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[2004] VSC 324
Supreme Court of Victoria
2004-09-01
Williams J
Original judgment source is linked above.
[2004] VSC 324
Accident Compensation - Workers' Compensation - Medical questions referred to medical panel - Judicial review - Whether medical panel assessed applicant's degree of impairment in accordance with s 91(1)(a) Accident Compensation Act 1985 - Preliminary issue - Adequacy of reasons.
"91 (1) In this Part, a reference to the assessment of a degree of impairment in accordance with this section is a reference to an assessment- (a) made in accordance with- (i) the AMA Guides; or (ii) methods prescribed for the purposes of this section- and in accordance with operational guidelines (if any) as to the use of those Guides or methods issued by the Minister; and (b) if the Minister has approved a training course in the application of those Guides or methods, made by a medical practitioner who had successfully completed such a training course."
S 91 (8) defined the "AMA Guides" as the American Medical Association Guides to the Evaluation of Permanent Impairment (4th Edition) ("the Guides").
"The Injury Model relies especially on evidence of neurologic deficits and uncommon, adverse structural changes, such as fractures, dislocations and loss of motion segment integrity. Under this Model DREs are differentiated using clinical findings that are verifiable using standard medical procedures. With the Injury Model, surgery to treat an impairment does not modify the original impairment estimate, which remains the same in spite of any changes in signs or symptoms that may follow the surgery and irrespective of whether the patient had a favourable or unfavourable response to treatment."[1]
"All persons evaluating impairments according to the Guides criteria are cautioned that either one or the other approach should be used in making the final impairment estimate. If one component were used according to the Guides recommendations, then a final estimate using the other component usually would not be pertinent or germane. However if disagreement exists about the category of the Injury Model in which the patient's impairment belongs, then the Range of Motion Model may be used to provide evidence on the question."[2]
"Description and Verification: The patient has significant signs of radiculopathy, such as (1) loss of relevant reflexes or (2) unilateral atrophy with greater than 2 - cm decrease in circumference compared with the unaffected side, measured at the same distance above or below the elbow. The neurologic impairment may be verified by electrodiagnostic or other criteria ... Structural Inclusions: (1) 25% to 50% compression of one vertebral body; (2) posterior element fracture, but not fracture of transverse or spinous process; a mild displacement disrupts the spinal canal, but the fracture is healed without loss of structural integrity. Radiculopathy may or may not be present. Differentiation from congenital and developmental conditions may be accomplished by examining pre-injury roent-genograms or bone scans performed after onset of the condition. Impairment: 15% whole-person impairment."[3]
The significance of these paragraphs will appear when I consider the adequacy of the reasons given by the panel for its answers to the medical questions.
"7. An impairment assessment of an injured person should be based on the person's clinical status at the time of the examination. Although page 3/100 paragraph 3 [of the Guides] suggests that surgery to treat an impairment does not modify the original impairment irrespective of whether the patient has a favourable or unfavourable response to treatment, the assessment for the purpose of the Victorian legislation is required of the patient's impairment once their impairment has stabilised. The `Injury or DRE Model' allows for post operative improvements to be assessed by listing previous spine operation with various descriptors and catagories (sic) in Table 70 (3/108)."
"[i]f the patient has a condition that meets the definition of a category that includes a structural inclusion, the physician need not determine if the other criteria for that category are present. If the patient demonstrates structural inclusions of two categories, the physician should place the patient in the category with the highest impairment per cent."
"Impairment Assessment of Post Surgical Back Injury Patients The relevant Victorian legislation requires that an injured person is assessed for impairment when their condition has stabilised. ... . It is required to assess an injured person's impairment based on their condition at the time of the assessment. Thus their impairment must be based on their condition after surgery, and will be affected by the outcome of the surgery. It should be pointed out that these concepts are inconsistent with the 4th Edition AMA guides, in which it stated on page 100 `with the injury model, surgery to treat an impairment does not modify the original impairment estimate, which remains the same in spite of any changes in signs or symptoms that may follow the surgery and irrespective of whether the patient has a favourable or unfavourable response to treatment'. Nevertheless, the Victorian requirements are that the impairment will be assessed when the person's condition is stable and assessed according to their impairment at the time of assessment. The Spine Reference Group therefore makes the following recommendations regarding applying Table 70 `Spine Impairment Categories' (3/108) to patients with previous spine operations. These should be used instead of the `previous spine operation' sections of the Table 70, as the Victorian requirements take precedence over the Guides. PATIENT'S CONDITION CATEGORY Previous spine operation (PSO) without loss of motion integrity Or radiculopathy II PSO with radiculopathy III PSO with loss of motion segment integrity IV PSO with loss of motion segment integrity and Radiculopathy V PSO with cauda equina syndrome without bladder or bowel involvement VI PSO with cauda equina syndrome with bladder or bowel involvement VII PSO with paraplegia VIII ... Previous surgery with residual pain but without evidence of loss of motion segment integrity or radiculopathy or cauda equina syndrome will fit into Category II. There may be dispute regarding this method of handling post spine surgery impairment, but the reference group believes that it is the correct application of the 4th Edition AMA Guides considering the Victorian requirements. A challenge may occur in due course, but the purpose of the presentation is to produce uniformity of application of the Guides."
The various assessments of the applicant's degree of impairment
"Firstly I do not think that anyone knows what the correct table to be used with respect to the impairment assessment is, as this I imagine is something that it is open to interpretation in the courts. I have used my understanding of the tables to reach my conclusions."
Mr Love had noted that combining the impairment assessments would have resulted in a whole person impairment at 24%.
"I have reviewed the records you forwarded to me on Paul John Taylor and would have the following comment. In the 4th Edition of the AMA Guides, we considered the result of the injury, not the treatment. Therefore the fusion has no impact on his impairment. Since this man has sustained an injury, he should be evaluated by the DRE method. Since he demonstrates 5 mm of translation of one cervical vertebra on another, he meets the definition of loss of structure integrity and therefore would qualify for DRE cervical-thoracic category IV and a resultant 25% impairment to the body as a whole. The fact that he has had surgery and improved is not considered in the 4th Edition of the AMA Guides, unlike the 5th."
"1. What is the degree of impairment resulting from the accepted injury/s assessed in accordance with Section 91 and is the impairment permanent? 2. Does the worker have an accepted injury, which has resulted in a total loss injury mentioned in the table in Section 98E(1)?"
"We submit that these 2 paragraphs unequivocally assert that surgery does not modify an original impairment. On this issue we draw your attention to the report/letter of Mr Robert H Harlason (sic) dated 10 June 2003 which states:
`The fact that he has had surgery and improved is not considered in the 4th Edition of the AMA Guides, unlike the 5th'.
2. We also submit that modification undertaken by the spinal reference group of the medical panel cannot alter the explicit provisions of S.91 which requires an assessment to be made in accordance with the Guides. 3. We also submit that the application of the DRE model without modification for the effective surgery is entirely consistent with that assessment method as it is based on predicted rather than actual outcomes."
Question 1. " In the Panel's opinion the worker has a 16% whole person impairment resulting from the accepted injuries to the toes and neck when assessed in accordance with Section 91 of the Act. The degree of impairment is permanent." Question 2. "No."
"The Panel reviewed X-Rays dated 27 November 1997 that showed a dislocated IP joint of the left great toe. X-Rays of the neck dated 13 February 1998 and 17 February 1998 showed anterior subluxation of C6 on C7. CT scan taken on the same date confirmed the subluxation and demonstrated a fracture of the right lateral mass of C6. Post-operative X-Rays dated 12 May 1998 show the presence of an anterior fusion of C6-7 using a plate, screws and bone graft. Alignment had almost been restored but there was minimal displacement still present in the fused segment. The Panel concluded that the worker suffering (sic) from residual dysfunction of the neck, but without clinical evidence of radiculopathy, secondary to a fracture dislocation of C6-7, treated operatively, relevant to the accepted neck injury. ... The Panel conducted an impairment assessment in accordance with the AMA Guides to the Evaluation of Permanent Impairment (4th Edition, 3rd Reprint) as required by Section 91 of the Act. The Panel considered that no further information was required from the worker's treating practitioners to carry out the assessment. The Panel carried out the assessment of the accepted neck injury in accordance with the Specific Procedures and Directions in Section 3.3f on page 101 of the Guides and the instructions from the Training Course approved by the Minister. The Panel assessed the worker's neck in accordance with Table 70 of Chapter Three and concluded that there is clinical evidence of neck injury, together with clinical evidence of structural inclusions comprising a posterior element fracture that has been operatively stabilised and healed without loss of structural integrity, but with residual mild displacement that disrupts the spinal canal. There is no clinical evidence of radiculopathy or cord injury. The Panel therefore concluded that the appropriate impairment category for the cervicothoracic spine is DRE Category III pursuant to Table 73 of Chapter Three, resulting in a 15 % of whole person impairment. The Panel considered that the use of the Range of Motion Model was inappropriate as the worker's neck impairment could be adequately assessed using the Diagnosis Related Estimates Model."
"The panel appears to have based its assessment of the level of impairment on clinical findings after surgery. The panel has not provided reasons for this approach despite the fact that it appears to be in direct contradiction to the Guides. We request that the panel provide further and better reasons for its opinion and assessment."
"(a) The Tribunal failed to assess the degree of the Applicant's impairment in the manner required by sections 98C and 91 of the Act and in accordance with the provisions of the American Medical Association Guides to the Evaluation of Permanent Impairment, Fourth Edition ("the Guides"); (b) If the Tribunal had regard to material other than the Guides, the Tribunal failed to disclose this information to the Applicant prior to reaching its decision and thereby was in breach of the rules of natural justice; (c) The Tribunal failed to take into account relevant considerations, namely the state of the Applicant's injury pre-surgery; (d) The Tribunal took into account irrelevant considerations, namely the effect of surgery on the Applicant's injury; (da) If the Tribunal was bound to take into account the effect of surgery upon the Applicant's spinal injury, the Tribunal erred by not applying the Range of Motion Model in order to assess the degree of permanent impairments; (e) The Tribunal failed to provide adequate or sufficient reasons for its decisions."
(a) John Alexander Binney of the applicant's solicitors, Belbridge Hague, sworn on 30 January 2004 and 5 February 2004, respectively, together with their exhibits;
(b) Jennifer Betty Lush of Slater & Gordon, the Melbourne agents of the applicant's solicitors, affirmed on 6 February 2004 and 9 February 2004, respectively, together with the exhibits to the 6 February 2004 affidavit; and
(c) Francis Thomas McDermott, a surgeon, sworn on 15 April 2004.
(a) Mr Geoffrey Klug sworn on 19 March 2004 together with its exhibits;
(b) Dr Peter Gibbons sworn on 19 March 2004 together with its exhibits; and
(c) Anastasia Coutsouvelis, of the first respondent's solicitors, sworn on 22 July 2004.
Submissions
The adequacy of the reasons - a preliminary issue
(a) how the instructions from the training course had been followed in making the assessment, including:
(i) whether the applicant's pre or post operative condition had been assessed;
(ii) whether the applicant's condition had been categorised using the suggested amended Table 70;
(b) how the degree of impairment had been calculated under the Guides, including:
(i) why the applicant's degree of impairment had been calculated under Table 73 of the Guides in the absence of findings of clinical evidence of radiculopathy or cord injury;
(ii) whether differentiators, including the ROM model, had been applied in the use of the DRE model;
(c) how the panel had responded to the submissions made in the applicant's solicitors' letter of 11 November 2003.
(a) it could be discerned from the language of the panel that it had assessed the post operative state of the applicant;
(b) the panel had assessed the applicant's condition for the purpose of categorising his degree of impairment under Table 73 with reference to Table 70 as it stood in the Guides, rather than in the amended form suggested by the training course notes; and
(c) the applicant's condition could only have been categorised in Category III if the panel had had regard to the notes relating to the presence of "structural inclusions" on page 104 of the Guides set out above at [11].
"In the case of total absence of reasons, the object of such provisions is better served by compelling the delivery of reasons rather than by outright quashing of the decision: but cf. De Smith, Judicial Review of Administrative Action, 4th Ed, p. 151 and Clarke v Wellington Rent Appeal Board [1975] 2 NZLR 24 at p.27. However, where the reasons are partly defective, in the sense that not all issues have been dealt with, then an order compelling delivery of further or better reasons would have an air of unreality about it. Such an order would merely give a tribunal an opportunity to patch up what has been shown to be defective in circumstances where it is more likely that the tribunal overlooked the issue altogether."
"It may be conceded that Parliament did not require the opinion given to take the form of a judgment but that does not mean that it did not consider it appropriate that, when asked, such panels should not give sufficient explanation of their reasoning as to enable a review thereof by the Supreme Court either under the Administrative Law Act or otherwise by judicial review."
"In the present context, they are medical reasons in sufficient detail, and only in sufficient detail, to show the court and the worker that the question referred to the panel has been properly considered according to law and that the opinion furnished is founded on an appropriate application of the members' medical knowledge and experience."
[5] Masters v McCubbery [1996] 1VR 636 at 650 per Winneke P.
[7] [1985] HCA 81; [1985] 159 CLR 550 at 583 per Mason J
[8] 70 ALR 554 at 572 per Burchett J
[9] [2002] FCA 1105; 192 ALR 385 at 387-8 per Finkelstein J
[10] [1999] VSC 249 at [39]- [43] and [51] per Smith J
[11] [1986] HCA 54; (1986) 161 CLR 141 at 145 per Mason, Wilson, Brennan, Deane and Dawson JJ
[12] (2000)204 CLR 82 at 116 per Gaudron and Gummow JJ, 153-4 per Callinan J
[13] Masters v McCubbery [1995] VICSC 209; [1996] 1 VR 635 at 640 per Winneke P
[14] Craig v South Australia [1995] HCA 58; (1994-5) 184 CLR 163 at 179 per Brennan, Deane, Toohey, Gaudron and McHugh JJ
[16] [1996] HCA 6; (1996) 185 CLR 259 at 271-2 per Brennan CJ, Toohey, McHugh and Gummow JJ
[17] see Re Refugee Tribunal; ex p Aala [2000] HCA 57; (2000) 204 CLR 82 at 116 per Gaudron and Gummow JJ
Taylor
Mountain Pine Furniture Pty Ltd [2004] VSC 324
(1986) 161 CLR 141
(1996) 185 CLR 259
(2000) 204 CLR 82