AAI Limited t/as GIO v Iliev
[2024] NSWPICMP 299
•16 May 2024
| DETERMINATION OF REVIEW PANEL | |
| CITATION: | AAI Limited t/as GIO v Iliev [2024] NSWPICMP 299 |
| CLAIMANT: | Gueorgui Iliev |
| INSURER: | AAI Limited trading as GIO |
| REVIEW PANEL | |
| MEMBER: | Terence Stern OAM |
| MEDICAL ASSESSOR: | David Gorman |
| MEDICAL ASSESSOR: | Shane Moloney |
| DATE OF DECISION: | 16 May 2024 |
| CATCHWORDS: | MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; claimant suffered injury in a motor vehicle accident on 13 February 2019; Medical Assessor (MA) Home determined that the injuries referred by the Personal Injury Commission and caused by the accident gave rise to whole person impairment (WPI) of 12%; the Medical Review Panel considered the issue of causation according to the Guidelines and determined WPI on the clinical signs on examination found at the time of the assessment by the Review Panel; the Review Panel certified that the injuries referred and caused by the accident equated to a total WPI of 7%; Held – the certificate of MA Home was revoked and a new certificate issued. |
| DETERMINATIONS MADE: | CERTIFICATE OF DETERMINATION 1. The Review Panel revokes the certificate of Medical Assessor Home, dated 7 December 2023. 2. The Review Panel substitutes the determination and certifies that the injuries caused by the motor accident and referred to the Review Panel, give rise to a whole person impairment of 7%. |
STATEMENT OF REASONS
INTRODUCTION
On 13 February 2019, Gueorgui Iliev (the claimant) was a passenger in a vehicle being driven by his son when a bus failed to give way and collided with the left rear side.
A full description of the accident is below.
Mr Iliev has brought a claim for common law damages under the Motor Accident Injuries Act 2017 (the MAI Act).
AAI Limited ABN 48 005 297 807 trading as GIO (the insurer) is the relevant insurer with liability to pay any damages to Mr Iliev.
Section 4.11 of the MAI Act provides that there is no entitlement to damages for non-economic loss unless the degree of permanent impairment of the injured person as a result of the injury caused by the accident is greater than 10%.
This dispute is in relation to whether the degree of permanent impairment sustained by Mr Iliev as a result of the injury caused by the accident is greater than 10%. This constitutes a medical assessment matter pursuant to Schedule 2, cl 2 of the MAI Act.
A medical assessment matter is determined in accordance with Division 7.5 of the MAI Act by a Medical Assessor.
The dispute as to permanent impairment was referred to Medical Assessor Alan Home who issued a certificate dated 7 December 2023.
REVIEW PROCEDURE
The insurer sought a review of the medical assessment of Medical Assessor Home.
The review provisions provide that a review panel consists of two Medical Assessors and a member assigned to the Motor Accidents Division of the Personal Injury Commission (the Commission). Accordingly, the President’s delegate referred the matter to this Review Panel (Panel) to assess.
Part 5 of the Personal Injury Commission Act 2020 (PIC Act) enables the Commission to make rules with respect to the practice and procedure before the Commission including proceedings before a panel reviewing a decision of a Medical Assessor.
12.Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the PIC Act. A review panel determines how it conducts and determines the proceedings and may determine the proceedings solely based on the written application.
The review is by way of a new assessment of all matters with which the medical assessment is concerned. However, s 7.25 of the MAI Act provides that the review of a medical assessment can be made on the basis of any agreement by the parties as to the degree of permanent impairment from a particular injury and whether a particular injury was caused by the accident, without those matters having to be the subject of assessment.
On 21 March 2024, the Panel agreed an examination was necessary.
RELEVANT LEGAL AUTHORITY
Section 7.21 of the MAI Act provides that the degree of permanent impairment of an injured person is to be assessed in accordance with the Motor Accident Guidelines (the Guidelines).
The Guidelines were issued pursuant to Division 10.2 of the MAI Act and adopt the American Medical Association’s Guides to the Evaluation of Permanent Impairment, Fourth Edition (AMA 4 Guides). The Guidelines are definitive with regard to the matters they address but where they are silent on an issue, the AMA 4 Guides should be followed.
Causation of injury is addressed under Part 6 of the Guidelines dealing with permanent impairment:
“6.6 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.
6.7 There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be a sole cause as long as it is a contributing cause, which is more than negligible. Considering the question 'Would this injury (or impairment) have occurred if not for the accident?' may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes.”
CERTIFICATE OF MEDICAL ASSESSOR HOME
Medical Assessor Home examined Mr Iliev on 27 November 2023, and issued a certificate under s 7.23 of the MAI Act.
The following injuries were referred to Medical Assessor Home for assessment:
(a) cervical spine: neck (aggravation) / discogenic / disc prolapses;
(b) lumbar spine back (aggravation) / discogenic / disc prolapses;
(c) left shoulder (aggravation) / rotator cuff injury;
(d) right shoulder (aggravation) / rotator cuff injury, and
(e) thoracic spine aggravation injury.
At [3] and [4] in his reasons, Medical Assessor Home considered both parties submissions.
He at [8] took a pre accident history. Mr Iliev confirmed a past history of a motor vehicle that occurred in 2008, in which his vehicle was struck by a semitrailer. He recalled injuries to his neck, back and both shoulders.
Mr Iliev recalled that he then worked at a factory in Wetherill Park punching metal. He recalled that he slipped downstairs, injuring his head and back. This resulted in a workers compensation claim which was finalised around 2013. He did not return to work.
Mr Iliev told Medical Assessor Home he recalled symptoms of pain in his neck, back and both shoulders in the period leading up to the subject accident. He believed that his symptoms were of mild severity. He recalled that he did not require medication at that time.
Medical Assessor Home took a history of the motor accident at [9] and a history of symptoms and subsequent treatment at [10]:
“In February 2019 he was involved in a motor vehicle accident as the rear left-sided seat-belted passenger in a Toyota Yaris sedan driven by his son on Darlinghurst Road in Darlington, when a bus, that was attempting to change lanes, impacted the vehicle on the left passenger side and pushing the car to the right. There was no secondary collision. Police and ambulance did not attend. He was subsequently transported from the scene of the crash by his son. He was taken home. Later that day he attended Dr Kaur, his general practitioner. He recalls that he was referred for physical therapy, but funding did not ensue. He attended Dr Maniam who arranged further scans of his neck and left shoulder, performed 4 March 2019. Dr Maniam arranged injection to the cervical spine. Mr Iliev recalls mild symptom benefit for two days before the symptoms returned to the previous level. More recently, he underwent further MRI scans of the lumbar spine. He underwent a CT-guided epidural injection. He recalls no…durable benefit following the procedure.”
Mr Iliev was taking Endone 5mg, Voltaren anti-inflammatory medication 50mg, and Paracetamol two to four tablets daily.
He described current symptoms of constant neck pain, average intensity 6 out of 10, more severe on the left side with difficulty moving his neck in all directions. He reported constant pain to the right shoulder of moderate severity. There was difficulty raising his arm above the horizontal. He described inability to sleep over his right side at night.
At the left shoulder, he had similar symptoms, but pain was less severe on the left.
He reported constant low back pain, average intensity 9 out of 10, more severe on the right side.
Pain, paraesthesia and numbness were worse in the morning when he woke.
Medical Assessor Home conducted a clinical examination. The results were set out in his reasons at [12]:
“General presentation
Mr Iliev is a 66-year-old, standing 166 centimetres and weighing 68 kilograms.
Cervical Spine
Examination of the cervical spine reveals normal spinal curvature. There is no muscle spasm. Active spinal motion is measured as follows: flexion half-normal range, extension half-normal range, right rotation one-third normal range, left rotation one-third normal range, right lateral flexion one-fifth normal range, left lateral flexion one-fifth normal range. There is normal myotomal power in all muscle groups. There is reduced sensibility in the left arm in a non-dermatomal pattern extending from the left shoulder to all the fingertips of the left hand. The deep tendon reflexes are symmetrically preserved. There is no muscle wasting.
Thoracolumbar Spine
On examination of the thoracolumbar spine he had normal spinal curvature and no muscle spasm. Thoracic rotation is symmetrically performed to one-fifth normal range, lumbar flexion performed to half-normal range, extension half-normal range, right lateral flexion half-normal range and left lateral flexion half-normal range. There is normal lower limb power in all myotomes. Deep tendon reflexes are symmetrically preserved. There is no measurable muscle wasting.
There is reduced sensibility declared in the right lower extremity elicited from the right hip to all the toes of the right foot in a non-dermatomal pattern.
Right Shoulder
At the right shoulder, active motion measured by goniometer is as follows:
Shoulder Movements
Active ROM Measured RIGHT
Flexion
90°
Extension
50°
Adduction
40°
Abduction
80°
Internal Rotation
30°
External Rotation
70°
Left shoulder
At the left shoulder, active motion measured by goniometer is as follows:
Shoulder Movements
Active ROM Measured RIGHT
Flexion
110°
Extension
50°
Adduction
40°
Abduction
90°
Internal Rotation
40°
External Rotation
80°”
At [14]-[15], Medical Assessor Home provided a summary of the relevant radiological and medical imaging, which the Panel considered below.
Medical Assessor Home, in diagnosis and causation, noted that Mr Iliev was involved in a motor vehicle accident in which he reportedly suffered subsequent complaints of pain in the neck, back and both shoulders.
He further noted that there is a past history of neck, back and bilateral shoulder pain documented by Dr Maniam.
He concluded the mechanism of accident was a collision with the left side of the car.
He was satisfied that it was plausible that Mr Iliev suffered injury to the left shoulder, either with direct impact to the door, or seatbelt contusion.
He was not satisfied that the claimant sustained a significant injury to the right shoulder given the mechanism of the accident. There was a prior history of extensive investigation of the right shoulder for a pre-existing right shoulder full thickness rotator cuff tear. The mechanism was not consistent with causing a material injury to the right shoulder.
Medical Assessor Home concluded that the following injury was caused by the motor accident:
(a) cervical spine: soft tissue injury;
(b) thoracic spine soft tissue injury;
(c) left shoulder: aggravation of pre-existing condition, and
(d) lumbar spine: aggravation of pre-existing lumbar spondylosis.
Medical Assessor Home concluded that the following injury was not caused by the motor accident:
(a) right shoulder rotator cuff tear.
Medical Assessor Home set out his findings for permanent impairment in a table at [19].
He concluded that the degree of permanent impairment caused by the motor accident was 12%.
SUBMISSIONS
Insurer’s submissions
The insurer provided written submissions dated 21 December in respect of the review. The submissions are summarised below.
The insurer submitted that the assessment is incorrect in that the Medical Assessor has:
(a) applied the wrong criteria in assessing permanent impairment, and
(b) failed to set out any reasoning, or alternatively the actual path of reasoning, supporting his findings of permanent impairment at the cervical spine.
Applying the s 7.31(7) and Wingfoot Australia Partners Pty Ltd v Kocak (2013) 252 CLR 480, Medical Assessor Home was required to provide a path of reasoning as to his findings of impairment for each injury arising from this accident.
The primary method disclosed for the assessment of diagnosis-related estimate (DRE) II at the cervical spine is “complaints of neck pain” and “asymmetrical spinal motion (dysmetria).” It appeared the Medical Assessor had assessed this spinal segment in accordance with Chapter 3, page 104 of the AMA 4 Guides which expressly refers to Table 73 of the AMA 4 Guides. This was in contravention of clause 6.2 of the Guidelines.
The reliance on the AMA 4 Guides constitutes the entirety of the Medical Assessor’s path of reasoning. Once it is accepted that this represents an error, one is left with no path of reasoning whatsoever, and the assessment is not compliant with s 7.21(7) or with the requirement to set out a path of reasoning.
The insurer further submitted that there is nothing in the examination which could satisfy the criteria for findings of DRE II pursuant to Table 6.8 of the Guidelines.
Claimant’s submissions in reply
Mr Iliev provided submissions in reply dated 22 February 2024, in respect of the review.
Mr Iliev submitted he relies on the Medical Assessment Certificate of Medical Assessor Home dated 7 December 2023.
MEDICAL EVIDENCE
Application for personal injury benefits
Mr Iliev completed the personal injury benefits form on 2 April 2019. He described the motor vehicle accident as:
“I was a passenger in a car driven by my son. We were heading north on Darlinghurst Rd in the right lane. A bus which was travelling in the left lane collided with the left rear of our car.”
Mr Iliev listed the following injuries as result of the motor accident:
“…neck, back, both shoulders, psychological injuries”
Certificate of Capacity, completed by Dr Surinder Kaur
The Certificate of Capacity dated 26 March 2019 sets out the injuries suffered by Mr Iliev as:
“Injury neck, lower back and both shoulders”
Dr Kaur lists the following management plan:
“MRI, cortisone injection”.
Reports of Dr Maniam (orthopaedic surgeon)
Dr Vijay Maniam, orthopaedic surgeon, provided a report dated 29 May 2019. Dr Maniam reported Mr Iliev was known to him previously and over the years had treated him for injuries sustained during the course of his work and in previous motor vehicle accidents. The areas treated previously were related to the cervical spine, lumbar spine, both shoulders and the right elbow.
He further commented that:
“In the more recent incident on 13/2/2019 he suffered injuries to the cervical spine and both shoulders.
It was a rear end/side collision when the car that he was travelling in was hit on the rear and the left side by a bus.
The emergency services were not called but he reported to his family doctor on the same day of the incident.
Through a referral from Dr Surinder Kaur, of Bankstown, he came to see me for further treatments.
The complaints made at the initial consultation date were that of cervical spine pain with radiation into the left upper extremity and bilateral shoulder pains of severe intensity, with movement restricted by more than 50% of normal.
Gueorgui lliev indicated that the symptoms from the previous episodes had somewhat regressed. He was not working at the time of the accident.
On examination the cervical spine exhibited restricted movements and spasmodic muscles and there were signs of impingement of the left C6 nerve root.
In the shoulders there was bilateral shoulder movement restriction with positive impingement but absence of any apprehension.
At the initial consultation, he had not commenced on any treatment, due to the lack of approval from yourselves.
He reported about a gradual deterioration in the hands since suffering injuries in the incident on 13/2/2019.
In his follow up visits multiple investigative tests were obtained and these revealed the following pertinent findings.
1. MRI cervical spine
Discovertebral changes throughout the cervical spine, with a left paracentral and paraforaminal C5/6 disc protrusion with compression of the left end cord and impingement on the left C6 nerve root.
2. MRI right shoulder
AC joint arthropathy.
Lateral arch impingement.
Subacromial subdeltoid bursal inflammation.
Full thickness retracted tear of the anterior mid supraspinatus.
Rotator cable/superior joint capsule tear.
3. MRI left shoulder- 4/3/2019
Full thickness retraction of the supraspinatus with fraying and irregularity of the retracted tendon margin.
AC joint arthropathy.
Subacromial/subdeltoid inflammation.
Degenerative change in the anterior labrum between 3 and 4 o'clock.
The treatment plan that has been formulated are:
i. an opinion from a neurosurgeon in relation to the left C6 impingement.
ii. In the interim a CT guided perineural injection would be beneficial.
iii. There are no other options for the right and left shoulder where a subacromial decompression and repair of the rotator cuff tendons will have to be undertaken.”
Dr Vijay Maniam, orthopaedic surgeon, provided a report dated 12 September 2019 with a diagnosis of bilateral rotator cuff tears. Dr Maniam made reference to radiological investigations showing evidence of tears to both shoulders, however, did not make reference to dates of such investigations.
Report of Dr Peter Conrad dated 31 May 2021
The report of Dr Conrad dated 31 May 2021 set out at least three motor vehicle accidents prior to the subject accident. On 5 August 2018 injuries to the neck and back, and unrelated rotator cuff problems of both shoulders was recorded. A further motor vehicle accident of 6 June 2009 caused neck, back, right elbow injuries and headaches. Another accident occurred in September 2016 which caused pain in the neck, shoulders and back.
Dr Conrad further commented:
“There is evidence that the shoulders have longstanding rotator cuff injuries and up-to-date MRI scans show considerable damage to both shoulders including rotator cuff tears. He has evidence of discal damage both in his neck and back as shown on MRI scans.”
Report of Dr Anthony Smith dated 15 July 2021
Dr Smith reported that Mr Iliev had spinal degenerative disease, and bilateral rotator cuff disease. He found that all the changes were described in the MRI of the neck and both shoulders would predate the motor vehicle accident.
He further commented that there was a low likelihood the rotator cuff tears being the result of wearing a seatbelt, as osteophytes and enthesophytes take years to grow. Dr Smith opined that the claimant was manufacturing physical signs, with gross inconsistencies.
Allied Health Recovery Request – Physiotherapy No. 1 dated 30 April 2019
Roger Berbari reported a diagnosis of cervical spine, whiplash, lumbar spine, bilateral shoulders. Current signs and symptoms were reported to include the following:
(a) tender paracervical muscles, Thoracic upper mid paravertebral, lumbar paravertebral muscles and bilateral subacromial space;
(b) cervical spine – flexion, extension, lateral right flexion, lateral left flexion – 1/2;
(c) lumbar spine – flexion – knee joint line, extension 1/4, lateral right flexion 3/4, lateral left flexion – mid thoracic;
(d) left shoulder – flexion 80 degrees, abduction 60 degrees, adduction – work in progress and,
(e) right shoulder – flexion 140 degrees, abduction 120 degrees, adduction – 40 degrees.
THE PANEL
The Panel’s examination
Medical Assessor Moloney conducted an examination of Mr Iliev on 26 April 2024, on behalf of the Panel.
Pre-accident history
Mr Iliev lived with his wife. He had been on a disability pension since 2013 and was unsure of the reason for this but thought it was his back and a mental condition. He could not recall the details of an accident in 2008 and remembered he had a Workcover injury in 2013 when he injured his neck and right shoulder. He also could not recall a previous accident in 2015 or the injury sustained in it.
History of motor accident
Mr Iliev stated that his son was driving a Toyota Yaris on 13 February 2019 when a bus failed to give way and collided with the left rear side of their car. He said that he was shocked and his son was able to drive home. The ambulance and police did not attend the scene. He was wearing a seatbelt at the time, but airbags did not deploy. He attended his general practitioner, Dr Kaur on the day of the accident.
History of symptoms and treatment following the motor accident
Dr Kaur referred him for scans of his neck and shoulders and then referred him to an orthopaedic surgeon, Dr Maniam, who organised MRIs. He stated physiotherapy gave some benefit and he was prescribed analgesics. He said at that time, he had pain in the neck, lower back and both shoulders. Dr Maniam organised injections into the lumbar and cervical spine which initially helped but the pain recurred. He also said that Dr Maniam wanted to operate on the right shoulder but said that no injections were administered to the right shoulder.
Present treatment
At present, medication was Voltaren 50mg One-A-Day, Panadol two per day, Endone 5mg at night and another analgesic which he could not remember the name of. He had physiotherapy once per week which helped but was self-funded.
There had been no further injuries or accidents since this motor vehicle accident.
Current symptoms
There was pain in the shoulders and right upper arm with stiffness in the neck particularly in the morning and constant pain. He woke with numbness in both hands each morning. There was low back pain with pain and numbness in a global distribution in the entire left leg. He had a poor sleep pattern due to pain.
Mr Iliev undertook light duties at home and went for walks and drove short distances such as to the local shops.
Clinical examination
Mr Iliev walked in the rooms with a normal gait but sat with a depressed affect and was teary at times. He stated that he is right-handed. His weight was 66.7kg and height measured at 166cm.
Cervical spine
On inspection of the cervical spine there was a normal curvature and on testing range of movement, flexion/extension was 50% of expected range and side bending, rotation was 30% of expected range bilaterally with no asymmetry. On palpation there was sensitivity to light touch over the entire cervical spine region, but no guarding or spasm was noted.
On neurological examination of the upper limbs, reflexes were equal bilaterally with normal power with a vague decrease in sensation to light touch in the entire left arm which was not in a dermatomal pattern. No muscle wasting was apparent with the circumference of the upper arms on the right 25.5cm and 25cm left (10cm above the olecranon process) and in the upper forearms 24.5cm in the right and 24cm on the left (5cm below the olecranon process).
Thoracic spine
On examination there was a normal contour and on palpation no guarding or spasm was noted. On testing range of movement flexion/extension was 50% of expected range as was side bending bilaterally. Rotation was limited to 40% of expected range bilaterally with no asymmetry. There were no signs of non-verifiable radicular complaint or radiculopathy in the thoracic spine region.
Lumbar spine
Mr Iliev walked with a normal gait but had difficulty standing on his heels and toes and felt unbalanced when squatting. On testing range of movement, flexion/extension was 60% of normal range as was side bending with no asymmetry. Straight leg raise on lying was 70° bilaterally but 80° when seated with negative sciatic nerve root tension signs.
On palpation there was tenderness over the lumbosacral junction, but no guarding or spasm noted in the lumbar musculature.
On neurological examination of the lower limbs reflexes were equal bilaterally with normal power and no muscle wasting was noted. The circumferences of the lower thighs 38cm bilaterally (10cm above the superior patella pole) and at the maximum circumference of the calves 32cm bilaterally. On testing for sensation there was a global decrease in sensation in the left leg to light touch and pinprick testing which was not in a dermatomal pattern.
Shoulders
On examination of the shoulders, no muscle wasting was apparent and on passive movement there was active resistance at 90° flexion and abduction which he says was due to pain in the upper arms and not in the shoulder joint or cervical spine. On passive movement no crepitus was detected and impingement tests were negative. Active movements were measured using a goniometer and repeated three times.
Shoulder Movements Active ROM Measured
RIGHT
Active ROM Measured
LEFTFlexion 100°/90° 110 = 5% UEI Extension 40° 40°= 1 % UEI Adduction 30° 40° = 0 % UEI Abduction 80°/90° 90 = 4 % UEI Internal Rotation 80°/70°/60° 60= 2 % UEI External Rotation 80°/70° 70° = 0 % UEI
Mr Iliev stated that all shoulder movements were limited due to pain in the upper arms not in the glenohumeral joint and there was no referral of pain from the cervical spine during any movement. The Medical Assessor explained to Mr Iliev that there were inconsistencies on testing range of movement of the shoulders and in comparison, to previous examinations. In particular the physiotherapist recorded 140° of flexion of the right shoulder and 120° of abduction two months after the accident and in 2021 Dr Smith recorded minimal movement of both shoulders.
Consideration of the parties’ submissions
At the first Panel meeting on 21 March 2023, the Panel concluded it would be necessary to conduct an examination in order to address the parties’ submissions in relation to the motor accident.
The insurer submitted that the Medical Assessor failed to set out any reasoning, or the actual path of reasoning, supporting his findings of permanent impairment at the cervical spine.
The Medical Assessors conducted a physical examination of the claimant, the results set out above.
The Panel found in comparison to the assessment of Medical Assessor Home, there was no dysmetria of the cervical spine. The Panel noted that in Medical Assessor Home's examination he also recorded no asymmetry in each of the three planes and should not have found dysmetria.
The Panel noted that it was well accepted that whole person impairment (WPI) is determined on the clinical signs on examination, found at the time of the assessment by the Panel, as against the time of the assessment by the Medical Assessor.
Permanent Impairment
The lumbar and thoracic spines were DRE 1 which was 0% WPI.
The Panel agreed with Medical Assessor Home in that the right shoulder was not injured in the subject accident, noting that he was sitting in the passenger side rear seat and the seatbelt would have been across the left shoulder. Furthermore, there was documentation of pre-existing injuries to the right shoulder with a full thickness supraspinatus tear. Thus, the uninjured right shoulder can’t be used as a baseline.
The Panel had assessed the left shoulder using range of movement on the day of his examination. Using figures 38,41 and 44 of AMA 4 Guides the upper extremity impairment adds to 12 % which converted to 7% WPI using Table 3.
Conclusion
The Panel revokes the certificate of Medical Assessor Home, dated 7 December 2023.
The Panel substitutes the determination and certifies that the injuries caused by the motor accident and referred to the Panel, give rise to a permanent impairment of 7%.
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