant relied on the particulars set out in the application and supporting documentation. The claimant brought the application within the time prescribed by s 7.26(10) of the Act and cl 34 of Procedural Direction PIC 7 (28 days).
2. The claimant submits that Medical Assessor Canaris' certificate is incorrect in a material respect for his failure to provide adequate reasons why he disagrees with the claimant's IME Dr George, that the claimant suffers from persistent depressive disorder, for which Dr George assessed 15% WPI. The claimant submits that the reasons of the Medical Assessor are unclear and vague.
3. It is further submitted by the claimant that Medical Assessor Canaris failed to have proper regard to the evidence of impairment and erred in respect to the determination of WPI. The claimant particularises objections to each of the assessments made by Medical Assessor Canaris under the categories of self-care and personal hygiene, social and recreational activities, as well as adaptation under the PIRS. In relation to adaptation, the claimant submits that Medical Assessor Canaris failed to consider the role of the claimant in her husband's business and her adaptation.
4. The claimant' application for review was opposed by the insurer on various grounds. As those submissions were not accepted by the President's delegate, it is not necessary to state them in detail. Briefly, they can be summarised as follows:

(a) The insurer notes that Medical Assessor Canaris' certificate is wholly consistent with the earlier Certificate of Medical Assessor Thomas Newlyn who also diagnosed post-traumatic stress disorder only. The insurer says the two certificates confirm that the claimant's injuries meet the criteria of post-traumatic stress disorder and that no review application was lodged in relation to Medical Assessor Newlyn's certificate.

(b) The insurer submits the claimant's assertion that the Medical Assessor failed to properly consider the report of Dr Graham George is incorrect and appears to be the primary basis for the review application. Particulars are given of the consideration that Medical Assessor Canaris gave to the report of Dr George and his suggested diagnosis of persistent depressive disorder (Dysthymia).

(c) The insurer submits that it is not a proper ground for review that the claimant's opinion on the PIRS class ratings is different from those of the Medical Assessor who took an extensive history and whose reasons disclose his actual path of reasoning.

(d) The insurer notes that Medical Assessor Newlyn and Medical Assessor Canaris came to the same conclusion in finding that the claimant had only sustained post-traumatic stress disorder and that a review would result in the same outcome.

1. President's delegate Stephanie Wigan issued a Determination of an Application for Review of a Medical Assessment on 19 April 2024 which stated the satisfaction of the President's delegate that there is reasonable cause to suspect that Medical Assessor Canaris' assessment was incorrect in a material respect. The basis of that decision was stated to be the applicant's submission that the Medical Assessor came to an incorrect assessment of the claimant's current impairment in accordance with the PIRS scale in relation to self-care and personal hygiene and adaptation. Accordingly, the claimant's review application was accepted.
2. The Panel is to reassess the claimant's psychiatric condition and injury. Pursuant to cl 128(1) of the Personal Injury Commission Rules 2021 (PIC Rules), the Panel is to conduct and determine the proceedings, in accordance with procedures determined by the Panel.
3. The Panel notes that the Medical Assessors on the Panel are required, in accordance with the Guidelines, to determine if the claimant has a psychological or psychiatric injury caused by the accident, and then make a diagnosis of that injury.
4. The Medical Assessors may, in their clinical judgment, diagnose a condition, in accordance with DSM-5, that is the same as, or different to, the diagnosis of Medical Assessor Canaris or the diagnoses of the treating doctors or Medico-Legal experts qualified by the parties, or the particular diagnosis that may have been included in the application or reply form.
5. Having a made a diagnosis, the Panel will then proceed to undertake an assessment of the whole person impairment (WPI), resulting from that injury.
6. As the claimant alleges that she suffered further psychological or psychiatric injury in the second accident, giving rise to further WPI, the Panel will be guided by the Oakley principles, as explained in Slade v Insurance Australia Limited t/as NRMA [2020] NSWSC 1031 per Wright J which, relevantly for present purposes, are to be effect that:

(a) where the further injury or impairment results from a subsequent incident, which would not have occurred had the claimant not been in the condition caused by the earlier motor accident, the added damage should be treated as caused by the earlier motor accident. In this situation, paragraph 6.34 of the Guidelines is not engaged, because the "injury or condition" is not "unrelated";

(b) where the further injury or impairment results from a subsequent incident, which would have occurred even if the claimant had not been in the condition caused by the earlier motor accident, but impairment is sustained or is greater because of aggravation of the earlier injury, the additional impairment resulting from the aggravated injury should be treated as caused by the earlier motor accident;

(c) where the further injury or impairment results from a subsequent incident, which would have occurred even if the claimant had not been in the condition caused by the earlier motor accident, but the impairment sustained includes no element of aggravation of the earlier injury, the subsequent incident and further impairment should be regarded as causally independent of the earlier motor accident;

(d) In the latter two situations, paragraph 6.34 of the Guidelines is engaged because the "subsequent..... injury or condition" is "unrelated" to the first motor accident, as that expression is to be understood in that paragraph. The Oakley principles provide a structure of analysis which is of assistance when applying the approach referred to in paragraphs 6.5 to 6.7 and 6.34 of the Guidelines and s 5D(1)(b) of the Civil Liability Act 2002.

1. The Panel is aware of the instruction given by his Honour in Slade that a necessary path of the Panel's task is to consider, in the light of the medical evidence, in to which of the three Oakley this case falls and then to determine the extent of the relevant causal connection between the WPI at the time of assessment and the subject motor accident.

1. A medical assessment matter is determined in accordance with Division 7.5 of the Act. The matter is determined at first instance by a Medical Assessor pursuant to and, on review, by a Review Panel consisting of two Medical Assessors and a Member assigned to the Motor Accidents Division of the Personal Injury Commission (Commission).
2. Part 5 of the Personal Injury Commission Act 2020 (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.[1]
3. Rules 127 to 130 of the Personal Injury Commission Rules 2021 (the 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.[2]
4. The review of the medical assessment is by way of new assessment of all the matters with which the medical assessment is concerned.[3]
5. All members of the Review Panel had no previous involvement with the claimant or with this matter.

1. Causation of injury is addressed in the Guidelines as follows:

"6.5 An assessment of the degree of permanent impairment is a medical assessment matter under cl 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 AMA 4 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 AMA 4 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 worsening of the impairment, which is a medical determination.
2. The alleged factor did cause or contributed to the worsening of the impairment, which is a non-medical determination.

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

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. See Briggs v IAG Limited t/as NRMA Limited.[4] See also Insurance Australia Limited t/as NRMA Insurance v Trkulja [2023] NSWSC 956,[5] wherein his Honour Justice Wright stated at (35):

"The question of causation of injuries was not dealt with in Part 5 of the Guidelines but causation was addressed in Part 6, which related to assessment of permanent impairment. There is no reason to think that different principes were intended to be applied when a medical assessment was being made in relation to causation of minor injuries."

1. Wright J then described the Panel's role in a medical review which is to:

"Consider whether the motor accident did cause or contribute to (the claimant's condition). This requires, not a consideration of material derived as a result of an internet search... but rather a consideration of the material referred to in 5.6 of the Guidelines, namely all the evidence available to the Panel, including all relevant findings derived from:

(1) a comprehensive, accurate history, including pre-accident history and pre-existing conditions;

(2) a review of all relevant records available at the assessment;

(3) a comprehensive description of the injured person's current symptoms;

(5) diagnostic tests available at the assessment, noting that imaging findings that are used to support the assessment should correspond with symptoms and findings on examination."

1. The words "in the circumstances" in the context of whether the treatment is "reasonable and necessary" must refer to the particular circumstances of the claimant. This is because Schedule 2 of the Act refers to treatment "provided or to be provided to the claimant".
2. The test of "reasonable and necessary in the circumstances" does not direct attention to the relationship between the accident and the treatment. That issue arises from consideration of whether treatment "relates to the injury caused by the accident".

1. The parties have presented their respective bundles of documents upon which they rely. The Review Panel (Panel) has read all the documentation. If a particular document is not referred to by the Panel, this does not mean that the Panel, or a Panel Member, has not read it, nor taken it into consideration. The same principle applies to parties not referring to, nor specifically relying upon, a document in their own bundle and submissions.
2. The fact that evidence is not referred to in these reasons does not mean it has been overlooked. It is not required that each piece of evidence be mentioned. The Panel is not required to "analyse every piece of information from every opinion contained in a document with which it was provided". The Panel has come to its own conclusions and has taken its own history.

1. The claimant relied upon the following material which the Panel has considered:

These submissions are direction to the second accident on 12 October 2018.

MRI report of cervical spine and ultrasound of bilateral shoulder

This certificate relates to the second accident but is in identical terms to the previous certificate relating to the first (subject) accident.

The Panel notes this decision relates to the certificate of Medical Assessor Canaris pertaining to the second accident.

DRS Medical Assessment Certificate - minor injury (psychological)

Medical Assessor Newlyn certified that the subject accident caused the claimant to suffer a Post-Traumatic Stress Disorder which is not a minor injury for the purposes of the Act. Under the heading Causation, Medical Assessor Newlyn said as follows:

"Ms Semawy had no psychiatric symptoms before the February motor accident. The post-natal depression symptoms of 2014 had remitted spontaneously. She developed psychiatric symptoms immediately following the accident of 11 February 2018 beginning with an Acute Stress Disorder that progressed to post-traumatic stress disorder. With brief psychological counselling, the post-traumatic stress disorder remitted before the October 2018 motor accident that has resulted in the development of further psychiatric symptoms."

Medical Assessor Newlyn said that the claimant's post-traumatic stress disorder, which is not a minor injury, has resolved.

Dr George noted the history of the first and second motor accident. Dr George opined that the first accident appears to have been most severe and caused the most psychiatric sequalae. He gave a diagnosis under DSM-5 of chronic post-traumatic stress disorder and persistent depressive disorder. His assessment of whole person impairment (WIP) under the psychiatric impairment rating scale (PIRS) for each accident was as follows:

Ms Semawy's presentation is consistent with that of Adjustment Disorder with Mixed Anxiety and Depressed Acute Mood. It also appears that Ms Semawy presents with features of post-traumatic stress disorder, including sleep disturbances, increased irritability/outbursts, impoverish concentration, hypervigilance, and exaggerated startled response.

I believe that Ms Semawy's condition is not the result of the motor vehicle accident on 12 October 2018 but (is) a re-triggering of psychological symptoms from a previous motor accident on 11 February 2018. I believe that Post-Traumatic Stress symptoms in particular may have already been present from the first accident given the nature and severity of the first accident. The pre-existing psychological symptoms from the first accident Ms Semawy reported to have significantly improved prior to the second accident.

Given the nature and severity of the second accident, that Ms Semawy was exposed to an event that post a serious threat to death or serious injury of not only herself but her children, that would have invoked a sense of intense fear and helplessness, I believe that it is a high probability that Ms Semawy would have experienced symptoms of similar nature and severity (i.e. Depression, Anxiety and Post-Traumatic Stress based symptoms) even without any pre-existing conditions.

Ms Semawy's presenting symptoms are consistent with a diagnosis of post-traumatic stress disorder and persistent depressive disorder in accordance with the DSM-V. Ms Semawy's diagnosis are confirmed and corroborated by her other treating and assessing medical professionals.

The prognosis for post-traumatic stress disorder and persistent depressive disorder varies, but with appropriate and timely treatment, significant improvement in symptoms is achievable. However, the extent of recovery is contingent upon Ms Semawy's adherence to the treatment plan, the severity of the trauma, the effective utilisation of self-management skills and reduction of ineffective coping mechanisms.

Confirmation as to the causal nexus between the accident and our client's injuries

There is a clear causal nexus between the motor accident on 11 February 2018 and 12 October 2018, and the client's diagnosed psychological conditions (post-traumatic stress disorder and persistent depressive disorder ). The accident served as the precipitating factors for the subsequent development of these mental health disorders. There have been on prior or subsequent injuries and/or accidents to the two accidents on 11 February and 12 October 2018.

The client's pre-existing changes and/or abnormalities were aggravated and/or accelerated and/or exacerbated by these subject accident

After a thorough examination of the available information, it is my professional opinion that Mrs Semawy's pre-existing changes and abnormalities have been aggravated and exacerbated by the motor accident on 12 October 2018. The initial accident (11 February 2018), being the most severe of the two accidents, is identified as the primary catalyst for the onset of post-traumatic stress disorder symptoms and has played a pivotal role in shaping the trajectory of her psychological wellbeing.

Furthermore, the subsequent accident within the seven month period appears to have been a contributing factor in the development of persistent depressive disorder. It is not uncommon for individuals with the history of trauma, such as the one experienced by Ms Semawy, in the first accident, to be at an increased risk for the onset of additional mental health challenges. In this case, the second accident has likely acted as a compounding stressor, further exacerbating the client's psychological distress and contributing to the emergence of persistent depressive disorder.

The cumulative effect of these traumatic events has had a profound impact on Mrs Semawy's mental health, and it is crucial to recognise the interconnectedness between the accidents and the evolution of her symptoms.

1. The insurer relied upon the following material which the Panel has considered:

• Insurer's submission in reply to review application dated 28 March 2024 (February 2018 motor accident).

• Insurer's submissions in reply to review application dated 27 March 2024 (October 2018 motor accident).

• Insurer's submissions in reply to WPI dispute dated 18 July 2023 (February 2018 motor accident).

(a) The insurer submits there needs to be proper delineation and apportionment between the two accidents based upon the reliable historical evidence.

(b) The insurer notes the medical evidence relating to post-natal depression and anxiety prior to the February 2018 accident.

(c) The insurer notes there was no mention of psychological symptoms in the claimant's application for personal injury benefits relating to the February 2018 accident.

(d) The insurer references entries in the clinical records relating to injury suffered in the February 2018 accident and imaging performed on 2 May 2018 relating to the cervical spine, lumbar spine and both shoulders. The GP notes recorded continued complaint of pain in the neck, back and shoulder, as well as psychological complaints.

(e) The insurer references various consultations with the treating psychologist relating to severe Anxiety and Depression with signs of Active Stress Disorder relating to the first accident.

(f) The insurer notes that the claimant was seen by Medical Assessor Garvey on 25 November 2018 in relation to a minor injury dispute. Medical Assessor Garvey confirmed that the injuries to the cervical spine, lumbar spine and both shoulders were minor injuries and had resolved. He found no evidence of radiculopathy, annular tears or disc protrusions.

(g) The insurer references the certificate dated 18 March 2019 by Medical Assessor Thomas Newlyn who confirmed that the claimant's post-traumatic stress disorder was not a minor injury. The claimant informed the Medical Assessor that she had a significant personality change following the first accident and that the subsequent accident made everything worse. Medical Assessor Newlyn opined that the claimant had suffered an Acute Stress Disorder that progressed to post-traumatic stress disorder following the first accident which had remitted with brief psychological counselling, before development of further post-traumatic stress disorder symptoms following the second accident.

(h) The insurer references clinical notes of treatment at the Psych Central Psychological and Consulting Services following the second accident.

(i) The insurer notes the claimant was examined by Dr Michael Hong, psychiatrist, on 3 August 2021 for the insurer. Dr Hong opined the claimant suffered from anxiety and post-traumatic stress disorder from the first accident, which was aggravated by the second accident. The claimant reported to Dr Hong the first accident had a much bigger impact than the second accident. Dr Hong opined the claimant had not yet reached the maximum medical improvement for the purposes of a WPI assessment, and she would need to undertake further treatment before her injuries could be viewed as stable.

(j) The insurer notes it subsequently had the claimant examined by Dr Graham Vickery, psychiatrist, whose report dated 7 March 2023 noted ongoing symptoms of rumination, disturbed sleep and reduced hygiene. The psychological symptoms resulting from the first accident reportedly were exacerbated by the second accident. Dr Vickery was unable to provide a WPI assessment as he believed that the claimant's injuries were not stable. He thought the claimant would need further psychological treatment and use of anti-depressant medication for another twelve months.

• The claimant relies upon the report of Dr Graham George dated 13 September 2022. Dr George diagnoses chronic post-traumatic stress disorder and persistent depressive disorder as a result of both motor accidents. 15% WPI is given for each accident (thus a total of 30%). The insurer submits this is incorrect methodology and that the historical impairments from psychological symptoms (as suppose to physical) need to be independently assessed, apportioned and appropriate deductions applied.
• The insurer submits a number of the PIRS class scores given by Dr George are exaggerated. Dr George reports the same level of functioning across both accidents, despite commentary of the claimant that the second accident didn't bring much change to her symptoms. This is also at odds to the self-reports of the second accident as described to Medical Assessor Newlyn.
• The insurer also does not support the diagnosis of post-traumatic stress disorder. With mind to the determination in Jarvis v Allianz Australia Insurance Limited [2022] NSWSC 161, in order to meet the DSM-5 Criteria for post-traumatic stress disorder , there must be exposure to stressors such as death, threatened death, actual or threatened serious injury. The minor nature of the subject February 2018 accident, where the claimant's vehicle was clipped in an overtaking attempt, cannot meet the severity of an accident that meets the Criteria A for a post-traumatic stress disorder diagnosis.
• The insurer submits that close scrutiny of the Class ratings related to psychological symptoms, and when also applied with apportionment deductions, demonstrates that the clamant would not have a medium Class III rating and with the cumulative scores would therefore not exceed 10% WPI.
• Insurer's submissions in reply to WPI dispute dated 18 July 2023 (October 2018 accident).

The insurer makes the same submissions as in relation to the first accident.

Documents in both claims - February 2018 and October 2018

• Clinical records of Karitane.
• Clinical records of Mr Chafie Awit, psychologist.
• Clinical records of Greenacre Sports Medine Clinic.
• PIC Certificate of Assessor Garvey dated 25 November 2018 re threshold injury dispute.
• Report of Dr Michael Hong, psychiatrist, dated 6 August 2021.

• Report of Dr Graham Vickery, psychiatrist, dated 7 March 2023.

1. The report of the Medical Assessors is as follows:

M21197/24

1. The claimant was medically examined by both Medical Assessors on 2 July 2025. The examination report is as follows.
2. The claimant was assessed by Medical Assessors Baker and Chew. The claimant attended via MS Teams and was assessed alone. She said she was 38 years of age. That she was living with her husband aged 40 years and her three sons aged 13, 11 and 8 years. The claimant said her husband and sons were all well at the time of this examination. Her children were attending school and her husband worked as a cabling technician.
3. The claimant was born in Auburn District Hospital in 1987. She was the second of five siblings. She had an elder brother, a younger brother and two younger sisters. She said that her father was born in Iraq, he was about 65 years of age. Her mother was born in Lebanon; she was 62 years of age.
4. The claimant reported that she enjoyed school. She had attended Melek Fahd Islamic school from Kindergarten to Year 11 located in Greenacre. In Year 12 she attended Bellevue Hills Girls High School.
5. The claimant said she had enjoyed the following at school, soccer and netball as her sports. She said she was never injured playing her school sport.
6. The claimant said that she was never exposed to any childhood trauma abuse or neglect.
7. The claimant said she commenced studying at UNSW after completing her school education. She successfully completed all her first year, semester one courses. She then married and had her first son. She did not continue with her university education as she was to have three sons in total of the subsequent years. She said she married for love.
8. The claimant said that she had no medical or psychological conditions prior to the birth of her first child. She said she would on occasion have seasonal hay fever which was self-limiting and resulted in her not having any impairment or sinus conditions.
9. The claimant said that between 2010 to 2011 she had worked in customer service for a local bank.
10. The claimant said that all her children were born naturally. She said that she had suffered from postnatal depression after the birth of her first son. She said that she attended Karitane on two occasions a few months apart as her first-born son had difficulty sleeping. She stated that she received evidence of based psychological treatment and had not been prescribed antidepressant medication.
11. The claimant said that she had received further psychological treatment with her psychological team after the birth of her second son. She stated she had the baby blues at that time. She said she had difficulty with settling her children to sleep. She reported she had been able to recover from her low energy, depressed mood, difficulty sleeping and irritable with the advice and mothercraft services provided through Karitane. She said she was not impaired by her brief periods of depression after the birth of her first son.
12. The claimant reported that she had a third son, and all three children were in the car when she had the first motor accident on 11 February 2018.
13. The claimant said that prior to the first motor accident she was fully independent in her self-care and personal hygiene. She said that she was able to care for her three children, her husband and the family home. She said that she was able to organise, cook and maintain health nutrition for her family. She was able to perform all the laundry, cleaning and vacuuming of her rented home.
14. The claimant said that she would participate in celebrations with her extended family, during Ramadan in the evening for visits and at Eid. She said that she participated in recreational activities with her sons. The family enjoyed frequent 10 pin bowling outings, going to see new movies at the cinema and playing soccer. She said she would watch her sons play soccer. They would start this sport at an early age in keeping with her husband's sporting experience. The claimant said that she enjoyed attending cafes and restaurants with her family and friends.
15. The claimant said she had commenced learning to drive a car as soon as she was legally of age. She said she had no difficulties learning to drive. She said she progressed through the staged licencing for NSW drivers without difficulty. She said that she had never had any prior speeding offences or driving whilst using a mobile phone offence. She said she had never had a motor accident prior to the first motor accident on 11 February 2018.
16. The claimant said that she was happy in her marriage. She said she was enjoying her life. She enjoyed caring for her children and contributing within extended family. The claimant reported she enjoyed her extended family and her friendship circle. She said she would participate in family events and birthdays of her children.
17. The claimant reported her concertation was normal and she was able to concentrate on the back-office administration tasks. She was able to read and talk in both English and Arabic. She was able to enjoy watching her favourite television series and movies without difficulty with remembering the narrative or story lines.
18. The claimant said that she was happy with her life and her role as mother, wife and contributor to her husband's business. She said she would perform "back office" work for her husband so he could spend more time providing billable services for his clients.
19. The claimant said she did not drink alcohol. She said she did not gamble. She was not allergic to any medication she had been prescribed. She did not smoke tobacco. She did no use illicit substances. She had no history of illicit substance use. She had no history of driving under the influence of a substance.
20. The claimant said that prior to the motor accident she was fully occupied caring for her children and assisting her husband in his small business.
21. The claimant said she had never lodged any personal injury claims in relation to her employment. She said the 11 February 2018 motor accident resulted in her first personal injury claim.

1. The claimant said that she and her husband had travelled from their home to Wollongong to visit her brother-in-law for a visit earlier on the same day as the motor accident. All her family was in the car. She said that her sons were in child restrains appropriate to their ages. Her children were in the back seat. She was seated in the passenger seat and her husband was driving.
2. The claimant said that the family was travelling home between 11.00 pm to 11.30 pm the same day. Her husband was driving within the speed limit of 100 kph. The claimant said that the other car was been driven by a woman who was later said to be intoxicated. She said the other car was travelling at about 145 kph. The other car hit the back panels of the claimant's car. The claimant's car spun and came to rest on a grass island. The other car flipped onto its roof.
3. The claimant said she her was shocked by the motor accident. She said she heard the noise of the impact of the cars. She said she then thought, "We are going to die!" She said the child had a DVD player playing children's stories in the back of the car. During the accident the player flew through the cabin of the car from the back seat into the front and struck the claimant in the face. She said she thought the player hitting her caused her to have a cut upper lip.
4. She said her husband assisted her and her children to a safer location high up and away from their car.
5. The claimant said her husband then went to investigate the other driver's condition. She said that her husband was able to speak with the other driver. They exchanged details. Whilst watching her husband the claimant saw the severe damage to the car and she became emotionally overwhelmed and distressed. She said she and the intrusive distressing thought, "How did we survive?"
6. The claimant reported that her husband called his brother. The ambulance and police attended. She was placed in a neck brace and on a trolley by the ambulance officers. She said as she was being positioned into the ambulance she heard on of her sons say, "Is mummy going to die?"
7. The claimant said she was unsure how her children or husband travelled but she thought they were transported by her brother-in-law to his home in Wollongong.
8. The claimant said that she looked at her foot and she could see the flesh under the skin of her left foot. She said she also had bleeding in the site of her open wound. She said her leathers were also ripped as were her leather gloves.
9. The claimant said she was waiting at Wollongong Hospital's emergency room. She said that she was waiting on MRI Scan but became too agitated to wait. She said it was 3 a.m. She became distressed and was worried that her baby son needed to be breast feed. She discharged herself from hospital and her brother-in-law took her to his home where her children were such that she could feed her third son who was a baby. She said her third son had continued to sleep close to her since the 11 February 2018 motor accident until recently. She said her third son and ongoing sleep difficulties which she managed with her mothercraft skills she had learnt from Karitane.
10. The claimant said that after caring for her children on the night of the first motor accident she then noticed she had a swollen mouth and lip. She said she did not have stitches. Whilst at her brother-in-law's home, she became increasing distressed tearful and agitated and was supported by her husband.
11. The claimant reported that she and her family were driven home by their brother-in-law in the middle of the following day. She said that she began to suffer from neck stiffness that was affecting both her shoulders. She reported that she had bruising on her face from where the DVD player had hit her during the motor accident.
12. The claimant attended her general practitioner, and she had her neck and shoulders investigated by MRI scan. She said she had inflammation and bruising. She reported she had not suffered from any fractures. She was not referred to a surgeon and her condition was managed conservatively.
13. The claimant did report pain in her neck, shoulders and back. Her presentation in relation to pain did not demonstrate and excessive pain behaviours or somatic symptom disorders.

Psychological symptoms caused by the motor accident

1. The claimant reported that she had developed psychological symptoms because of the motor accident. She developed the following symptoms consistent with posttraumatic stress disorder:
   1. The motor accident on 11 February 2018 was sufficient to meet criterion A for posttraumatic stress disorder.
   2. The claimant was initially avoidant of driving and traveling in motor cars after the motor accident in February 2018.
   3. The claimant remained hypervigilance when driving or traveling as a passenger and reported more distress when in heavy traffic or near heavy vehicles.
   4. Increased angry outbursts towards husband
   5. Poor concentration with her not persisting with the reading if stories to her children or novels for herself in either Arabic or English. She also lost interest in watching television programs.
   6. Difficulty feeling happiness with her children
   7. Loss of interests in attending extend family celebrations, movies and tenpin bowling
   8. Increased social isolation
   9. Difficulty with feeling positive feelings towards her husband
2. The claimant reported that she also had developed depressive psychological symptoms because of the motor accident in February 2018. She developed the following symptoms consistent with Major depressive disorder:

The following symptoms have been present during the same two-week period and represent a change from previous functioning with the claimant experiencing a depressed mood as well as the following:

• Depressed mood most of the day, nearly every day, as evidenced by the claimant's feelings of worthlessness.
• Insomnia nearly every night with initial and middle insomnia where she would wake from sleep at about 3.00 am and not return to sleep.
• Diminished ability to concentrate with increased indecisiveness when attempting to make decisions.
• Intrusive distressing depressive rumination that "I will have more accidents."
• Fatigue with loss of energy nearly every day.

1. The claimant was assessed by her general practitioner, and she was referred to a physiotherapist, osteopath and psychologist. She reported that she preferred been treated by the osteopath as she would receive hydrotherapy and acupuncture which she found beneficial. She also attended her physiotherapist once every 8 weeks. Hs stated that her pain was managed with Nurofen. The claimant reported that she continued to experience pain affected her shoulders, neck and back.
2. The claimant said she was referred to a male clinical psychologist for psychological treatment of her psychological injury sustained in this motor accident. She attended this psychologist for three sessions. She reported that rapport with the psychologist was not establish during these treatment sessions.
3. The claimant was the referred to a second psychologist. She reported that she did establish rapport with this female clinical psychologist. She reported that she was attending initially about fortnightly and the monthly. She reported that she attended continuously for about 5 years after the first motor accident at a frequency of about 2once every two months. The claimant reported she was treated with cognitive behavioural therapy, relaxation skills training and mindfulness.
4. The claimant was reviewed by her general medical practitioner. She was referred to a psychiatrist. She reported that she became pre-occupied with the care of her busy family and could not find time to attend. She reported that she was initially prescribed Sertraline (Zoloft) 50mg daily for the first year after the initial motor accident. Then she was prescribed Mirtazapine (Avanza) 30mg at night, until recently when she was again changed to Desvenlafaxine (Pristiq) 50mg daily. She said she was not referred to a psychiatric hospital for treatment as an inpatient. She said she was not referred for repetitive transcranial magnetic stimulation for treatment of her psychological injury.

Psychiatric Impairment Rating - First Motor accident - 11 February 2018.

1. The claimant was asked about how her activities of daily living and psychological functioning had changed since the first motor accident and before the second motor accident.

1. The claimant reported that she was independent in her self-care and personal hygiene. She said she was more reliant on her mother and husband to assist her. She reported that her husband initially took about three days off work to reorganise the family. She continued to care for her children's nutrition. She continued to supervise her children's bathing, and personal hygiene. The claimant's husband helped with the cleaning of the home and groceries and some prepared food was provided by the claimant's mother. The claimant said she stopped breast feeding as her energy levels were too low and she required more flexibility to assisting her children. The claimant was assessed as having a class 2 mild impairment for this table of functioning.

1. The claimant reported that she had becoming increasingly isolated and was not attending family events. She said she was less interested in her children's sport and attending her children's sport. She reported her interest in watching television and was also reduced. She reported that she would still organise and recognise her children's birthdays within the family home. The claimant was assessed as having a class 2 mild impairment for this table of functioning.

1. The claimant reported that she initially stopped driving however the children's need resulted in her sharing driving and transport with her mother. She said her mother would assist with picking up the children. The claimant said she was able to drive in local and familiar locations, after the first motor accident in February 2018. The claimant was assessed as having a class 2 mild impairment for this table of functioning.

1. The claimant said that she was more irritable and agitated after the first motor accident. She said that she had strain in her marriage. She was not expecting to become separated or divorced from her husband. She reported that she was less tolerant of her children's noisy play and that she had less times positive feeling towards her children. The claimant reported that she had tension in her relationship with her other as her mother was required t assist her during this time. The claimant was assessed as having a class 2 mild impairment for this table of functioning.

1. The claimant reported that prior to the motor accident she would read stories to her children in both Arabic and English. She said that she enjoyed reading novels in her own time as well. Since the first motor accident she was less interested in reading to her children. She reported she could read however her concentration would wane after about thirty minutes. She reported her pace of reading was slowed. She reported that her interest in reading had decreased, and she lacked persistent to read for long periods as she had before the February 2018 motor accident. The claimant was assessed as having a class 2 mild impairment for this table of functioning.

1. The claimant reported that she had difficulty continuing her work role for her husband. She said she was slow in her book-keeping, and other organized activities which she had to do to support her husband whilst he worked in the field. The claimant reported that her care of reh children was less. She reported that she had improved in her childcare and was spending more time caring from her children as her psychological injury had stabilised before the second motor accident in October 2018. The claimant was assessed as having a class 2 mild impairment for this table of functioning.

The claimant reported that she was driving with her eldest son was stilling in the front passenger seat and the two younger children were restrained in the back seat in their age-appropriate travel seats. She said this second motor accident happened about six months after the first accident.

The claimant said that she was returning from her mother's house with her children. The family was heading home. The claimant said she was driving through a traffic light-controlled intersection. She said she had the right of way with the green light in her favour. She reported that without warning, the other driver hit the left side of her car at speed.

The claimant reported that her car spun 180 degrees and was facing in the opposite direction after her vehicle came to rest. The claimant reported that she became very distressed. She said her first thoughts were of a depressive theme, "I'm going to keep having accidents!" The other driver approached her after the accident. The two women exchanged details.

The claimant said that an ambulance was called as her eldest son and injuries to his left shoulder, knee and legs. The claimant's son was not transferred to hospital. A tow-truck was called as her car was not drivable. The car was subsequently not repaired by the insurer and was "written off".

The claimant said that her two smaller sons were not injured in the motor accident as they were protected in their "baby-seats" in the rear seat of the car. She then called for assistance from her father who at his home. The family were driven home by the claimant's father.

The claimant said she had been driving her husband's work vehicle when the second accident happened.

Aggravation of symptoms after second accident - 12 October 2018

The claimant reported that she had become more depressed and agitated since the second motor accident. She said that she was more distressed, anxious and hypervigilant. She described having frequent on going distressing intrusive depressive ruminations. She said she would not be able to stop these worries with her thinking, "I'm going to have more accidents!" "I made things worse for my children!" "I do enjoy my children playing soccer anymore."

The claimant reported her first son's physical injuries resolved with conservative care.

The claimant reported that her youngest son developed phobic anxiety after the motor accident. She said he was "afraid of the dark" and she would have him sleep close to her for many years in the main bedroom, where she and her husband both slept. The claimant reported that eh also had a fear of heights. The claimant said that her third son's phobic anxiety and only begun to settle over the few months prior to this examination.

The claimant reported that her second son was also injured in the motor accident. She reported that he would often "startle" to loud and unexpected noises. She said he was also slowly settling over time.

The claimant reported her sleep and self-esteem were poor since the motor accident. She described having to be more reliant on her mother and her husband. She described not been able to provide book-keeping for her husband as well as other "back office" duties. She said that her energy became low, and she could not concentrate since the second motor accident. The claimant described her loss of interest in pleasurable activities such as attending extended family events, socialising with her husband in public. She said her husband would take her sons to soccer and she would remain at home, as she preferred to isolate herself as she no longer enjoyed watching her sons' sport.

The claimant reported that she was less interested in participating in her children's games. Family events including, tenpin bowling and going to the cinema" all were stopped, as she could not remain in noisy areas or groups without becoming distressed.

Treatment after second motor accident - 12 October 2018

The claimant said that he attended her general practitioner, and she was referred to a psychologist for more cognitive behavioural therapy, mindfulness and relaxation skills training. She reported that rapport with the clinical psychologist was strained. She reported that the psychologist was repetitively prompting her to talk about the second accident. The claimant described becoming more distressed and unable to think without become more depressed in her mood with depressive themes and inappropriate guilt, that she was responsible for harming the children and making her husband's business life hard after his work vehicle was "written off".

The claimant reported that after about five sessions with the clinical psychologist, the claimant could not tolerant any more treatment with a focus on her trauma and she ceased attending.

The claimant reported that she had been treated with Sertraline, Mirtazapine and was currently prescribed Desvenlafaxine 50mg daily. She said that she had relived no benefit from her treatment with these medications. She said she was not referred to a psychiatric hospital for treatment as an inpatient. She said she was not referred for repetitive transcranial magnetic stimulation for treatment of her psychological injury.

The claimant reported that her current symptoms since the Octobre 2018 motor accident included the following:

• Poor sleep with the claimant waking every three hours.
• Recurrent and frequent nightmares of been spun 180 degrees and her son been injured in the motor accident.
• Increased irritability and outburst of anger towards her husband.
• Increased "snapping" at her children for noisy play which continued to distress her.
• Loss of interest in socialising with her husband at her sons' soccer games each Saturday.
• Loss of hope that she would recover from her psychological injuries.
• Loss of capacity to experience positive feelings such as happiness.
• Loss of interest in maintaining health nutrition with reduced appetite and cooking.
• Loss of interest in maintaining social network to her extended family.
• Poor concentration with loss of interest in reading in Arabic and English.
• Poor concentration with reduced capacity to quickly shift between Arabic and English whilst speaking as she could have prior to the October 2018 motor accident.
• Increased visits from her mother where she will attend her home three times each week to cook meals, shower the children and assist with laundry and cleaning.
• Frequent errors whilst attempting to help her husband in the back office resulting in her been asked to stop assisting by her husband in about 2021. Her work would cause increased confusion with her husband's accounts.
• Increased depressive ruminations of worthlessness and uselessness as a mother and wife.

1. The claimant presented as an agitated sullen and depressed woman who looked her stated age. She was wearing a traditional veil. The examination was for about 90-minute. The claimant reported pain but did not demonstrate any excessive pain related behaviours. She required breaks when she was tearful and she was provided with time to resettle when she experienced intrusive involuntary depressive themes such as, "I'm going to have more accidents." "I need to protect my children." "I'm responsible for the children being hurt" and "I don't enjoy the children like I did." before the second accident.
2. The claimant reported loss of joy and pleasure in her life. She said she was not as interested in intimacy with her husband. She said she would not manage her self-care and personal hygiene. She said she relied on support of her other and husband to support her care for her children. Her energy was low. She had a depressed mood most days for most of the day.
3. The claimant reported that she was no longer performing any "back office" business duties as requested by her husband she ceased work in his business in about 2021. She reported her depressive rumination included uselessness and worthlessness in her primary roles as a mother, wife and worker for her family. She said she had intrusive and distressing depressive thoughts, she did not report suicidal thoughts. She said her relationship with her husband was strained and her relationship with her children was strained and not as enjoyable as she had before the second motor accident.

1. Using DSM-5-TR the claimant's psychological injury was DSM-5-TR F32.1 Major depressive disorder - of moderate severity is defined as:

The following symptoms have been present during the same two-week period and represent a change from previous functioning with the claimant experiencing a depressed mood as well as the following:

• Depressed mood most of the day, nearly every day, as evidenced by the claimant's feelings of worthlessness.
• Markedly diminished interest with inability to experience pleasure in almost all activities for most of the day, nearly every day as evidenced by the loss of her role in her husband's business, loss of her interest in her self-care and personal hygiene and loss of interest sharing recreational and social activities with her husband and sons every week they play football.
• Insomnia nearly every night with initial and middle insomnia where she would wake from sleep at about 3.00 am and not return to sleep.
• Diminished ability to concentrate with increased indecisiveness when attempting to make decisions, perform complex book-keeping tasks and care of her sons.
• Intrusive distressing depressive rumination that "I will have more accidents."
• Fatigue with loss of energy nearly every day.

Posttraumatic stress disorder - cross over symptoms that were present at the examination included:

• Increased agitation and irritability towards the children due to their noisy play.
• Increased tension and agitation with her husband with inability to experience positive emotions.
• Hypervigilance whilst in a motor car and in traffic.
• Nightmares about motor accidents.

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

This criterion is met by the claimant not been able to return to work successfully and leaving work in 2021 with her husband due to her increased disorganised behaviour caused by her major depressive disorder symptoms.

The episode is not attributable to the physiological effects of a substance or to another medical condition.

This criterion is met as the claimant does not use illicit substances and does not have a substance use disorder.

The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

This criterion is met as the claimant does not have a history of any of these conditions.

There has never been a manic episode or a hypomanic episode.

This criterion is met as the claimant does not have a history of any of these conditions.

For the above reasons the claimant meets all the criteria required to diagnose DSM-5-TR F32.1 Major depressive disorder - of moderate severity.

1. The Medical Assessors note that the claimant had been diagnosed with posttraumatic stress disorder by clinicians as documented in the forwarded papers - however at the time of the examination the presence of the claimant's Major depressive disorder was clinically to the fore with residual post-traumatic stress disorder symptoms persisting on occasion during the examination. The claimant did have some symptoms of posttraumatic stress disorder such as recurrent nightmares, and negative cognitions. She did not have prominent clinical symptoms of post-traumatic stress disorder, for these reasons at the time of this assessment the use of DSM-5-TR criteria for cross-cutting symptoms of posttraumatic stress disorder was more in keeping with the clinical history of the claimant's psychological injury because of the motor accident.
2. The Medical Assessors note that the claimant did report pain in relation to her physical injuries. Her reports and behaviour during the examination were not excessive.
3. At the time of this assessment the claimant did suffer from pain. The Medical Assessors noted the following guidelines:
   1. 6.214 impairment due to physical injury is assessed using different criteria outlined in other parts of these Guidelines, and
   2. 6.215 the PIRS must not be used to measure impairment due to somatoform disorders or pain.

The Medical Assessors note that pain from any cause is excluded from assessment under these guidelines.

1. The Medical Assessors note that the history provided by the claimant and the nature of her psychological injury is more severe than defined using DSM-5-TR Adjustment disorders as defined starting at page 319 of the manual. At the time of this examination the diagnosis of adjustment disorder of any type was excluded where other clinicians have recognised major depressive disorder which had slowly increased in clinical presence and increased psychological impairment as assessed under PIRS.

1. The claimant was independent in her lifestyle, capacity to work, capacity to care for her three sons and socialise in her extended family network before the motor accident in February 2018. She had contributed to her husband's business by performing back-office duties before the motor accident in February 2018.
2. The claimant had suffered from depression before the February 2018 due to her first son's birth and poor sleep. She attended Karitane and was treated for her depression. Prior to the February 2018 motor accident she was not depressed, and her condition had entered full remission. The claimant was a confided mother and carer of her three sons as well as a confident bookkeeper and back-office assistance for her husband's small business.
3. The claimant was in a significant motor accident in February 2018. The claimant was improving in her level of functioning and had returned to driving with her three sons in the car when she was in a second motor accident in October 2018.
4. The claimant suffered from physical injuries due to both motor accidents.
5. The claimant had initially returned to her with her husband before her major depressive disorder was aggravated by the second motor accident in October 2018.
6. The nature of the motor accident in February 2018 could cause the representation of the claimant's major depressive disorder.
7. The Medical Assessors agree that the February 2018 motor accident did cause the manifestation of the claimant's symptoms of major depressive disorder.
8. The claimant reported a history of her improving medical functioning with her returning to drive and travel with her three sons. She was returning to work for her husband's small business in her usual role.
9. The Medical Assessors agree that the second motor accident in October 2018 could have caused the claimant's major depressive disorder to become aggravated by the event and cause deterioration in the claimants' functioning due to the aggravation of the psychological injury (major depressive disorder).
10. The Medical Assessors agree that the motor accident in October 2018 did cause an aggravation of the claimant's psychological injury with her Major depressive disorder becoming clinically to the fore because of the second motor accident.

Assessment of whole person impairment at examination (after October 2018 motor accident)

1. The claimant reported that she would have support from her mother who would cook meals for her and her children. The food her mother cooked would be frozen and eaten as pre-prepared meals when she was too low in her energy to make meals for her sons. She said that her sons were now 13, 11 and 8 years. She gave then chores. She said she would receive help with cleaning. She did not require prompting to shower or maintain her personal hygiene. She was able to supervise her sons' hygiene. She was independent in her self-care and personal hygiene.
2. For these reasons the claimant was assessed as mildly impaired. This is a class 2 impairment.
3. The claimant reported she had lost interest and no longer enjoyed attending family events such as her boys, soccer each weekend. She said she would not go with her husband and her boys to watch their games. She said she would be asked by her sons to attend however she was not interested and said she would refuse every time.
4. The claimant said she rarely attended extended family events or celebrations. She said that she had stopped attending cafes and restaurants to socialise with her husband in public.
5. For these reasons the claimant was assessed as moderately impaired. This is a class 3 impairment.
6. The claimant reported that she was able to travel in her local and familiar area. She reported she was distressed when driving. She stated she would be hypervigilant and have intrusive distressing depressive ruminations that she would have more motor accidents. She reported she restricted her travel to the minimum necessary.
7. For these reasons the claimant was assessed as mildly impaired. This is a class 2 impairment.
8. The claimant reported strain in her marriage. She reported that she was less able to feel joy, happiness and affection towards her husband and children. She reported that she would isolate herself from extended family and not join extended family social events.
9. The claimant was not expecting separation or estrangement from her husband or children.
10. The claimant did not report any domestic violence, periods of separation or community services caring for her children.
11. For these reasons the claimant was assessed as mildly impaired. This is a class 2 impairment.
12. The claimant reported she could not read Arabic or English stories to her children since the October 2018 motor accident. She said her concentration and pace of switching between Arabic and English was reduced. She reported she could not complete her book-keeping without making frequent simple errors that she had not made prior to the motor accident.
13. The claimant reported that she had stopped read Arabic as she was slower in this language. She reported that she was less able to remain interested, and she would abandon these tasks within a few minutes - prior to her completing stopping on request on her husband.
14. The claimant had stopped cooking from recipes as she would make errors and spoil the food.
15. For these reasons the claimant was assessed as moderately impaired. This is a class 3 impairment.
16. The claimant said she was unable to continue to organise her husband's small business back-office. She said she had attempted to return to this role during 2021 - however her pace of task completion was poor. She would make frequent errors that confused her husband and delayed the accounts been finalised. After an extended period of assistance from her husband - the claimant was removed from the family business by her husband.
17. The claimant received ongoing assistance from her mother in the care of her children she was performing few of the necessary mothercraft duties.
18. The Medical assessors assessed a Class 5 severe impairment as the claimant could not return to any mainstream role within the Australia jobs market either as a "back-office" work or as a childcare.
19. For these reasons the claimant was assessed as totally impaired. This is a class 5 impairment**.**

1. The Medical Assessors noted that the claimant had been diagnosed with various psychological conditions before the motor accident. The claimant said she had experienced depression after the birth of her first son. The claimant said she had been resilient and used medical and psychological services early. This early intervention by Karitane had the claimant to have two more sons, and work for her husband prior to the motor accident in February 2018.
2. The claimant said prior to the motor accident she had been successful in her roles as mother, wife and office worker for her husband.
3. The claimant said she was not permanently impaired by her the events she had experienced before the February 2018 motor accident.
4. The Medical Assessors agreed that claimant's Major depressive disorder in compliance with DSM-5-TR criteria was in full remission before the motor accident in February 2018.
5. For these reasons the Medical Assessor have not made any apportionment for pre-existing psychiatric impairment.

1. The claimant had received evidence-based psychiatric and evidence-based psychological treatment. The claimant was treated was not a psychiatric inpatient of a psychiatric hospital at any time since the February 2018 motor accident. The evidence-based treatment the claimant received after the February 2018 motor accident had enabled the claimant's functioning to improve without entering full remission prior to the October 2018 motor accident. The treatment provided during this time has provided the claimant with mild improvement in her psychiatric symptoms as evidenced by her not requiring hospitalisation for her psychological injury and her return to driving with her children in the car.
2. We have considered the effects of treatment during this time as mild.
3. For these reasons the Medical Assessor have adjusted the claimant's assessment of whole person impairment by 1% WPI, in relation to February 2018.
4. The effects of treatment for the October 2018 motor accident were assessed as zero (0% WPI). The reasons for the assessment of the effects of treatment after the October 2018 motor accident was because the claimant's condition had markedly deteriorated and treatment had not caused and change in her condition. The removal of treatment would in the Medical Assessors opinion does not change the claimant's assessment of whole person impairment. For these reasons the effects of treatment in relation to treatment after the October 2018 motor ancient was assessed as 0%WPI.

1. The Panel adopts the extensive reasons provided by the Medical Assessors. We confirm that the impairment is based on the evaluation at the time of the medical assessment (cl 1.21 of the Guidelines) and we have relied on the combined clinical expertise of the Medical Assessors when examining the claimant.
2. Clause 1.215 of the Guidelines appears under the heading for the assessment of "mental and behavioural disorders" and provides:

"The PIRS is not to be used to measure impairment due to somatoform disorders or pain."

1. The claimant had suffered and is suffering from extensive pain caused by the motor accident and has received substantial treatment for pain. The claimant had also experienced significant clinical side-effects from the pain treatment she had received.
2. The assessment guidelines for assessment of psychiatric whole person impairment requires the exclusion of impairment caused by physical condition and pain from all causes.
3. The table for the assessment of the permanent impairment based on these reasons is set out below:

The claimant received evidence based psychiatric and psychological treatment.

The claimant reported that she would have support from her mother who would cook meals for her and her children. The food her mother cooked would be frozen and eaten as pre-prepared meals when she was too low in her energy to make meals for her sons. She said that her sons were now 13, 11 and 8 years. She gave then chores. She said she would receive help with cleaning. She did not require prompting to shower or maintain her personal hygiene. She was able to supervise her son's hygiene. She was independent in her self-care and personal hygiene.

For these reasons the claimant was assessed as mildly impaired. This is a class 2 impairment.

The claimant reported she had lost interest and no longer enjoyed attending family events such as her boys, soccer each weekend. She said she would not go with her husband and her boys to watch their games. She said she would be asked by her sons to attend however she was not interested and said she would refuse every time.

The claimant said she rarely attended extended family events or celebrations. She said that she had stopped attending cafes and restaurants to socialise with her husband in public.

For these reasons the claimant was assessed as moderately impaired. This is a class 3 impairment.

The claimant reported that she was able to travel in her local and familiar area. She reported she was distressed when driving. She stated she would be hypervigilant and have intrusive distressing depressive ruminations that she would have more motor accidents. She reported she restricted her travel to the minimum necessary.

For these reasons the claimant was assessed as mildly impaired. This is a class 2 impairment.

The claimant reported strain in her marriage. She reported that she was less able to feel joy, happiness and affection towards her husband and children. She reported that she would isolate herself from extended family and not join extended family social events.

The claimant was not expecting separation or estrangement from her husband or children.

The claimant did not report any domestic violence, periods of separation or community services caring for her children.

For these reasons the claimant was assessed as mildly impaired. This is a class 2 impairment.

The claimant reported she could not read Arabic or English stories to her children since the October 2018 motor accident. She said her concentration and pace of switching between Arabic and English was reduced. She reported she could not complete her book-keeping without making frequent simple errors that she had not made prior to the motor accident.

The claimant reported that she had stopped read Arabic as she was slower in this language. She reported that she was less able to remain interested, and she would abandon these tasks within a few minutes - prior to her completing stopping on request on her husband.

The claimant had stopped cooking from recipes as she would make errors and spoil the food

For these reasons the claimant was assessed as moderately impaired. This is a class 3 impairment.

The claimant said she was unable to continue to organise her husband's small business back-office. She said she had attempted to return to this role during 2021 - however her pace of task completion was poor. She would make frequent errors that confused her husband and delayed the accounts been finalised. After an extended period of assistance from her husband - the claimant was removed from the family business by her husband.

The claimant received ongoing assistance from her mother in the care of her children she was performing few of the necessary mothercraft duties.

The Medical assessors assessed a Class 5 severe impairment as the claimant could not return to any mainstream role within the Australia jobs market either as a "back-office" work or as a childcare.

For these reasons the claimant was assessed as totally impaired. This is a class 5 impairment.

The effects of treatment for the aggravation of the claimant's psychological injury were assessed as 0%WPI. The claimant's condition had not improved with this treatment.

Evidence based psychiatric and psychological treatment

The claimant reported that she was independent in her self-care and personal hygiene. She said she was more reliant on her mother and husband to assist her. She reported that her husband initially took about three days off work to reorganise the family. She continued to care for her children's nutrition. She continued to supervise her children's bathing, and personal hygiene. The claimant's husband helped with the cleaning of the home and groceries and some prepared food was provided by the claimant's mother. The claimant said she stopped breast feeding as her energy levels were too low and she required more flexibility to assisting her children. The claimant was assessed as having a class 2 mild impairment for this table of functioning.

The claimant reported that she had becoming increasingly isolated and was not attending family events. She said she was less interested in her children's sport and attending her children's sport. She reported her interest in watching television and was also reduced. She reported that she would still organise and recognise her children's birthdays within the family home. The claimant was assessed as having a class 2 mild impairment for this table of functioning.

The claimant reported that she initially stopped driving however the children's need resulted in her sharing driving and transport with her mother. She said her mother would assist with picking up the children. The claimant said she was able to drive in local and familiar locations, after the first motor accident in February 2018. The claimant was assessed as having a class 2 mild impairment for this table of functioning.

The claimant said that she was more irritable and agitated after the first motor accident. She said that she had strain in her marriage. She was not expecting to become separated or divorced from her husband. She reported that she was less tolerant of her children's noisy play and that she had less times positive feeling towards her children. The claimant reported that she had tension in her relationship with her other as her mother was required to assist her during this time. The claimant was assessed as having a class 2 mild impairment for this table of functioning.

The claimant reported that prior to the motor accident she would read stories to her children in both Arabic and English. She said that she enjoyed reading novels in her own time as well. Since the first motor accident she was less interested in reading to her children. She reported she could read however her concentration would wane after about thirty minutes. She reported her pace of reading was slowed. She reported that her interest in reading had decreased, and she lacked persistent to read for long periods as she had before the February 2018 motor accident. The claimant was assessed as having a class 2 mild impairment for this table of functioning.

The claimant reported that she had difficulty continuing her work role for her husband. She said she was slow in her book-keeping, and other organized activities which she had to do to support her husband whilst he worked in the field. The claimant reported that her care of reh children was less. She reported that she had improved in her childcare and was spending more time caring from her children as her psychological injury had stabilised before the second motor accident.

Effects of treatment - Motor accident 11 February 2018

The effects of treatment received for the first motor accident demonstrated a mild treatment effect with the claimant returning to driving her car with the children in the car whilst she was driving before the 12 October 2018 motor accident.

The Total Whole Person Impairment was 6% WPI plus 1% WPI produces 7%WPI.

Pre-existing Psychological condition before 11 February 2018

Evidence based psychiatric and psychological treatment

The claimant was independent in her self-care and personal hygiene. The claimant reported that she was independent in her care of her three sons. The claimant was able to provide nutrition to her sons and herself. She was breast feeding prior to the February 2018 more accident.

The claimant was able to complete all the necessary hygiene for her large family. The claimant was able to laundry and clean her home independently before the February 2018 more accident. The claimant was assessed as Class 1 for this table for function.

The claimant enjoyed playing with her young sons whilst the family joined together to play games and share recreational activities that included, tenpin bowling events, attending the movies and playing soccer.

The claimant would socialise with her husband in public at cafes and restaurants. The claimant would visit her extended family. She would participate in traditional celebration with the family throughout the year.

The claimant would participate in her children's birthday celebrations and school events throughout the year.

The claimant was assessed as Class 1 for this table for function.

The claimant was able to travel without impairment prior to the February 2018 motor accident.

The claimant was able to drive a car without distress or hypervigilance prior to the motor accident.

The claimant could travel to unfamiliar locations without impairment before the February 2018 motor accident.

The claimant was assessed as Class 1 for this table for function.

The claimant reported that she had no tension or strain in her marriage. She said her marriage was a "love marriage" and she had enjoyed her relationship. She reported she enjoyed her sons and their progress. She reported that she had a strong bond with each of her sons. She reported she enjoyed her role as mother and wife.

The claimant was assessed as Class 1 for this table for function.

The claimant reported she could cook from new recipes, learn and successfully apply new skills as well as perform her husband's small business, book-keeping and other complex tasks before the February 2018 motor accident without impairment.

The claimant was able to switch between Arabic and English whilst talking without impairment. The claimant was able to read in both Arabic and English without impairment before the February 2018 motor accident without impairment.

The claimant was assessed as Class 1 for this table for function.

The claimant took appropriate and successful advice to assist with her adjustment to motherhood after the birth of her first son. She reported that she was able to care for her children without impairment after been treated by Karitane's service providers. She was able to perform the duties and perform her mothercraft role with the same capacity as the normal population.

The claimant could work in her husband's small business back office, performing these roles without impairment.

The claimant was assessed as Class 1 for this table for function.

The Total Whole Person Impairment for pre-existing condition was 0% WPI.

The assessment of whole person impairment for the motor accidents as assessed by PIRS

• 22% whole person impairment at the time of this examination.
• 7% whole person impairment assessed as prior to the motor accident in October 2018.
• 0% whole person impairment assessed as prior to the motor accident in February 2018.

The apportionment for the motor accident on 12 October 2018 is as follows:

• 22%WPI minus 7%WPI produces a final whole person impairment of 15%WPI in relation to this motor accident.

The apportionment for the motor accident on 11 February 2018 is as follows:

• 7%WPI minus 0%WPI produces a final whole person impairment of 7%WPI in relation to this motor accident.

The apportionment for pre-existing impairment the motor accident on 11 February 2018 is as follows:

• Pre-existing impairment due to the claimant's depression prior to the 11 February 2018 motor accident was assessed as 0%WPI.

1. The Panel conducts a new assessment of all the matters with which the medical assessment is concerned.[6]
2. The Panel is not required to choose between medical opinions and is required to form its own opinions.[7] The Panel's role is not to correct error in the decision of the original Medical Assessor.
3. The Panel adopts the Medical Assessors' examination report and adds the following further reasons.
4. As stated in the examination report, the Medical Assessors agree that the motor accident in October 2018 did cause an aggravation of the claimant's psychological injury arising from the subject accident in February 2018, with the claimant's major depressive disorder becoming clinically to the fore because of the second motor accident. It necessary follows that this case falls into second Oakley Category as previously described.
5. The Medical Assessors have explained the basis for their assessments and findings. The Medical Assessors respectfully note the views expressed by Medical Assessors Canaris and Newlyn each of whom assessed the claimant some time ago.
6. The medical assessment of permanent impairment is made at the time of examination. In that respect, the assessments made by Dr George and Medical Assessor Canaris are outdated, and do not reflect current symptomatology, in the Medical Assessors' opinion. The diagnosis made by the Medical Assessors is similar to that made by Dr George and Ms Ali. The Medical Assessors note that neither of the insurer's qualified experts, Dr Hong and Dr Vickery, made an assessment of whole person impairment.
7. The Panel is conscious that a strict interpretation of the Oakley principles would compel most of the Medical Assessors' assessment of WPI to be attributed to the subject February 2018 accident. However, as neither party has made submissions on the proper application of the Oakley principles to these claims, and as the same insurer is on risk for both accidents, the Panel believes that the strict application of the Oakley principles would yield an artificial result. The Panel prefers to apportion impairment between the two accidents in accordance with its examination findings.

1. For the above reasons, the Panel concludes the Certificate dated 21 February 2024 should be revoked. The new Certificate appears at the commencement of these reasons.

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

[5] Insurance Australia Limited t/as NRMA Insurance v Trkulja [2023] NSWSC 956.

[7] Allianz Australia Group Limited v Keen [2021] NSWCA 287 and Insurance Australia Group Limited v Marsh [2021] NSWCA 31