Issued under Division 7.5 of the Motor Accident Injuries Act 2017

1. Revokes the combined certificate issued by Medical Assessor Shen dated 19 January 2024.
2. Certifies that the degree of the claimant's whole person impairment resulting from the psychological or psychiatric injury caused by the accident is not greater than 10%.

1. Mervat Sidra was involved in a motor accident on 3 September 2020. She was 61 years of age at the time of the accident
2. Ms Sidra says she injured her back, neck, right shoulder and arm in the accident and she says she also sustained a psychological or psychiatric injury. Ms Sidra made a claim for statutory benefits and then damages against QBE, the third-party insurer of the vehicle she says caused the accident.
3. A medical dispute about the degree of Ms Sidra's whole person impairment (WPI) has arisen in connection with that claim and the claimant referred that dispute to the Personal Injury Commission (the Commission) for assessment.
4. On 19 January 2024, Medical Assessor Shen determined that Ms Sidra sustained a post-traumatic stress disorder and persistent depressive disorder as a result of the accident and the degree of her WPI was 11% which is of course greater than 10%.
5. The insurer then lodged an application with the Commission seeking a review of the Medical Assessor's decision. On 21 March 2024, Ms Wigan, a delegate of the President determined there was reasonable cause to suspect a material error in the assessment and allowed the Review to proceed. On 3 February 2025 the President's delegate convened this Review Panel (the Panel) to conduct the Review.
6. The assessment of WPI has been complicated due to the presence of pre-existing physical and psychological complaints as well as a subsequent accident and claim.

1. Ms Sidra's claim and her entitlements to compensation are governed by the provisions of the Motor Accident Injuries Act 2017 (the MAI Act).
2. In a claim for lump sum compensation, damages are assessed in accordance with common law principles as modified by the MAI Act. Under Part 4 of the Act, an injured person can make a claim for damages for both certain types of economic (pecuniary) losses and damages for non-economic (or non-pecuniary) loss.
3. Damages for non-economic loss are limited and restricted by the provisions in Division 4.3 of the MAI Act. For example, non-economic loss damages are limited to a maximum amount in accordance with s 4.13[1] and entitlement to those damages is restricted by s 4.11 to persons who have a greater than 10% WPI as a result of the injuries sustained in the accident.
4. If there is a dispute about the degree of the claimant's permanent impairment, damages for non-economic loss cannot be awarded and disputes are referred for medical assessment.[2]

1. Division 7.5 of the MAI Act provides for medical assessments by the Commission including provisions relevant to an original medical assessment such as Medical Assessor Shen, further medical assessments and the review of medical assessments by this Panel[3].
2. Applications for review of a medical assessment are made to the President of the Commission on grounds that the assessment "was incorrect in a material respect" (s 7.26(1)). If the President, or his delegate is satisfied "there is a reasonable cause to suspect that the medical assessment was incorrect in a material respect" then the President arranges for the application to be referred to a review panel consisting of a member of the Commission and two medical assessors (s 7.26(2) and (2B)).
3. The review is not an appeal looking for error and is not confined to the issues raised in the application (or the reply) but is "a new assessment of all the matters with which the medical assessment is concerned" (s 7.26(3A)).
4. Rule 128 of the Personal Injury Commission Rules (the Rules) 2021 permits the Panel to determine its own proceedings and the Panel is not bound by the rules of evidence and may inquire into relevant matters as it thinks fit.

1. Permanent impairment is to be assessed in accordance with Part 6 of the Motor Accident Guidelines (the Guidelines)[4] which are largely based on the American Medical Association's Guides to the Evaluation of Permanent Impairment, Fourth Edition (AMA 4 Guides).
2. Specific provisions from the Guidelines and the AMA 4 Guides will be considered later in these reasons when the degree of Ms Sidra's permanent impairment is discussed.

1. Medical Assessor Shen examined the claimant on 15 January 2024 and issued his certificate on 19 January 2024. The Medical Assessor confirms at [2][5] that he was asked to assess a "psychiatric condition - posttraumatic stress disorder and major depressive disorder."
2. Medical Assessor Shen took the following history at [8]-[10]:

(a) the claimant's mother had died in September 2022. The claimant had no partner or children but was in regular contact with her brother. She said she contacted her brother less since the accident;

(b) the claimant has no friends but does have friends in Egypt who she contacts;

(c) she watches Egyptian television;

(d) at the time of the accident, she visited people's homes to talk to them about religion and invited them to her place;

(e) the claimant was at the time of the accident seeking assistance from the National Disability Insurance Scheme (NDIS) and was in receipt of social security benefits - the claimant did not know how she sustained a previous back injury which apparently led to her receipt of social security benefits;

(f) the claimant confirmed an earlier motor accident (2005) but said she had no psychological injury as a result, and

(g) the claimant gave a history of the accident and being pushed and pulled and "her neck whipped forwards" and she lost consciousness for 15 minutes. She was screaming with pain after the accident but did not go to the hospital because she needed to look after her mother.

1. Before the accident the claimant was reported to have depression, had been prescribed Duloxetine or Cymbalta (a medication used to treat depressive disorders), difficulties with sleep and struggles with appetite and anxiety.
2. The claimant said she became more depressed after the accident but not more anxious. She said she got more anxious after the subsequent accident in September 2021 which caused further injuries and even more pain.
3. The claimant reported "persistent pain everywhere in her body"; she was depressed all the time with this persistent pain, and had problems with insomnia and poor appetite. She had intrusive memories of the current and subsequent accident and was hypervigilant.
4. The claimant reported seeing a psychologist which was not helpful and that she had been prescribed Cymbalta and Axit but was not sure how helpful that was. It is reported that she had declined further treatment.
5. The claimant said:

(a) she showers every 15 days as she cannot do it by herself and changes clothes every day with significant difficulty due to her physical injuries;

(b) she buys and prepares her own meals;

(c) she does some shopping with significant pain;

(d) she has been able to drive alone within the local area but with significant discomfort and pain;

(e) her concentration is poor, and she cannot read due to poor concentration, and she was not always able to concentrate due to her pain;

(f) she is not working and last worked in childcare in 2010 but ceased this work at that time due to back and neck pain, and

(g) at the time of the current car accident she looked after her mother 24 hours a day, but her mother had carers who came to help with heavy lifting and other aspects of care because the claimant could not do this.

1. Medical Assessor Shen diagnosed a post-traumatic stress disorder "from both the subject accident and subsequent accident and she likely had a pre-existing post-traumatic stress disorder". He also diagnosed a persistent depressive disorder which was pre-existing and had been aggravated by the current and subsequent accidents.
2. He assessed her current WPI at 17%, her pre-existing impairment at 6% which meant a WPI caused by the accident of 11%.

1. The insurer says the Medical Assessor has provided insufficient reasons:

(a) he did not explain why he came to a different diagnosis to Dr Anand or why he assessed different ratings for her functioning [8];

(b) he did not set out the criteria for post-traumatic stress disorder and persistent depressive disorder and how the claimant satisfied the criteria [9];

(c) the medical assessor discusses the claimant's functioning before the accident, her functioning between the current accident and the subsequent accident and her present functioning which is confusing and difficult to follow [10];

(d) while saying the current accident had contributed to both disorders, the Medical Assessor listed only Persistent Depression as a "pre-existing or subsequent impairment" [11];

(e) the Medical Assessor did not clearly reference psychological symptoms leading to limits in functioning [12];

(f) the adaptation rating did not consider the claimant's ability to focus during the examination or that her inability to read letters was due to pain [13], and

(g) the pain rating appears to be due to physical factors [14].

1. The insurer alleges the Medical Assessor failed to follow the guidelines:

(a) the insurer cites cl 6.218 and says the Medical Assessor assessed the claimant's current, previous and subsequent impairment, which is incorrect, and

(b) the Medical Assessor should have assessed the pre-accident impairment, the claimant's impairment before the subsequent accident and her current impairment and that her accident caused impairment would have been the impairment before the subsequent accident less the impairment from the pre-existing impairment.

1. In the insurer's original submissions, QBE sets out the evidence concerning the claimant's pre-accident conditions noting a long history of physical problems, depression since 2009, disability support payments since 2010 and an application for NDIS support (due to amongst other things major depressive symptoms) less than a month before the current accident.

1. The claimant says the Medical Assessor has provided adequate and detailed reasons, that he is not required to deal with each piece of evidence, that Medical Assessor Shen has reached a different conclusion to Dr Anand and can do so.
2. The claimant refers to the "Permanent Impairment Guidelines" and cites clauses 1.17-1.21.[7] The claimant then cites cl 6.31 and 6.31 which she attributes to the "Permanent Impairment Guidelines"[8] and says that the Medical Assessor has complied with cl 6.220.
3. The claimant refers to the decision to be made by the "proper officer" and the test of materiality.[9]

1. The Panel met on 23 April 2025. The Panel reported to the parties on 1 May 2025 as follows:

(a) the injury referred for assessment by Medical Assessor Shen was a "psychiatric condition - post traumatic stress disorder and major depressive disorder";

(b) 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. The Medical Assessors may, in their clinical judgment, diagnose a condition that is the same as, or different to, the diagnosis of the original Medical Assessor or the diagnoses of the treating doctors or medico-legal experts or the particular diagnosis that may have been included in the application or reply form. Having made a diagnosis, the Panel will then proceed to undertake an assessment of the WPI resulting from that injury;

(c) the assessment of WPI in Ms Sidra's case is complicated by the presence of what appears to be a pre-existing condition at the time of the current (2020) accident and a subsequent condition which developed after or was made worse by the 2021 accident;

(d) the relevant Guidelines applicable to Ms Sidra's claim are the Motor Accident Guidelines which provide at cls 6.31 and 6.218 for the assessment of pre-existing conditions, and

(e) the Guidelines also provide at 6.34 for impairment assessment where there is a subsequent condition and the parties were provided with the relevant cases.[10]

1. The claimant advised the Panel that she did not rely on any medico-legal or qualified experts in relation to the current accident. She provided details of her 2005 accident and referenced the existing records (referred to below).
2. The insurer also provided additional documentation about the current accident.

2005 accident and pre-accident records of Dr Dowla

1. The claimant's solicitor provided the following information about the claimant's 2005 accident in submissions attached to an additional bundle of documents uploaded to the Commission's electronic file on 23 May 2025:

(a) she was with her husband;

(b) she does not remember the full extent of her injuries but recalls an operation on her hand and seeing a psychologist (she did not remember their names);

(c) she made a claim and settled it but cannot remember how much for, and

(d) the claim was made against NRMA.

1. Dr Dowla, neurologist produced his clinical records,[11] and these include details of the 2005 accident as follows:

(a) it occurred on 13 June 2005, and the claimant was a front seat passenger;

(b) a truck travelling at 70km hit the back of the vehicle;

(c) the claimant had pain in her chest, left arm, lower back;

(d) Dr Seneviratne from Huntington Heights Family Medical Practice was Ms Sidra's general practitioner (GP) at the time;

(e) she had carpal tunnel release surgery, and

(f) she had treatment from Dr Alam, psychiatrist and Dr Shirin, psychologist and was prescribed Tofranil.

1. It appears the claimant was first referred to Dr Dowla on 14 July 2004 and she saw him on 10 August 2004. The notes are handwritten and not easy to read but a there is a reference to a CT scan of the claimant's spine in 2002.
2. The claimant saw Dr Dowla in 2013, 2014, 2015, 2016 and 2017 with various complaints
3. In a letter to Dr El-Wahsh dated 25 October 2013[12], Dr Dowla records the following diagnoses:

(a) right carpal tunnel syndrome with decompression in 2005;

(b) left carpal tunnel syndrome with injection in 2005;

(c) car accident 2005 - anxiety neurosis, post-traumatic stress disorder, Tofranil;

(d) lumbar spondylosis;

(e) thyroid nodules and thyroidectomy 2011;

(f) hypertension / high blood pressure,

(g) non-insulin dependent diabetes melitus (NIDDM) 2010,

(h) obesity;

(i) osteoporosis with L5 end plate fracture from 2013;

(j) gastroesophageal reflux disorder (GORD);

(k) varicose vein surgery 2008 and umbilical hernia 2009;

(l) physical assault, Blacktown Westpoint 2013 resulting in:

(i) severe left shoulder injury,

(ii) mild right shoulder injury

(iii) exacerbation left carpal tunnel syndrome;

(iv) exacerbation of cervical spondylosis and neck pain;

(v) exacerbation of lumbar spondylosis and lower back pain from end plate fracture, and

(vi) severe exacerbation of underlying anxiety and depression from emotional trauma.

1. Dr Dowla's report sets out in detail what occurred in the 2013 assault. The claimant was involved in an altercation with security guards, witnessed by her neighbour and friends "causing severe emotional reaction." She was apprehended, held tightly, she felt her legs paralysed, she was punched from behind and treated as if she was a thief. Police were involved. She attended her GP and then the hospital. "On examination she was highly emotional and teary." She had difficulty walking and was in pain. His opinion was that the claimant "suffered severe physical and mental injury as a result of the physical assault". He increased her dose of Tofranil and continued Endone.
2. On 14 April 2015 the claimant was seen again and Dr Dowla told Dr El-Wahsh that the claimant had reported an exacerbation of lower back pain "after she felt stressed."
3. On 23 January 2017 the claimant had seen a Dr Spencer, rheumatologist and it was suggested she see Dr Needham, pain specialist. On 22 June 2017 she was seen having had successful decompression of the left carpal tunnel earlier in the year.
4. Ms Sidra attended Dr Dowla on 27 July 2020. In the letter sent to her GP Dr Chen[13] sleep apnoea with CPAP was added to the diagnoses listed, with a date of 2011 given. Nerve conduction studies were done by Dr Dowla at this time but there was no neuropathy or radiculopathy.
5. On 4 August 2020 Ms Sidra attended on Dr Dowla with pain in both hands and her current medications were noted as Cymbalta and Lyrica.

Claim form and claim documents - September 2020 car accident

1. The claim form was signed and dated 23 October 2020.[14] The claimant says in that form that she had never made a compulsory third party (CTP) claim before. The description of the accident is that there was an initial rear end collision, the tow bar on the claimant's car got stuck in the front of the insured car and there were some attempts made to separate the two cars after the initial impact.
2. The claimant described (at this point six to seven weeks after the accident) physical symptoms only "back, neck, right shoulder and right arm" and "I feel dizziness nearly fell to the ground couples of times."

1. The ambulance report from the current accident reports[15] on the case as follows:

"[Call to] 61 [year old] female involved in 2 car mva. [On attendance] patient first vehicle which was rear ended at approx. 50 km/h, minor damage to both vehicles, no airbags deployed, seatbelt worn. Patient sitting in vehicle, stating she has neck pain and thoracic back pain. States she has [history] of bugling discs in both areas. Patient wanting to self extricate from the vehicle and taken into the ambulance for further assessment. Patient currently taking Lyrica and Endone daily for back pain. Patient able to ambulate, groaning in pain... denies dizziness or headache, denies headstrike ... complains of cervical spine tenderness on palpation. No chest trauma or seat belt marks ... no limb injuries, complains of thoracic back pain... Patient declining paramedic advice stating she will be fine and that she needs to go home to attend to her elderly mother. Patient requesting an injection of morphine for the pain so she can go home. Patient advised morphine cannot be administered if patient about to drive, and due to her severe pain she warrants further medical assessment ... patient still declining treatment. Patient demonstrating competency and capacity, able to receive, believe, retain and explain the risks of declining treatment. Towies and bystanders also attempting to convince patient to be transported to hospital for further assessment, with no change in patient's decision ... patient able to ambulate off stretcher and back into vehicle and drove away from the scene."

1. The claimant attended the police station on 9 September 2020 to make a report[16] saying she was still in pain (neck and back). She says:

"Driver 2 [the claimant] stated that she was staionary at traffic light on the 03/09/2020 in Vehicle 2 when Vehicle 1 collided with the rear of her vehicle. This caused a load of metal in the rear of Vehicle 2 to shift and go into vehicle 1. Both drivers got out and exchanged details and ambulance were called to check on driver 2. Ambulance advised the Driver 2 should be conveyed to the hospital as she was complaining of pain .. driver 2 refused to do this and was not conveyed to hospital."

1. Part of an accident report form (ARF) dated 6 November 2020 which is said to have been completed by the insured driver[17] says that he went to change lanes and go around stationary cars in front of him but was cut off by a car doing the same thing behind him and he was unable to stop in time and "bumped Toyota in front hooked up on her tow bar."
2. The insured driver also reports "the lady appeared to be OK, Ambo's checked her out, hospital visit was refused, she was walking around no problem."

1. NSW ambulance personnel record this history of the accident:[18]

"[Call to] 62 [motor vehicle accident] with injuries. [On attendance] paramedics met by police and gained a brief handover of the incident. Police stated truck slowly rolled into back of van with [patient] inside. Minor damage to rear bumper of van. [patient's] car was stationary when hit by truck. Truck going less than 10 km/h."

(a) the claimant was in no obvious distress;

(b) she was alert and orientated;

(c) she complained of headache, visual disturbance, pain in the neck back and head which was sharp but did not radiate;

(d) she complained of dizziness and light-headedness, and

(e) the claimant was said to have walked to the ambulance and walked into hospital and could turn her neck in all directions. She denied nausea and vomiting and loss of consciousness and there was no confusion or memory loss.

1. The police report[19] suggests the insured driver was slowing behind the claimant's vehicle when he "touched" the accelerator instead of the brake colliding with the rear of the claimant's vehicle causing minor damage.
2. The police record the speed of the vehicle as 15km and that neither vehicle was towed from the scene and airbags did not deploy.

1. Consultation notes for Dr Moussad with the claimant on 18 August 2020[20] refer to a NDIS form and that the claimant's main disability stated was her chronic back pain, reduction in mobility and "lifelong disability". The second disability was said to be diabetes causing peripheral neuropathy, right and left carpal tunnel, right and left shoulder osteoarthritis, right and left knee osteoarthritis "sleep apnoea and with tiredness and sleeping during the day and not able to focus or concentrate and major depression symptoms with loss of interest".
2. On 19 August 2020[21] is a further consultation note citing:

(a) mobility and motor skill issues - the claimant had balance issues and has fallen multiple times requiring ambulance assistance, she cannot use stairs and requires support worker and mobility aids, cannot use her hands, misses showers as she cannot perform the task. He also notes the claimant cannot go to the community because she feels dizzy;

(b) communication - gets frustrated because of her limitations, pain and restricted mobility make communication difficult and her depressed mood, lack of concentration and loss of interest and social isolation interfere with her communication;

(c) social interaction - unable to go out without support and has no family or friends because of her depression. Cannot maintain friendships, loss of self-confident and difficulties coping and feeling, and

(d) self-management - not able to make decisions due to pain and depressed mood, needs support worker to assist with money handling and self-management.

1. In a patient medication summary dated 19 August 2020 (before the accident), Dr Moussad has listed Cymbalta (morning and night); Endone daily, Lyrica twice a day, Targin twice a day and other medications. A further medication summary dated 19 October 2020 (after the accident) has similar medications listed with the same quantities of Cymbalta, Endone, Lyrica and Targin.
2. There is an unsigned certificate of fitness[22] typed out for Dr Moussad and dated 5 September 2020 diagnosing "neck pain, back pain, headache, anxiety." There is another unsigned certificate dated 7 September 2020 in similar terms. A third and also unsigned certificate dated 17 October 2020 includes "insomnia".
3. Dr Moussad wrote to the QBE case manager on 16 December 2020[23] seeking approval for an MRI, noting the claimant had neck pain radiating to both shoulders and upper limbs and back pain radiating to lower limbs and this pain is causing sleep disturbance. There is no reference to any psychological symptoms.
4. Dr Moussad provided a referral to Professor Papantoniou, orthopaedic and spine surgeon on 11 January 2021 for management of the claimant's neck and back injuries. A referral for physiotherapy was provided on 3 February 2021. A referral for opinion and management of the claimant's hand tremors was provided to Dr Dowla, neurologist dated 16 March 2021.
5. Ms Sidra's first attendance on Dr Dowla after the accident was on 17 March 2021. The claimant was concerned about further tremors, tingling and numbness affecting her feet and hands, he considered she had anxiety related symptoms and referred her to a psychologist.
6. A referral was provided by Dr Moussad to Ms Boutros on 9 April 2021[24] for "opinion and management re depression and anxiety." The corresponding consultation note[25] records depression and anxiety symptoms, flashbacks, insomnia, counselling referral for further counselling.
7. The claimant first saw Ms Boutros on 18 May 2021 and reported "this accident changed my life." The claimant said while ambulance attended, she returned home because of her

(a) pain is intense;

(b) "stayed at hospital for six days waiting for the pain to get better";

(c) discs in back and neck and headaches affect her eyes and shoulders, fluid on the elbow, pain under the breast, pain in leg and in all of her body;

(d) her husband left her in 2017, and she has no social support and no children;

(e) she feels useless and screams with the pain, she has pain when she drives;

(f) she is crying profusely;

(g) she has pain at night which wakes her up, and

(h) she has diabetes from stress.

1. The claimant attended Ms Boutros again on 4 June 2021 complaining of shoulder pain, nightmares, waking fearing she will be hit. She was having panic attacks if she drives near the accident scene. She felt everything had been exacerbated and she forgets things. Ms Sidra's headaches were ongoing, she never had blood pressure issues before but now stress is causing it and her heart rate increased. She says she cannot sleep.
2. Ms Sidra returned to see Dr Dowla on 15 June 2021 when it was reported that the claimant complained of more pain (in particular right shoulder pain) since the car accident on 3 September 2020. The claimant was concerned about a worsening tremor, tingling and numbness in both hands and feet. He considered "she has anxiety symptoms" and recommended that she see a psychologist and continue Lyrica, Cymbalta and Endone. He prescribed Inderal for the tremor.
3. On 18 June 2021, the claimant had seen Dr Moussad for right shoulder and elbow which showed damage. The claimant could not reach things and was upset and depressed as a result. She is shaking all the time and her back causes 24 hours of pain. Endone was not helping. Ms Boutros thought pain management may be required. The claimant was waking up screaming and her sleep was poor with ongoing negative ruminations. Her house was in a poor state and this upset her.
4. On 24 September 2021 Ms Sidra saw Dr Dowla for ongoing pain and tremor noting she had been hit by a truck on 8 September 2021 "but did not fall." She had mild peripheral neuropathy, and he again considered the claimant had symptoms of anxiety.
5. On 24 September 2021 Dr Dowla wrote a letter of support to the National Disability and Insurance Scheme (NDIS)[26] in answer to a series of questions which refers to:

(a) chronic pain in the lower back and neck caused by "multiple car accidents since 2005";

(b) because of her physical symptoms her home cannot be cleaned, and she cannot answer the phone, and her communication and social interactions are affected;

(c) she cannot go to the shopping centre to buy groceries;

(d) her diabetes related peripheral neuropathy is worsening;

(e) she has bilateral knee joint arthritis worse after her multiple motor accidents including the 8 September 2021 accident and she cannot do self-care or interact socially;

(f) she has vertigo and feels constantly dizzy, and

(g) "in relation to depression anxiety and posttraumatic stress disorder, she has seen a psychologist in the past, but I am not sure if she has seen any psychiatrist. She is taking Duloxetine. She has severe social anxiety, and she is unable to communicate."

1. Dr Dowla saw the claimant again in November and December 2021 and further in June and September 2022 by which stage the claimant's diabetic neuropathy was further progressing and Dr Dowla considered the claimant had developed arthritis in her hip. He continued to suggest she has psychological symptoms.
2. Dr Moussad referred the claimant to Ms Boutros on 3 December 2021 noting the claimant "feels down and anxious for long period getting worse after MA on 8/9/2021."[27]
3. On 18 December 2021 the claimant reported to Ms Boutros that a truck hit her from behind and when driving she continuously looks in the rear-view mirror. Her stress levels are high, and the pain is too much. She cannot look after her mother due to her emotional and physical pain. The claimant was said to have body shaking and she was dizzy all the time. She was ruminating "Why me?"
4. On 31 December 2021 the claimant returned to Ms Boutros with low mood and feeling depressed with the pain making it worse. The claimant had been to physiotherapy and was having pain radiating all over her body and flaring up everywhere. She was complaining of ongoing dreams and waking up scared and sweating.
5. The claimant was having difficulty driving and looking in the rear-view mirror constantly. She was reminded of the accident all the time and triggers flashbacks. She is tired and has headaches and worries about not being able to make a cup of tea for herself or her mother.
6. On 14 January 2022 the claimant had shaking all over her body whereas before it was in her hands. She is emotional all the time and wants to cry and cannot bear bad news. She had ongoing bad dreams, pain in her stomach and her stress levels were high.
7. On 31 January 2022 Ms Sidra reported nightmares the previous week the worst she has had and she had been too scared to drive since then. Her screams were waking her up from her dreams.
8. The final note is dated 6 February 2022 and the claimant had headaches, was depressed and "can't cope", was fearful driving and had nausea all the time. Her blood sugar levels were high and she was crying.
9. An Allied Health Recovery Request (AHRR) was completed by Ms Boutros on 22 February 2022 seeking approval for eight sessions. On that day the claimant attended due to nightmares, and she was getting upset very easily and ruminating on her life.
10. On 24 March 2022 the claimant was referred to Dr Way, psychiatrist for "feeling down and anxious for long period getting worse after MVA on 8/9/2021."[28]
11. Dr Nazha, pain physical wrote to the claimant's GP on 26 April 2022.[29] The claimant gave him a history first accident of the accident in September 2021 and then the previous accident in September 2020. She said that before the accidents she had chronic pain but "I could live with it". He also has a history that "she did not have any significant problems after her first motor vehicle accident" but that her second accident resulted in fibromyalgia with significant pain all over her body. He recommended further investigations, topical therapies no opioids and psychological counselling. He listed her medications as Duloxetine, Cartia, Lyrica, Atozet, Nexium, Noten, Oroxine, Ozempic, Symibcort and Tritace. The claimant was 164cm tall and weighed 105kg. While Dr Nazha was aware of the claimant having seen Dr Dowla, he did not have any of Dr Dowla's records or reports.
12. On 21 June 2022 Ms Sidra saw Ms Boutros and was again in pain and she said she only leaves home for doctors' appointments and physiotherapy and hates her life.
13. On 26 July 2022, the claimant was not sleeping due to pain. She was waking several times and night and was tired during the day. She was having scary dreams. She was worried about the future. She was not going out. She cannot change her clothes and cannot be tidy.
14. Dr Way, psychiatrist wrote a report to Allianz dated 4 October 2022. He refers to a referral from Dr El-Wahsh for management of chronic anxiety and depression which had worsened since her 8 September 2021 accident. He notes since the accident Ms Sidra has developed depressed mood with recurrent panic symptoms, an exacerbation of chronic pain, mood irritability, startle response to loud noises and sleep disturbances with horrific nightmares of behind hit by a truck (she says she was hit by a truck in the Allianz accident not the current QBE accident). Ms Sidra gave a history of her September 2020 car accident and said she had a panic attack at the scene which was why the insured driver called an ambulance.
15. The claimant was described as being "unkempt and distressed and became teary" when recounting the accident. She said the September 2021 accident has "destroyed my life." He diagnosed a "major depression with acute PTSD which seems to have been resolving". He advised he would be happy to help with an NDIS application and started her on supportive psychotherapy.
16. On 16 November 2022 the claimant attended Ms Boutros. Her mother had died four days before. Ms Sidra's pain was exacerbated. She no longer had aged care or family support and was not sleeping due to her pain. She was having bad dreams. Her brother had his own pressures so was no support to her.
17. The claimant recommenced sessions with Ms Boutros on 14 December 2022. Her nightmares had increased and she was being chased by scary people.
18. She had lost 19kg. She was reporting dizziness all the time, not sleeping at night but taking naps during the day. She could not sleep or lie down.
19. She could not find any one to help her at home. She had no motivation and no ability.
20. On 11 January 2023 the claimant reported to Ms Boutros that she was finding it hard to drive due to her shoulder. She was easily upset and had been seeing a psychiatrist. Her stomach was upset, and she was still in pain. She had nightmares but her doctor would not give her any more mediation. "Only wakes up for appointments. Will fall asleep throughout the day."
21. On 25 January 2023 the claimant reported ongoing pain with changes in the weather. Dreams were ongoing. She was feeling sick all the time and losing weight. Ms Sidra says she does not like to socialise or hear loud sounds, and she used to be very social. The cost of living was a concern in terms of her medications. The claimant was encouraged to exercise, but she said she cannot walk.
22. On 13 March 2023 the claimant was emotional, she had been very sick and was feeling unsupported and was crying. She was counselled and advised about agencies who could be approached for assistance.
23. Ayman Kassir of Starlight Psychology completed an AHRR for the claimant in relation to the Allianz accident and claim on 8 September 2021[30]. The diagnosis was stated as a post-traumatic stress disorder along with a comorbid diagnosis of major depressive disorder. Eight sessions were sought.
24. On 27 June 2023 Dr Way wrote again to Allianz clarifying that while he was seeing the claimant every three months, and she needed more regular intervention with her psychologist. He reports the claimant had driven through a red light and had been fined $450 and she was concerned at her decreased concentration and forgetfulness. The claimant was depressed and her affect reactive and she was said to be "preoccupied with obsessive worries about her not having any social support." The claimant was not, at that time, reporting flashbacks of the accident or nightmares but was unable to attend church because she could not drive anymore (her license having been taken away).
25. Dr Way recommended ongoing psychological therapy and NDIS support and pain management and said he had written a comprehensive psychiatric report in support of the NDIS application.
26. The claimant saw Dr Dowla twice in 2023 and again in 2024.
27. At her most recent attendance on 28 January 2025, Dr Dowla records that the claimant's driver licence had been cancelled due to her sleep apnoea. She had varicose veins resected and was having hip joint pain, headache and neck pain. Her tremor was slightly worse. She was taking Lyrica, Cymbalta, Palexia and Mirtazapine.

1. The claimant has not put any medico-legal reports before the Panel
2. The insurer relies on a report from Dr Wallace, orthopaedic surgeon dated 18 August 2022.
3. Dr Wallace has a history of the claimant's pre-accident complaints, her first accident (2020) and her second accident (2021). He records constant aching in the C5-C7 area worse on the right side but with no radiation. Housework and lifting made the pain work.
4. In the lumbar spine she complained of constant aching pain at L4/5.
5. The claimant complained about intermittent paraesthesia in the hands and legs.
6. The claimant was 164cm tall and weighed 95kg.
7. Dr Wallace has a report that the claimant can dress herself but slowly. Her sleep was said to be disturbed due to neck and back pain, and she had difficulty driving a motor vehicle. The claimant's mother received support, and the claimant was said to be unable to provide support to her.
8. Dr Wallace diagnosed musculoligamentous strains in the cervical and lumbar spine and aggravation of pre-existing symptomatic degenerative spondylosis. He assessed WPI at 0%.
9. The insurer also relies on a report of Dr Anand, neuropsychiatrist dated 7 November 2022.
10. The claimant said she returned home after the accident to care for her mother but developed auditory hallucinations and nightmares and went to see her GP.
11. He has a history of the claimant's pre-accident depression due to previous injuries and conditions and her marital breakdown. Dr Anand notes the date of the claimant's mother's death. The claimant reported taking Lyrica, Endone, Targin, Noten, Cymbalta, Axit, Tritace, Oroxine, anticoagulant medication, insulin, Ozempic and Panadol Osteo.
12. The claimant reported treatment from Dr Way, psychiatrist, Ms Boutros (who she had not seen for a while), a psychologist from Carer Gateway and another from the University Pain Clinic. She has been seeing Dr Dowla since 2004.
13. The claimant reported living alone and being limited in the chores she can do. She reported being able to cook simple meals. She goes to physiotherapy and watches a Christian television channel from Egypt. She drives locally. He noted no concentration issues, and that the claimant was able to recite her 12 medications and had no word finding difficulty. The claimant was active on Facebook, had a brother and her friends came over occasionally.
14. He diagnosed a major depressive disorder with prominent anxiety which was an aggravation of a pre-existing condition.
15. He diagnosed WPI at 7% less 2% for a pre-existing condition making a total of 5%.

1. On 7 March 2022 Medical Assessor Wan determined a treatment dispute finding that while lumbar and cervical spine injections were related to the injuries sustained in the accident, they were not reasonable and necessary in the circumstances.
2. In another certificate dated 7 March 2022, Medical Assessor Wan considered the claimant's neck, thoracic and lumbar spine injuries were minor injuries and that there was no shoulder, elbow, arm, foot, leg or hip injuries caused by the accident.
3. Medical Assessor Shen determined on 20 June 2022 that Ms Sidra had a post-traumatic stress disorder and major depressive disorder caused by the accident both of which were not minor (now not threshold) injuries.
4. On 29 January 2024, Medical Assessor Home determined the claimant had a WPI of 5% due to a cervical spine injury sustained in the car accident and that the claimant sustained a temporary exacerbation of a pre-existing lumbar spine condition which led to no assessable impairment.

1. Medical Assessor Robertson determined on 27 March 2023, a treatment dispute arising out of the 8 September 2021 Allianz accident. The treatment concerned consultation with a pain psychologist.
2. Medical Assessor Robertson has a history of multiple pre-accident complaints but the claimant stated that she had no psychiatric problems before the "subject" Allianz accident but had a previous pain management program due to chronic back pain. The claimant reported mainly chronic right shoulder pain, back, neck and left leg pain after the accident and that Dr Way started her on Duloxetine (90mg). Dr Way was assisting the claimant with her application to become an NDIS participant.
3. Dr Robertson had a history of both the 2020 and 2021 accidents but not the 2005 accident and it does not appear he had Dr Dowla's extensive notes.
4. Dr Robertson has a history of the claimant seeing Ms Boutros and Dr Nazha. He notes the claimant "has been long-term socially isolated and this has not changed significantly since the accident."
5. On examination he noted that:

"She spoke in a highly impressionistic and overly dramatic manner, and appeared excessively focused on her pain experience, her grievance with the insurer and her perceived incapacity. But she was cooperative."

1. He noted most of Ms Sidra's complaints were attributable to physical pain and that gastrointestinal and chronic pain inhibited her social life.
2. He considered the claimant had longstanding chronic pain exacerbated by the September 2021 accident as well as the current September 2020 accident.
3. He noted abnormal illness behaviour and considered she had a somatic symptom disorder. He was of the view the treatment in dispute should be allowed. He considered that Ms Sidra did not report symptoms suggestive of a post-traumatic stress disorder.
4. Medical Assessor Sidorov assessed the claimant on 16 May 2023 as having an adjustment disorder with mixed anxiety and depressed mood as a result of the 8 September 2021 accident. He had a history from the claimant of her seeing Dr Way from 2010 to 2011. He also had a history of the current accident which the claimant reported was similar to the September 2021 accident, that she had generalised pain over her body and that she had been referred for a pain management plan. She did not give Medical Assessor Sidorov a history of any psychological symptoms or treatment following the September 2020 accident.
5. The claimant was taken to hospital after the Allianz accident and police had attended the scene. The claimant felt her physical pain had become worse. She reported physical pain not improvement everywhere in her body. The claimant also described having bad dreams every night.
6. He found the claimant's injury was a threshold injury.
7. Medical Assessor Truskett found on 25 October 2022 that the claimant's physical injuries arising out of the Allianz accident were threshold soft tissue injuries.
8. Medical Assessor Home found on 14 April 2023, a variety of treatment modalities including a consultation with a gastroenterologist, cortisone injections, referral to a pain specialist and so on were not related to and not reasonable and necessary treatment in the circumstances.

RE-EXAMINATION FINDINGS - MEDICAL ASSESSORS BARRETT AND SINGH

1. The claimant attended the re-examination on 18 June 2025 with Medical Assessors Singh and Barrett and she was assessed by MS Teams. She was located at her lawyer's office and was unaccompanied. Internet connectivity was good throughout the re-examination.
2. The following are the clinical findings of the Medical Assessors.

1. Ms Sidra is a 66-year-old woman, who lives alone in Doonside. She divorced in 2017 and had been single since. She has no children. She has been in receipt of a disability support pension or payment (DSP) since 2010.
2. Ms Sidra was born in Cairo, Egypt, the third of four siblings. She reported a normal birth and milestones. She reported a happy childhood, completing high school in Egypt. She completed a degree in accounting, then a Masters of Statistics at Cairo University. She worked for the Bureau of Statistics.
3. She was raised in the Brethren (Christian) faith. She reported religious discrimination throughout her life, which took the form of verbal abuse and unfavourable treatment. For this reason, she migrated to Australia in 1992 when she was 33-years-old.
4. She married in 1994, by arrangement. She described the marriage as unhappy from 2000, when she discovered her then husband's infidelity and financial dishonesty. However, she remained married due to a sense of stigma regarding divorce, until her husband chose to leave her in 2017. She has been single since.
5. Since her arrival in Australia, she worked in a school library for about six months. She completed TAFE courses in English and childcare, then worked in a childcare centre, before running her own family daycare business from 1998 until 2010.
6. She denied any history of previous workers compensation claims. She denied any forensic history.
7. She is a non-smoker, who does not use alcohol or other drugs. She denied a history of gambling.

Previous medical, psychiatric history and pre-accident functioning

1. Ms Sidra said she first injured her back in 1994 when carrying a heavy, wet blanket.
2. She was involved in a previous motor accident in 2005, when travelling as a passenger in a car which was hit from the rear. She explained, "It was not that bad" and said neither police nor ambulance attended the scene. It was put to her that the documents describe the accident as having occurred at 70km/hr, but she responded to the effect that after the current accident, which was a more severe accident, she did not consider the 2005 accident to be severe.
3. She acknowledged injuries to her neck resulting from the 2005 accident.
4. Ms Sidra denied any psychiatric injuries from the 2005 accident. It was put to her that this was inconsistent with the available records. She responded, "I was scared for a time", "scared from driving". It was put to her that the records indicate that she was referred to a psychologist and possibly a psychiatrist. She responded that she saw a psychiatrist on one occasion before he closed his practice. She said she did not avoid driving, after her accident as she had to drive for work, and repeated that her symptoms resolved after a few months.
5. She had four surgeries between 2008 and 2010, including two within a one-year period. She stated, "My doctor finds me very stressed".
6. She described a sense of feeling dismissed by doctors involved in treating her physical condition, and that she was psychologically impacted by her pain, multiple surgical procedures and their complications, and by her physical conditions on her ability to work and care for her mother (while she was alive) and herself. As a result, she said her GP had prescribed the tricyclic antidepressant, "Tofranil", imipramine, which she took for about two to three years. She was referred to a psychiatrist, Dr Way but does not recall the details of his treatment. She does recall however, that he assisted her with the previously rejected DSP application. She was clear with us that the DSP was granted only based on her physical condition. It was put to her that it was implausible that the DSP would be granted on the basis of a psychiatrist's report about her physical condition, but she maintained there was no psychiatric condition. This inconsistency could not be resolved.
7. In 2013, she was the victim of an assault. She said that staff at Target had refused her return of a faulty Dyson vacuum and called centre security. She reports that security staff locked her in a room for three hours, pulled her hair and hit her. As a consequence, she reports exacerbation of her back pain for two years after this assault. She went to the police, but no charges were laid. She took civil action for her injuries, but cannot recall whether this was on the basis of physical or psychiatric injuries. She said she received a financial settlement for her injuries.
8. In the period prior to the September 2020 accident, Ms Sidra reported experiencing chronic back pain. However, she stated that she had been able to manage her pain with Endone.
9. In the period prior to the September 2020 accident, Ms Sidra reported, "I have depression from pain", "I had depression from life". However, she then denied substantial symptoms of depression saying, "I was very happy", "I was enjoying my life - visiting people".
10. The panel put to her that this was internally inconsistent and inconsistent with her treating GP records, specifically that her GP described loss of interest, isolation, fatigue, reduced self-care and needing a support worker for activities of daily living, and that she had been treated with the antidepressant Duloxetine (Cymbalta). Ms Sidra's response was that she had such symptoms only for a short period, perhaps a month, in August 2020, because she had discovered her husband was unfaithful (in 2017) leading to separation and she was contemplating divorce. She reported that once she had settled upon the decision to divorce (in 2020), she improved. She was uncertain as to how long she took Duloxetine, but said she was using it for pain. The Panel notes there is no significant mention about her husband, their separation and the decision to divorce in the records before the Panel.
11. At the time of the accident, Ms Sidra said she was living with her mother, following her father's death. She was waking early, getting her mother breakfast. Again, it was put to her that the GP records state that she needed a support worker for her mother because she could no longer cope and this support worker assisted both Ms Sidra and her mother with their activities of daily living. The Panel noted that her own need for care was inconsistent with her being able to care for her mother. She responded that the GP records related to a period, "before - it was a short time".
12. She said that before the accident she was cooking every second day, in batches. Her mother had care provided by aged care, who performed cleaning and laundry for her mother, and she did her own cleaning and laundry, using Endone when needed. She was showering twice a week, which was usual for her, as "I am tired". She was visiting friends, three times a week, and was visited by friends, twice a week. She was attending church once a week, regularly walking and watching Christian TV channels from USA and Egypt. Her brother regularly visited for meals. She was driving regularly, including to her brother's home. She denied concentration impairment. It was put to her that the GP records describe concentration impairment before the accident, but she reported only a short finite period of concentration impairment whilst contemplating divorce.

1. The subject accident occurred on 3 September 2020. Ms Sidra was reluctant to discuss the accident, responding, "You have the records - It's hard to remember", explaining it was distressing to recall the circumstances of the accident, her significant physical injuries and her severe pain. With encouragement, she reported that she was driving a 2016 Toyota Tarago van and was returning from her brother's home. She was stationary at a set of traffic lights when she was hit from the rear. She said, "The man came very, very fast". When I put to her that the records suggest a low-impact accident, she replied, "This is lie".
2. An ambulance was called because, "I could not breathe", but she did not want to go to hospital because she felt obliged to return to her mother, as her mother needed her. Instead, she drove home. She said her car was repaired. She was uncertain of the cost of the repairs.

History of symptoms following the motor accident.

1. Ms Sidra reported that the accident worsened her back, hip and shoulder pain. She did not mention her neck or upper limbs. She described her pain as so severe she could not put her feet on the floor due to pain, could not stand to cook, and could not clean and wash her body.
2. She said she was prescribed Lyrica and used Panadol Osteo, four tablets daily.

1. Ms Sidra reported being fearful of driving at night but has not avoided doing so. She reported shaking and sweating when she saw a car behind her or if a car changed lanes behind her. She was vigilant, checking her mirrors, "like crazy", as the driver or as a passenger.
2. She reported that once, after the accident she was, "hearing voices", occurring at night prior to sleep, but whilst awake. She could not hear the content. She checked outside to see if it was her neighbour. She found the experience frightening, "scared I was going to die", "I thought I was sick", "I felt I would die in my bed".
3. She reported, "I don't like to hear any voice", "I don't like to talk to anyone, I don't like to go out". She explained that it was because, "I am very stressed", "I can't hear talking, noise, even the TV".
4. She woke every hour, but could not explain why she woke. Her appetite was reduced, and she lost 20kg, then regained 10kg. She denied suicidal ideation.
5. Prior to the September 2021 accident, she was predominantly at home because, "pain became double or triple". She was not attending church. She was caring for her mother, but only in the form of sitting with her and providing her food and water. She did however report at this time being able to drive locally to buy food and medications.

1. Ms Sidra said she was driving the same car, her Toyota Tarago van, at about 2.00pm. She had travelled to the local shops and was returning home when she was hit from the rear. However, she described the accident as, "but not like the other one", saying it was not as severe as the September 2020 accident, citing by way of example that the eggs she bought were undamaged. However, she reported, "My whole body shook", police and ambulance attended, and she was taken to Mt Druitt Hospital emergency department.
2. She describes left shoulder pain after this accident which was treated with a steroid injection.
3. She denied any change in her psychiatric symptomatology, "The same", "Still feeling I will die". She confirmed returning to Dr Way after this accident.

1. Ms Sidra lives alone in a home in Doonside as her mother has passed away. She has aged care support three times a week. She cooks only once a week, simply preparing meals by boiling food, "I burn food - leave on stove", and mostly relies on takeaway food. She is fearful of showering alone due to, "headache and dizzy", "scared to when dizzy and in pain", but enjoys a shower with the assistance of her carer.
2. She spends her day, "sitting on chair". She goes to church about once a month, but does not attend, "if I feel not well", "pain and headache and can't open eyes", "dizzy", and because she cannot sit down, cannot concentrate, "sleepy". However, when she does attend church, "I enjoy it very much" there are "beautiful people" there.
3. She is able to drive locally. She will also sometimes drive further, to her brother's home in Strathfield or to appointments at Westmead Hospital, although she reports she is impacted by dizziness and poor concentration when driving and sometimes requires analgesics.
4. The Panel notes Ms Sidra lost her license due to a mobile phone use caused by a lack of concentration and recently she may have had her license taken away due to a diagnosis of sleep apnoea. The Panel is concerned at the claimant's reports of dizziness and poor concentration while driving and even more concerned if she is driving without a license or while her license has been suspended.

1. Ms Sidra was well groomed, wearing a blue top. Her hair, which appeared recently coloured, was tied back. She sighed frequently throughout the assessment, which she reported was due to pain, and she needed to stand at times which she said was due to pain. She maintained good eye contact and a full range of facial expressions throughout the re-examination. Her speech was normal.
2. Her affect was warm, bright and reactive. She smiled frequently and laughed readily at times. She described her mood often as "fearful of dying".
3. She was preoccupied by her physical condition, pain and symptoms particularly of dizziness and concentration impairment. She reported, "I am in a very bad condition", "I never forgot this accident; it make my life different", "I'm dizzy most of the time".
4. She did not report re-experiencing symptoms, like flashbacks or nightmares. She was not hopeless. She did not report any psychotic symptoms. She confirmed she has been driving since the accident.
5. Objectively, she was able to maintain attention and focus well throughout the assessment of more than 1.5 hours. She was able to recall questions previously asked and add to her answers.
6. She denied any suicidal thoughts. She did not report any risk to others.
7. She has partial insight into her condition, considering her pain and physical symptoms to be the predominant cause of her current condition.

1. The Panel met on 15 July 2025 to discuss the above re-examination findings, the issues in dispute between the parties and in order to finalise the Review and these reasons.

1. The Panel notes there has been some evidence of exaggeration in that the claimant reported to Medical Assessor Shen that she was pushed and pulled and her neck whipped forwards and she lost consciousness for 15 minutes in the accident. This is contrary to the recently produced records which suggests there was no loss of consciousness, and the claimant was able to walk around after the accident.
2. The Panel also notes the claimant has appeared to minimise her symptoms from her first and third accident (and her physical state before the current accident) and has maximised her symptoms arising from the current accident. Her suggestion that she recovered from the 2005 accident in a few months is not borne out by the evidence of Dr Dowla in particular. In addition, her explanation for the August 2020 Centrelink certificate from Dr Moussad and his corresponding clinical note is not medically plausible.
3. The Panel considers that there were inconsistencies between the claimant's account of her pre-accident mental state and functioning and that contained in the contemporaneous records of the treating GP, as well as her account of the subject accident and that contained in the records. These inconsistencies were put to her throughout the assessment, but after consideration, the Panel found that the inconsistencies were not resolved by her responses. The 2005 accident was said to have occurred at 70 kms per hour whereas the 2020 and 2021 accidents appear to involve less severe incidents. The current accident in particular does not appear to have been significant as the claimant was able to get back in her car and drive it home.
4. The claimant gave evidence to the Medical Assessors that her memory of events was poor.
5. It is now 20 years since the claimant's first (2005) accident, nearly five years since the current accident and nearly four years since her third accident. The Panel does not expect the claimant to recall with clarity all dates and details of her treatment following each of the three accidents. The Panel also notes that the circumstances of all three accidents appear to be similar that is she has had three rear end accidents, and the Panel accepts that Ms Sidra may confuse the details of her treatment.
6. The Panel therefore is of the view that the claimant's history of the accident and her symptoms before and after it is not reliable and prefers to rely on the evidence in the contemporaneous records and the objective findings of the mental state examination.

1. Under Schedule 2(2)(a), Medical Assessors (and Review Panels) must determine the degree of permanent impairment of a claimant as a result of the injury caused by the accident.
2. Clause 6.6 of the Guidelines refers to causation as follows:

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

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

(1) The alleged factor could have caused or contributed to worsening of the impairment, which is a medical determination.

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

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

Could the accident have caused or contributed to a psychiatric disorder?

1. The Medical Assessors note the circumstances of the motor accident. While a rear end collision, the history of it given by the insured driver suggests it was not a 'standard' rear end collision in that the insured vehicle was stuck on the tow bar of the claimant's vehicle. That explains the description of the accident contained in the claim form of the attempts made to separate the two cars. The Medical Assessors also note the report of the insured vehicle's speed in his report (45kmph) and in the ambulance report (50kmph).
2. It is the clinical judgment of the Medical Assessors that the circumstances of the current accident could have caused or contributed to the development of a psychiatric condition particularly in a claimant already vulnerable from an earlier (2005) accident and ongoing physical conditions and symptoms (as at August 2020).

Did the accident cause or contribute to a psychiatric disorder?

1. The claimant denied to the Medical Assessors any psychiatric injuries resulting from her 2005 accident at first but then said she was scared and scared about driving for a time and that her symptoms resolved after a few months. The claimant could not recall psychiatric injuries resulting from her detention by security personnel and alleged assault in 2013. When her more recent pre-accident symptoms were put to her, she accepted their presence but only for a short period which she said was a month and only in the context of her divorce from her husband.
2. The Panel does not accept this history. When the totality of Dr Dowla's records are considered, it is clear that the claimant experienced significant symptoms (including psychological symptoms) after her 2005 accident and severe symptoms (including psychological symptoms) after the 2013 assault. When Dr Moussad's records are considered along with the application for NDIS funding on 19 August 2020, three weeks before the current car accident, it is clear the claimant was experiencing clinically significant symptoms of depression and anxiety as a result of chronic physical symptoms before the current accident.
3. While the claimant's claim form completed on 23 October 2020 did not mention psychological symptoms, Dr Moussad's certificates of fitness dated 5 and 7 September and 17 October 2020 diagnosed anxiety.
4. Although the claimant did not seek treatment for anxiety and depression until April 2021, the Panel accepts that the claimant had symptoms of anxiety and depression before that. The Panel accepts therefore that the motor accident on 3 September 2020 did cause or contribute to a psychiatric disorder.

1. The Medical Assessors consider that the most appropriate diagnosis on the basis of the claimant's current presentation, is a Somatic Symptom Disorder in accordance with the diagnostic criteria set out in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR) at page 351 which are as follows:

(a) Criterion A requires "one or more somatic symptoms that are distressing or result in significant disruption of daily life";

(b) Criterion B requires there to be "excessive thought, feelings or behaviours related to the somatic symptoms" manifesting in" at least one of the following:

(i) disproportionate and persistent thoughts about the seriousness of one's symptoms;

(ii) persistently high level of anxiety about health or symptoms, and

(iii) excessive time and energy devoted to these symptoms or health concerns;

(c) Criterion C - the state of being symptomatic is persistent (typically more than six months)

1. The Medical Assessors note that the commentary in DSM-T-5R states[31] that "the diagnosis of somatic symptom disorder and a concurrent medical illness are not mutually exclusive, and these frequently occur together."
2. The commentary also notes that a somatic symptom disorder does not mean the claimant is malingering as the patient's suffering is authentic, regardless of it not being medically explicable.
3. Ms Sidra fulfils the DSM 5 criteria, as she has:

(a) somatic symptoms which are distressing and cause disruption to her daily life - the claimant reported pain in her back and hip and shoulder so severe she could not put her feet on the floor, could not stand and could not clean and wash her body. She has reported elsewhere pain all over her body. She complains of dizziness and headache. Since September 2021 she said she has had difficulty leaving home because of her pain and the frequency of church visits has declined;

(b) she has excessive:

(i) thoughts - she repeatedly said she has fears about dying from her injuries and pains,

(ii) feelings - she has reported to the Medical Assessors and others great distress regarding her pain which he describes as constant and severe and

(iii) behaviours - she avoids activities at home and socially due to her pain, and

(c) Ms Sidra has high levels of anxiety, and she reports being very stressed about the state of her health and her life, and

(d) her symptoms have persisted for more than six months.

1. In terms of the specific type of somatic symptom disorder, the Panel is of the view that the claimant's disorder is "with predominant pain" because the dominant characteristic of her somatic symptoms is pain and the Panel also consider her disorder is "persistent" because she has had severe symptom and marked impairment for more than six months.
2. The records of Dr Dowla, and Ms Sidra's history, indicate that this excessive preoccupation with her physical symptoms was present prior to the subject accident, from at least 2005 when Dr Dowla suggested she had anxiety related symptoms, and she was prescribed Tofranil (an antidepressant) and 2010 such that she was referred to the psychiatrist Dr Way and prescribed Duloxetine. Dr Dowla in 2013 recommended she continue to see Dr Alam, psychiatrist and see Dr Shirin, psychologist and she continued on Tofranil and Loxalate (another antidepressant).
3. The records of Dr Moussad also support the excessive thoughts, feelings and behaviours noting that in August 2020 the claimant reported chronic back pain, reduction in mobility and lifelong disability, with communication issues, lack of social interaction and inability to manage her own care before the current motor accident.
4. The Medical Assessors note that the claimant's own history at the re-examination was that her physical symptoms worsened after the current car accident, and were further worsened by the September 2021 accident. In terms of the September 2021 accident, the Panel notes after that accident the claimant was referred to Dr Way. He records a history from the claimant of being hit by a truck in that accident and she reports significant psychiatric symptoms from that accident which she attributes to that accident. While the September 2020 accident is referred to, the claimant did not complain to Dr Way of any clinically significant symptoms from it.
5. The Medical Assessors are of the clinical opinion that the claimant's Somatic Symptom Disorder was temporarily exacerbated by the subject accident, as a result of worsening of the pre-existing pain and that this exacerbation ceased as a result of the worsening of the claimant's pain after 8 September 2021 accident.

1. The Panel notes the previous diagnoses of other medical assessors and examiners:

(a) 20 June 2022 - Medical Assessor Shen - post-traumatic stress disorder and major depressive disorder caused by the September 2020 accident;

(b) Dr Way diagnosed on 4 October 2022, "major depression with acute PTSD which seems to have been resolving";

(c) 27 March 2023 - Medical Assessor Robertson diagnosed a somatic symptom disorder arising out of the 8 September 2021 accident;

(d) 15 May 2023 - Medical Assessor Sidorov diagnosed an adjustment disorder with mixed anxiety and depressed mood as a result of the 8 September 2021 accident, and

(e) 19 January 2024 - Medical Assessor Shen maintained his diagnosis of a post-traumatic stress disorder and major depressive disorder caused by the September 2020 accident.

1. The Medical Assessors did not find evidence of a depressive disorder as there was no pervasive sadness of mood, no issues with motivation or energy, no reported depressive thoughts such as hopelessness or helplessness and no suicidal thoughts. Ms Sidra's affect was bright and reactive during the re-examination. It is the clinical judgment of the Medical Assessors that their mental state examination findings were not supportive of a diagnosis of a significant, primary mood disorder such as a depressive disorder.
2. The Panel notes that Medical Assessor Sidorov diagnosed an Adjustment Disorder. It is the clinical judgment of the Medical Assessors that a diagnosis of Adjustment Disorder cannot be made where the symptoms meet criteria for another disorder, in this case, Somatic Symptom Disorder.[32]
3. The Medical Assessors did not find evidence for a post-traumatic stress disorder. While the accident may not have been a usual rear-end accident due to the connection of the two motor vehicles by the tow bar and the apparent steps taken to uncouple them, criterion A of a post-traumatic stress disorder requires exposure to death, threatened death, actual or threatened serious injury or actual or threatened sexual violence. The commentary[33] refers to a number of particular stressor events one of which is a "severe motor accident." It is the clinical judgment of the Medical Assessors that the accident as described by the insured and the claimant would not fulfil criteria A for post-traumatic stress disorder, noting Ms Sidra was able to drive her car home and did not seek urgent treatment, which would is not behaviour consistent with the belief that the accident had put her at risk of serious injury or death. Further, she did not describe any current re-experiencing symptoms or significant avoidance symptoms, which are also required for a post-traumatic stress diagnosis. The Panel notes this was a similar observation made by Dr Way in his report of 27 June 2023.
4. The Medical Assessors also considered the possibility of a specific (simple) phobia of car travel, but considering there was no period of complete driving avoidance, and as Ms Sidra says she can still drive outside of her local area to her brother's home, despite her anxiety symptoms, the panel considered that her symptoms do not cause significant functional impact or distress to reach the threshold required for such a diagnosis.

1. In accordance with cl 6.19 before an impairment assessment is undertaken, the state of the condition causing the impairment must be such that it is appropriate to assess. The Medical Assessors are of the view that the claimant's mental health state is static and Ms Sidra's condition stabilised and it is appropriate to assess.
2. Clause 6.21 of the Guidelines says that the evaluation must consider the impairment as it is at the time of the assessment. That is, the Panel must assess the claimant and her condition as she presents at the re-examination.

The separation of physical impairments from psychiatric impairments and pain

1. Clause 6.36 provides that impairment resulting from physical injuries must be assessed separately from any impairment resulting from any psychiatric or psychological injury. This also reflects provisions in the MAI Act. For example, a 5% physical impairment cannot be combined with a 6% WPI from a psychiatric disorder to overcome the 10% threshold.[34]
2. Clause 6.38 provides that a separate allowance for permanent impairment due to pain is not to be assessed and that each chapter of the AMA 4 Guides "includes an allowance for associated pain in the impairment percentages." In other words, the impairment percentages for various conditions includes an allowance for pain that accompanies the condition. Clause 6.38 is important in the light of the Medical Assessors' diagnosis of a Somatic Symptom Disorder which is a psychiatric condition but one which is dependent on the presence of symptoms of illness or injury including pain symptoms.

The assessment of mental and behavioural disorders

1. Clause 6.35 says that psychiatric impairment is assessed in accordance with the Mental and behavioural disorders part of the Guidelines.[35] Clause 6.213 of the Guidelines states that impairment for a mental and behavioural disorder must be attributable to a disorder recognised in the current edition of the DSM or the International Statistical Classification of Diseases and Related Health Problems. The Medical Assessors have diagnosed Ms Sidra with a somatic symptom disorder which is recognised in the current edition of the DSM that is the fifth Edition (text revision) version (DSM-5-TR).
2. As Chapter 14 of the AMA 4 Guides does not allocate percentages for psychiatric impairment, clause 6.203 requires the assessment of a psychiatric impairment to be undertaken in accordance with the Psychiatric Impairment Rating Scale (PIRS) and states that the AMA 4 Guides are "for background or reference [use] only."
3. Importantly in this case, cl 6.215 states that "the PIRS must not be used to measure impairment due to somatoform disorders or pain". As physical injuries are to be assessed separately, and physical injuries causing physical impairments include an allowance for pain, this might explain why somatoform disorders or pain are excluded from the PIRS.
4. Ms Sidra's inability to care for herself, engage in social or recreational activities, travel and function socially are affected by her feelings, thoughts and behaviours about pain. While the Panel doubts there is much accident-related diminution in concentration, persistence and pace (due to the claimant's ability to sustain focus and engagement with the Panel throughout the re-examination), any such impairment is, on the claimant's history related to her thoughts, feelings and behaviours about pain. Finally, the claimant's inability to work, perform her pre-injury roles or discharge other obligations and responsibilities is due to her thoughts, feelings and behaviours about pain.
5. It is the clinical judgment of the Medical Assessors that all of Ms Sidra's psychiatric or psychological symptoms are explained by the diagnosis of Somatic Symptom Disorder. It therefore follows that the claimant's impairment resulting from that disorder cannot be assessed using the PIRS.

1. The Panel is of the view that the claimant has no assessable impairment under the PIRS arising from the Somatic Symptom Disorder. There is no provision in the Guides or the Guidelines which permits the assessment of impairment resulting from this disorder other than the PIRS. The degree of the claimant's WPI resulting from her psychiatric or psychological injury must therefore be assessed at 0%.
2. Medical Assessor Shen diagnosed a post-traumatic stress disorder and persistent depressive disorder and found the degree of the claimant's WPI was 11%.
3. As the Panel has come to a different diagnosis and a different conclusion if follows that Medical Assessor Shen's certificate must be revoked.

[1] The current maximum as of October 2024 is $654,000.

[4] Section 7.21. The current version of the Guidelines is Version 9.3.

[5] The numbers in square brackets are a reference to the section number in the Medical Assessor's reasons.

[6] The numbers in square brackets are a reference to the paragraph number in the submissions.

[7] This would appear to be a reference to the Motor Accident Permanent Impairment Guidelines which apply only to accidents before 1 December 2017 and claims made under the Motor Accident Compensation Act 1999. Identical clauses are contained in the Motor Accident Guidelines at clauses 6.17-6.21.

[8] This would appear to be a reference to the Motor Accident Guidelines which apply to accidents occurring on or after 1 December 2017.

[9] The Panel notes the "proper officer" was the title of the decision-maker in the previous scheme who made the decisions which are now made by the President of the Commission or his delegate pursuant to s 7.26 of the MAI Act.

[10] State Government Insurance Commission v Oakley (1990) 10 MVR 570 (Oakley) and Slade v Insurance Australia Limited t/as NRMA [2020] NSWSC 1031 (Slade).

[11] Uploaded with the claimant's bundle of documents filed on 23 May 2025.

[12] Page 51 and 55 of the additional bundle.

[15] Page 2 of the insurer's additional bundle filed 13 June 2025.

[16] Page 9 of the insurer's additional bundle filed 13 June 2025.

[17] Page 13 of the insurer's additional bundle filed 13 June 2025.

[18] Page 2 of the claimant's additional bundle filed 12 June 2025.

[19] Page 8 of the claimant's additional bundle of documents filed on 12 June 2025.

[20] Page 103 of the claimant's bundle.

[21] Page 102 of the claimant's bundle.

[29] Page 365 of the claimant's bundle.

[32] See criterion C for an Adjustment Disorder at page 319 of DSM-5-TR.

[35] Clause 6.201 provides that impairment must be assessed by a psychiatrist.