Abdul-Raouf v QBE Insurance (Australia) Limited

DETERMINATION OF REVIEW PANEL
CITATION:	Abdul-Raouf v QBE Insurance (Australia) Limited [2025] NSWPICMP 717
CLAIMANT:	Farkunda Abdul-Raouf
INSURER:	QBE (Insurance) Australia Limited
REVIEW PANEL
MEMBER:	Terence O’Riain
MEDICAL ASSESSOR:	Wayne Mason
MEDICAL ASSESSOR:	Alan Doris
DATE OF DECISION:	17 September 2025
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; assessment of threshold psychological injury under section 1.6(3); claimant suffered injury in a motor vehicle accident; psychological conditions existing before accident; Medical Assessor found the claimant did not sustain a psychological injury as a result of the accident; claimant sought review; Held – claimant had sustained exacerbations of pre-existing post-traumatic stress disorder, cannabis use disorder, and somatic symptom disorder (predominant pain) caused by the accident; certificate revoked; not a threshold injury.
DETERMINATIONS MADE:	CERTIFICATE OF DETERMINATION Assessment of threshold injury Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017 1. The Review Panel revokes the certificate of Medical Assessor Verma dated 1 January 2024. 2. The Panel certifies that the following injuries caused by the accident were not threshold injuries: · exacerbation of pre-existing post-traumatic stress disorder; · exacerbation of a cannabis use disorder, and · exacerbation of a somatic symptom disorder (predominant pain).

REASONS

BACKGROUND

Farkunda Abdul-Raouf (the claimant) was injured in a car accident on 29 March 2023.
The insurer is liable for the claimant's entitlements to statutory benefits and damages following the Motor Accident Injuries Act 2017 (MAI Act).
A dispute arose because the insurer classified the claimant's psychiatric condition arising from the accident as a threshold injury under the definition in s 1.6 of the MAI Act.
That classification affects the claimant's continuing entitlement to statutory benefits and common law damages.
The claimant disputed the insurer's decision and filed an Application to Resolve a Medical Dispute in the Personal Injury Commission (Commission).
Medical Assessor Surabhi Verma issued a certificate date 1 January 2024 which found the claimant had a major depressive order with anxious distress but found the accident did not cause that condition. The Medical Assessor declined to assess whether the condition was a threshold injury.
The claimant applied under s 7.26 of the MAI Act to refer the medical assessment to a Review Panel on the grounds that the medical assessment was incorrect in a material respect. The insurer opposed that application.
The Presidential delegate decided to refer the assessment to a Review Panel (Panel) on

11 April 2024.
The Commission President constituted this Panel to review Medical Assessor Surabhi Verma’s assessment dated 1 January 2024.
This Panel met on 17 April 2025.
The Panel noted the claimant's treating psychiatrist Dr Shreshtha’s clinical notes were not included with the bundles. To facilitate assessing this matter the Panel directed the parties to provide copies of those notes.
In later submissions dated 29 May 2025, Lionheart Lawyers for the claimant indicated they were unable to obtain any records of Dr Bikash Shrestha from Bella Vista Psychiatry or Kellyville Private Hospital, where the doctor had previously practised.
The Panel decided re-examination was required and Medical Assessors Mason and Doris would conduct this examination on behalf of the Panel via Microsoft Teams on 16 June 2025 at 9.00am.
The claimant attended that appointment.

The Review

Part 5 of the Personal Injury Commission Act 2020 (the 2020 Act) enables the Commission to make rules about the practice and procedure before the Commission including proceedings before a Panel that will review a decision of a Merit Reviewer or a Medical Assessor.[1]
[1] Section 41(2) of the 2020 Act.
Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made under Part 5 of the 2020 Act. A Review Panel determines how it conducts and determines the proceedings and may determine the proceedings solely based on the written application.[2]
[2] Rule 128 of the PIC Rules.
The term “threshold injury” is defined in s 1.6 of the MAI Act and includes a “threshold psychological or psychiatric injury.” A threshold psychological or psychiatric injury is a psychological or psychiatric injury that is not a recognised psychiatric illness: s 1.6(3).
Section 1.6 provides the regulations may exclude or include a specified injury from being a soft tissue injury or a threshold psychological or psychiatric injury. Part 1, cl 4 of the Motor Accident Injuries Regulation 2017 (the Regulation) further define threshold psychological or psychiatric injury to include acute stress disorder and adjustment disorder.
Part 5 of the Motor Accidents Guidelines (the Guidelines) are made pursuant to s 10.2 of the MAI Act. The Guidelines contain the procedure for assessing whether an injury caused by an accident is a threshold injury for the purposes of the MAI Act. Version 10 of the Guidelines applies to accidents occurring on or after 1 December 2017. In respect of assessing whether an injury is a threshold injury, the Guidelines provide:
“5.3 The assessment will determine whether the injury related to the claim is a soft tissue injury or a threshold psychological or psychiatric injury caused by the accident.
5.4    Diagnostic imaging is not considered necessary to assess threshold injury.
5.5    A diagnosis for the purpose of a threshold injury decision must be based on a clinical assessment by a medical practitioner or other suitably qualified person independent from the insurer.
5.6    The assessment of whether an injury caused by the accident is a threshold injury for the purposes of the Act should be based on the evidence available and include all relevant findings derived from:
(a) a comprehensive accurate history, including pre-accident history and pre-existing conditions
(b) a review of all relevant records available at the assessment
(c) a comprehensive description of the injured person’s current symptoms
(d) a careful and thorough physical and/or psychological examination
(e) diagnostic tests available at the assessment. Imaging findings that are used to support the assessment should correspond with symptoms and findings on examination.”
Clauses 5.10, 5.11 and 5.12 of the Guidelines refer to the assessment of threshold psychological or psychiatric injury. These clauses provide:
“Minor psychological or psychiatric injury assessment
5.10 In assessing whether an injury is a threshold psychological or psychiatric injury, an assessment of whether a psychiatric illness is present is essential.
5.11 The assessment of whether a psychiatric illness is present must be made using the Diagnostic & Statistical Manual of Mental Disorders (DSM-5), Fifth Edition, 2013, published by the American Psychiatric Association.
5.12 Where the symptoms associated with the injured person’s psychological or psychiatric injury do not meet the assessment criteria for a recognised psychiatric illness, with the exception of acute stress disorder and adjustment disorder, the injury will be considered a threshold injury.”
The Guidelines deal with causation of injury as follows:
“Causation of injury
6.5    An assessment of the degree of permanent impairment is a medical assessment matter under clause 2(a) of Schedule 2 of the Act. The assessment must determine the degree of permanent impairment of the injured person as a result of the injury caused by the accident. A determination as to whether the injured person's impairment is related to the accident in question is therefore implied in all such assessments. Medical assessors must be aware of the relevant provisions of the AMA4 Guides, as well as the common law principles that would be applied by a court (or the Personal Injury Commission) in considering such issues.
6.6    Causation is defined in the Glossary at page 316 of the AMA4 Guides as follows:
'Causation means that a physical, chemical, or 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 accident. The 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.”
The Commission’s decision makers consider the Guidelines above as applicable to any aspect of assessing causation, despite the above relating specifically to permanent impairment.
It is necessary for the Panel to consider whether the accident caused or contributed to the diagnosed psychiatric condition: Briggs v IAG Limited t/a NRMA Insurance [2022] NSWSC 372 at [75]. The accident does not have to be the sole cause as long as it is a contributing cause, which is more than negligible: Owen v Motor Accidents Authority of NSW [2012] NSWSC 650 at [50]. Further, the provisions of the Civil Liability Act 2002 apply, in particular s 5D and s 5E.

Assessment under Review

Causation and reasons

The Commission’s psychiatric Medical Assessor Surabhi Verma issued a certificate dated

1 January 2024 in which she concluded the claimant’s major depressive disorder with anxious distress was not caused by the accident.
The claimant migrated to Australia with her family from Afghanistan at 6.5 years of age. Her parents separated when she was 9 years old. She was pressured to perform at school where she experienced bullying. She denied other forms of abuse throughout childhood.
She met her husband in high school and married at 20. She has two sons now 22 and 23 years of age. She commenced work as a teacher but suffered a fractured fifth metatarsal and developed CRPS and multifocal dystonia resulting in constant pain since then. Her work was curriculum development.
The claimant’s history of the accident on 29 March 2023 consisted of being rear ended while stationary. She was in extreme pain. A tow truck and ambulance attended and she was taken to Blacktown Hospital and then discharged. She was in a wheelchair because of pain and then proceeded to use a walker. She was not able to stop thinking about the accident. She became socially withdrawn and hypervigilant.
Her mother died on 24 October 2023 and made her swear she would start work. She continued to work on reduced hours. She hired seven people and trained them to do her work.
She had disturbed sleep and ruminations with a raised heart rate. She was detached from her feelings and had physical concomitants of anxiety.
She drove to Wagga Wagga in June 2023 with some hypervigilance.
She saw a psychologist monthly and had two sessions with a psychiatrist since August 2023 and was prescribed an antidepressant. She denied past and family psychiatric problems.
She described memories of the accident which consisted of a feeling that she was compelled to help the other driver.
She was able to sleep a little bit with Neulactil. She has lost some weight. Medications consist of periciazine 2.5 mg, Norflex, Minipress 3 mg in the evening, escitalopram 20 mg, cannabis oil and Topaz oil. There is a past history of depression in 2009 and anxiety and depression in 2022 before the accident.
When questioned about these conditions the claimant denied them.
Medical Assessor Verma concluded the claimant had a pre-existing condition major depressive disorder with anxious distress which had not been exacerbated or materially contributed to by the accident. The Medical Assessor declined to assess whether the injury was threshold.

EVIDENCE

Treatment providers’ records

NSW ambulance report is dated 26 June 2023. The claimant was a restrained driver stopped at an intersection when rear ended by another vehicle at approximately 60 kmph. Minimal damage to patient's car. Hit her head on side window. Nil loss of consciousness. Pre-existing lower back pain from CRPS was worse post-accident; patient unable to stand up. IV morphine provided and transported to Blacktown hospital. GCS scores all 15.
Psychology AHRR 1 is dated 10 May 2023. Diagnosis was depression/anxiety/post-traumatic stress disorder. Pre-injury capacity was described as 14 hours/day as an academic mentor and tutor. Eight psychological counselling sessions were proposed by Ms Zeina Boutros.
Dr Parul Agarwal confirmed prescription of medicinal cannabis dated 22 June 2023.
On 26 July 2023 Ms Isabella Mamas of Work Focus Australia noted mild impairment in self-care and hygiene, moderate impairment in relation to social and recreational activities, mild impairment in relation to travel, and mild deficit of social functioning, concentration persistence and pace and adaptation.
Treating psychiatrist Dr Ghana Chapagain provided a report dated 8 September 2023. She noted bullying in childhood and marriage at the age of 21. She has two adult sons. She diagnosed post-traumatic stress disorder following accident on a background of complex physical comorbidity with chronic pain. Prazosin 1 mg at night was commenced to manage nightmares and flashbacks with a plan to increase to 3 mg. She prescribed escitalopram 10 mg and suggested trauma-based CBT with a psychologist.
Clinical record of Myhealth Castle Towers is dated 6 March 2025. General practitioner (GP) is Dr Fariya Kabir. The record commences 5 July 2017 Dr Aitken (had been using methadone for pain) and on 13 August 2022 Dr Kabir when she presented for scripts for dystonia. The notes revealed relevantly:
(a)    10 February 2023 presents with anxiety/depression. Major depression and CRPS diagnosed;
(b)    24 April 2023 presents following motor vehicle accident on 29 March 2023. Complains of lower back pain and afraid of driving. Wants referral to psychologist. Tearful, fear of dying, sleep poor, weight loss, irritable. Referred to psychologist Ms Zeina Boutros;
(c)    8 May 2023 loss of balance in ensuite; left index finger injury;
(d)    20 June 2023 again presents distressed. Lurasidone 40 mg and mirtazapine 15 mg. Also prescribed baclofen 25 mg, diazepam 5 mg and Norflex 100 mg for CRPS;
(e)    27 June 2023 ondansetron (anti-nausea) 8 mg TDS;
(f)    12 September 2023 seen by psychiatrist, diagnosed with post-traumatic stress disorder, got her car back on Friday and forced herself to drive it. Using escitalopram 10 mg and prazosin 3 mg. Mirtazapine 15 mg ceased;
(g)    10 October 2023 escitalopram increased to 20 mg;
(h)    7 November 2023 manage to drive a small distance;
(i)    9 January 2024 adult son could not find carotid pulse for 30 seconds. CT brain with contrast;
(j)    8 February 2024 crying, unable to eat, stress at home. CT brain NAD. Feels sister and husband are against her and she is possibly delusional;
(k)    23 April 2024 was admitted to The Hills Clinic, seen by psychiatrist, very emotional and talkative, going through divorce, advised to see psychologist;
(l)    14 May 2024 coming off medicinal cannabis and developing dystonia. Alprazolam 3 mg at night;
(m)     20 May 2024 needs admission to mental health hospital for extreme anxiety and post-traumatic stress disorder;
(n)    26 May 2024 receptionist received concerning email from patient. Advised to contact 000;
(o)    29 May 2024 admitted to Westmead Hospital. Referred to pain clinic;
(p)    20 June 2024 recent admission to Westmead. Seen by acute mental health. Was agitated and talking about how police behave. Needs a mental health care plan. Recent suicide threats and was taken to Westmead Hospital by police. Current high dose of cannabis and losing weight. Escitalopram increased to 30 mg;
(q)    20 September 2024 finger and toe pain, impaired short-term memory, dropped charger on foot;
(r)    22 October 2024 fitness to drive examination. Seeing psychologist Ms Maxine Blackburn;
(s)    11 December 2024 wants referral to psychologist;
(t)    14 January 2025 recent suicidal threats and taken to Westmead Hospital by police. Current high dose of cannabis and losing weight, and
(u)    past medical history consist of migraine 2006, CRPS 2007 following right ankle surgery, major depression 2009, dystonia 2015, spinal cord stimulator 2017, acne and eustachian tube dysfunction 2021, anxiety depression 2022, asthma and nausea 2022.
The application for personal injury benefits dated 24 April 2023 records that the claimant was stationary waiting to make a right-hand turn when she was rear ended by another vehicle. Injuries were listed to neck, mid back, rib cage, lower back, radiculopathy into lower limbs plus post-traumatic stress disorder, anxiety and depression.
Pain management specialist Dr Alan Nazha provided a report dated 11 March 2022. He had provided a spinal cord stimulator in April 2019. He noted obviously significant mental health concerns with plans to be referred to a psychologist. She uses baclofen and Norflex. She required a change of batteries for the stimulator. She had pressured speech during the consultation with high distress levels. He noted referral to Dr James Yu for medicinal cannabis. In a previous report dated 26 July 2022 Dr Yu noted she has had pain since 2007 following a foot fracture while working as a schoolteacher. She had surgery in 2008 with

Dr Robert Adler. Her condition deteriorated. There was an unsuccessful trial with a spinal cord stimulator in 2000. She had 2 ketamine infusions in 2015 and 2017 which provided significant pain relief. She has had physiotherapy and two pain management programs at Royal North Shore Hospital. She also had two cortisone injections. There is a background history of migraine, dystonia anxiety and depression. Analgesic medications tried included Physeptone, OxyContin, OxyNorm, Endep, Lyrica, Tegretol and cannabis. She works full-time as an online tutor and uses a walking stick for ambulation. Medication consists of baclofen 25 mg TDS and Norflex 100 mg BD. She has been smoking cannabis for seven years.
Certificate of capacity dated 28 July 2023 indicates mid to lower back pain, neck pain and anxiety. She is capable of working seven hours/day on four days/week.
Treating pain management specialist Dr Robert Adler retired from practice in August 2017. He noted she had benefited from the use of Physeptone 10 mg and considered she may need 20 mg. He described her as having a very rare form of CRPS with generalised dystonia. Her care was transferred to Dr Alan Nazha. On 24 January 2018 he noted spinal cord stimulation was successful in reducing neuropathic pain. She is sleeping better and mood has improved. She is also using less cannabis. Weight-bearing has improved.
Medical discharge summary of The Hills Clinic indicates admission on 12 February 2024 for and discharge on 16 March 2024 “AGAINST MEDICAL ADVICE” because of problems with supply of medicinal cannabis. Primary diagnosis was major depression along with CRPS and post-traumatic stress disorder. Lives with son and ex-husband and works as a sole trader in educational curriculum. Medication was escitalopram 10 mg, nortriptyline 25 mg at night, baclofen 12.5 to 25 mg three times daily, prazosin 3 mg at night, orphenadrine 100 mg twice daily and cannabis oil 1 mL twice daily. Treating psychiatrist was Dr Bikash Shrestha. He reported sexual and emotional abuse in childhood. Diagnosis was major depressive disorder and post-traumatic stress disorder. MoCA 29/30 although stated to be cognitively impaired due to worsening chronic pain.

Discharge summary of Westmead Hospital indicates the claimant attended on 26 May and was discharged on 27 May 2024 to the care of her sons. Principal diagnosis was chronic pain syndrome and suicidal ideation. Patient had sent a letter to the GP threatening suicide. ;She had been sexually and emotionally abused in past. Marriage broke down. Vehicle accident. Lives with two sons and ex-husband. Sister blocked the marriage. Mother died of cancer. Raised by one of the woman. Sons Youssef and Bilal. Suicidal email described on page 30 of 62 of the Westmead ED record (P182). Wants methadone.
Pain management team at Westmead Hospital provided a report to the GP dated 18 June 2024. She was discharged from The Hills Private clinic because of cannabis access issues. She weaned off them successfully but presented to Westmead Hospital in a pain crisis on

31 May 2024. Since discharge from Westmead, she has gone back on medicinal cannabis to good effect from a pain point of view. Mental health issues continue including poor sleep, anxiety, depression and generalised low mood.
The pain management team were not able to prescribe medicinal cannabis and did not recommend the use of methadone. They recommended referral to pain specialist Dr Allen Nazha and the use of simple analgesia such as regular paracetamol. Short acting opioids during a pain flareup would be acceptable during a mental health admission but the scripts would not continue on discharge from The Hills Clinic. Recommendation was for Endone 5 mg as needed with a maximum of 20 mg daily for pain flares. He also recommended follow-up with the medicinal cannabis prescriber.
Clinical record of psychologist Ms Maxine Blackburn is dated 11 April 2025. Initial referral was on 5 September 2024 by community care coordinator Catherina du Plessis of “The Way Back” Seven Hills. K10 score was 46/50. Conditions were extremely severe post-traumatic stress disorder, depression, anxiety and stress.
Longstanding complex trauma was noted and calming and grounding techniques were recommended with possible subsequent EMDR when more stabilised. There was a subsequent referral on 20 March 2025. PCL-5 score 73/80 on 25 October 2024. K10 score was 38/50 on 7 November 2024. DASS 42 on 25 October 2024 was extremely severe, extremely severe and severe.
Events described for Criterion A of post-traumatic stress disorder were polygamous family, parents splitting when she was 9, a lot of collective secrets, some reference to family member being assassinated, groomed by a policeman, twin brother died in childbirth. There were 18 counselling sessions between 18 September 2024 and 10 April 2025. There were no typewritten records. Ms Blackburn's handwriting superficially seems legible but it is difficult to gather important information. There were occasional references to auditory hallucinations.

Other evidence

Physical Medical Assessor Nel Wijetunga’s certificate dated 27 November 2023 certified accident caused cervical spine, thoracic spine and lumbar spine soft tissue injuries being threshold injuries.
The history of the CRPS and pain management was noted.

Disputes and issues the parties identified

Submissions

Claimant’s submissions

The claimant’s earliest submission refers to the insurer’s failure to properly consider claimant’s medical history before and after the accident when considering whether the claimant’s condition satisfied the definition of threshold injury.
The claimant’s submissions refer to the medical history summarised above as supporting her contention that her psychological injuries would satisfy the non-threshold classification.
In respect to the review application the claimant submitted Medical Assessor Verma demonstrably failed to consider the clinical material and medico-legal related material that was provided by both parties and has provided inadequate detailed reasons which did not demonstrate the path of reasoning..

Insurer’s submissions

The insurer refers to the claimant’s clinical history summarised above.
The insurer submits that post-accident, there is limited evidence with respect to psychological symptomology.
The claimant has not provided sufficient medical evidence which supports presence of any psychiatric injury in accordance the DSM-5 criteria, nor cls 5.10 to 5.12 of the Guidelines.
Save for the above post-accident records, the insurer submits that the claimant’s symptomology with respect to psychiatric injury has been formed based on self-reporting, in the absence of a specialist opinion to corroborate the continued nature and extent of same.
The insurer submits that both Zeina Boutros and the claimant’s GP have made informal diagnosis of psychological injuries and have diagnosed the claimant with psychiatric injuries without consideration of, or reference to, the DSM-5 criteria.
In the absence of any objective medical evidence or formal psychiatric diagnosis which relates to the subject accident, the insurer submits the psychological symptoms alleged are deemed a threshold injury, in accordance with the MAI Act and Regulations.

REVIEW PANEL FINDINGS

Brief personal details

Medical Assessors Mason and Doris interviewed the claimant via MS Teams on

17 April 2025. After explaining the purpose of the examination, they obtained the following history.
Ms Abdul-Raouf is a 45-year-old woman who lives with her husband and two sons in a North Western Sydney suburb. She is working 10 hours/week from home tutoring students in her role as a curriculum designer in her own company. Her 45-year-old husband is a senior systems integrations manager. Her 23-year-old son is completing a master’s degree in education and her 22-year-old son is employed doing data entry for a law firm while also completing a master’s degree.

Psychosocial history

Ms Abdul-Raouf was born in Kabul, Afghanistan. She was a twin; her twin brother was delivered first stillborn. She was significantly underweight and spent between one and three months in an incubator. Her mother died of non-Hodgkin's lymphoma at 78 years of age in October 2023. Her 78-year-old father lives in Sydney. She has a sister aged 48 who lives in Sydney but said they have not spoken for two years. Her parents separated when she was 9 years of age. She maintained contact with her father until 18 years of age and has not spoken to him since. She has two older half-brothers, who live in Australia.
She described a turbulent early life. She said a paternal uncle had been taken by the Russians and it is not known if he survived. Another uncle was assassinated; he went to get school supplies and did not return. The family fled Afghanistan for political reasons and travelled to Germany while she was still an infant. They moved to the United States when she was three or four years of age where she learned to speak English “by watching Sesame Street”. The family then migrated to Australia when she was six years of age. She described herself as functionally illiterate until nine years of age. She said she had learning issues because of inattentive ADHD; she said she was frequently referred to as a "space cadet".
When asked about abuse in childhood she said she was sexually abused at 9 years of age by a male cousin who was eight years older. She also described sexual abuse by the male friend of a neighbour when she was 14 years of age. She described this as being "put on layby" for later, presumably referring to grooming. These events did not involve intercourse. She said she informed a family member about her step cousin and was told she had misunderstood the events. She said the perpetrator telephoned her home and spoke to her mother about it.
Ms Abdul-Raouf attended three primary schools. She attended several high schools. Despite a very disrupted academic journey at seven different schools and learning difficulties, she stated she did well and completed her HSC with a good result. She described significant bullying in school. She said she was taunted with an obscene variation of her first name (f--k her harder). She also stated she did not have a friend. She said she was an observant Muslim and initially wore a hijab for a number of years but does not do so now.
She met her husband when she was 16 or 17 years of age in high school. They married in 2000 when she was 20 years old and went on to have two sons aged in their early twenties. She said there are relationship difficulties with her husband because of her ongoing psychological problems but she believes the relationship is solid.
With regard to further education Ms Abdul-Raouf said she completed a Bachelor of General Studies at Western Sydney University and then a Bachelor of Teaching at the University of New England. She said she started teaching at age 19 in a private school. In 2007 she was teaching at the Australian Islamic College of Sydney in Mount Druitt when she slipped in a wet area and fractured the fifth metatarsal in her right foot. She subsequently started her own business in curriculum development and coaching. She said before the accident she was working between 40 and 80 hours/week with educational institutions and private tutoring clients.
Leisure activities before the accident consisted of being a motoring enthusiast; she enjoyed driving in her Nissan Z sports car. She also described herself as a social butterfly who enjoyed socialising with friends. She said she was very different from when she finished school and described this as "finding her voice". She enjoyed playing and watching football. She also enjoyed playing pool and watching movies. She enjoyed going to the beach with her family.
Past insurance claims consisted of a 2007 worker's compensation claim following the fracture injury of her foot. This resulted in a worker's compensation claim settlement in 2010. She said she was able to utilise that money to start her own business in 2015. She denied any past accidents. She also denied any history of problems with the law.
Medical history consists of the development of chronic regional pain syndrome. She said the metatarsal bone initially united out of alignment and had to be surgically fractured and reset. Consequent to the development of CRPS she also developed widespread pain accompanied by dystonia. She came under the care of pain management specialists.
A spinal cord stimulator had been inserted which was not successful. She had two ketamine infusions (2015 and 2017) which assisted at the time but relief did not persist. She said the pain started in her foot and it has now generalised to her entire body. The spinal cord stimulator remains in situ with an incompetent battery and does not provide relief. Multiple pain management medications has been trialled including Lyrica, Physeptone, amitriptyline and Tegretol with most success coming from the use of medicinal cannabis which commenced before 2018.
At the time of the accident pain management medication consisted of medicinal cannabis, baclofen 25 mg three times daily, diazepam 5 mg as needed and Norflex (orphenadrine) 100 mg twice daily. She had attended pain management programs. Ms Abdul-Raouf was questioned about her capacity to deal with pain and she said while it is constantly there, she has learned to tolerate it and at times can work through it. She obtains medicinal cannabis through Dr Arun Nagarwal which she believes has been the most helpful agent in dealing with the pain.
Medical history consists of the generalised chronic regional pain syndrome and dystonia as described above. She also noted difficulties with asthma, acne, eustachian tube dysfunction and generalised dermatitis.
When asked about past psychiatric history Ms Abdul-Raouf stated she had always been resilient and denied any previous psychiatric problems. She was questioned about a diagnosis of depression in 2009 when she was assessed by a psychiatrist in Westmead Hospital. She was not able to account for this. She was also questioned about a GP entry regarding anxiety and depression one year before the accident. She attributed this to her mother's illness who was diagnosed with cold agglutinins, which is a rare autoimmune disease, and the development of non-Hodgkin's lymphoma. Ms Abdul-Raouf said she was managing her mother's treatments and was probably affected by that. Her mother died in October 2023.
Current medications consist of baclofen 25 mg twice daily and Norflex 100 mg three times daily. She uses medicinal cannabis consisting of 2 types of oil. Rocky Road contains 30 mg of THC per ml. Ruby contains 25 mg of CBD and 25 mg of THC per ml. She also uses THC flower. She described using the oil at least 6 times per day and inhaling from vape like devices approximately 20 times per day. In addition, she uses the antidepressant escitalopram 40 mg at night, the mood stabiliser lamotrigine 50 mg at night and prazosin 4 mg at night.
Ms Abdul-Raouf denied using alcohol, cigarettes, recreational drugs, coffee and gambling. She said she ceased smoking cigarettes 17 years ago.
When asked about pre-accident functioning, she said she was regularly attending the gymnasium. She acknowledged she had difficulty walking long distances and needed to use a walker. She said she was making progress but if pain flared up, she had to use the walker. Apart from that she was able to use one Californian crutch. She stated she was able to work all day, enjoyed driving and could do some housework. She said she enjoyed being a mother and a traditional wife. She described no difficulties with self-care and personal hygiene and said she did have a circle of friends.

History of the accident

Ms Abdul-Raouf said she was stationary at a red traffic light in her Nissan 370 Z car waiting to turn right. Her son was in the front passenger seat and both wore seatbelts. Her car was suddenly hit from behind on the left side and propelled forward a few metres into the intersection. She said she did not see the vehicle coming. She immediately felt electricity through her body and was unable to get out of the car. She was assisted by her son to get out. She said the 18-year-old driver of the other vehicle lost control of himself and was stating "I might as well kill myself" so she tried to calm him down. She stated after that she blacked out due to pain but she could still hear him.
A tow truck attended and her other son came to the accident site and took photographs. She believed the young man was looking down at his phone and at the last minute tried to swerve to avoid a collision but hit the left side of her car.
Ambulance and police attended and she was transported to Blacktown Hospital where she said she spent a long time but was discharged on the same day. She said there were concerns the spinal cord stimulator wire had moved and might have to be removed. This did not turn out to be the case.

Symptoms and treatment following the accident

Physical symptoms consisted of a feeling as if "someone stomped on me", especially on her lower back. Ms Abdul-Raouf said she could not move properly and she was bedbound for a couple of days. However, she said she just made herself keep going. She said she is in more pain than she was before the accident. She said she has difficulty sleeping and feels agitated to the extent that she wants to rip her hair and skin off.
She experienced anxiety one week later getting into a car. When questioned she acknowledged that she travelled with her husband to Wagga Wagga in September 2022 and she was able to drive at that time. She said she cannot drive a car now because of fear.
She said she became extremely stressed and her weight plummeted to 52 kg. She said after three weeks she was in trouble because she could not sleep and could not control her thoughts. She said she was tired and irritable and was getting into arguments with her husband. She described distressing dreams in which she would see her husband and children all dead lying upside down in a car. Nightmares would keep her awake for three to four hours at night. She said she feels perturbed and at times feels like she cannot breathe. She said she is anxious, particularly as a passenger in a car. She said her husband has purchased an electric vehicle with dashcams both front and rear which makes things worse for her as a passenger.
When asked about mood she said she feels depressed and worthless but does not feel like killing herself. However, she said she is not looking after herself but does not want to hurt herself. She was questioned regarding suicidal messages to the insurer and her GP.
She dismissed these by saying she was frustrated at being passed around like she was in a pinball machine.
She was questioned about auditory hallucinations which were reported during a number of hospitalisations. She denied that this was the case but did acknowledge she does talk to herself. She also acknowledged that at times she had been suicidally depressed.
She was questioned about an episode in January 2025 in which police were involved. She said she was taken to hospital because of a severe dystonic episode but was allowed to go home after 30 hours.
She went on to say she is okay if she does not leave the house. She said she does not speak to family members or to friends. She said she is a problem for her husband because she will not meet with his friends or business acquaintances if they come to the house; she said she would go upstairs to her room.
The Panel members noted reports of her being delusional in February 2024 thinking her sister and husband were against her. She denied this was a major issue.
She was admitted to The Hills Clinic in April 2024 and to Westmead Hospital in May 2024. Ms Abdul-Raouf stated these admissions were necessary because of difficulties accessing medicinal cannabis for pain control. She denied major psychiatric exacerbations.
Treatment has consisted of hospital admissions under the care of psychiatrist Dr Bikash Shrestha.
The Panel note no medical records were available from Dr Shrestha. However, Ms Abdul-Raouf advised she continues to consult with him online via Hello Doc on a monthly basis and he has recently prescribed lamotrigine 50 mg to be taken at night along with escitalopram 40 mg and prazosin 4 mg. She had been referred to psychologist Ms Zeina Boutros but the consultations did not continue.
More recently she consults psychologist Ms Maxine Blackburn online on a weekly basis for treatment with CBT, EMDR and desensitisation using visualisation.

Injuries or conditions since the accident

Ms Abdul-Raouf referred to her mother’s death in October 2023 which resulted in grief and distress which she believes has since resolved.

Current symptoms

Ms Abdul-Raouf continues to suffer generalised pain and dystonia. She described depressed mood, impaired sleep, nightmares of the accident, fear of driving, avoidance, intermittent suicidal thoughts without intent, impaired concentration, anger and irritability and social isolation.

Mental state examination

The claimant is a 45-year-old right-hand-dominant woman. She was located alone in her home. She said her husband and son were present elsewhere in the house. She was identified from her photograph on her NSW driver license. She was interviewed using the Microsoft Teams application with a good Internet connection. The interview commenced at 9.00am and concluded at 11.00am.
The claimant was cooperative with the examination and was unfailingly polite throughout. She frequently attempted to provide excessive irrelevant information in response to direct questions and often had to be redirected to the question at hand.
Facial mannerisms were evident throughout the interview. Pain behaviour was evident in that she needed to stand and move on a number of occasions.
She appeared to struggle to remain alert and focused throughout the interview. She often sat with her face in her hands or rubbed her hair throughout the interview. While not overtly drowsy she appeared to have some difficulty retaining focus.
She informed the Panel she was using medicinal cannabis on approximately 20 occasions throughout the day to control pain; the Panel considered the possibility that her cognitive ability was affected.

The claimant did not appear to be anxious or depressed throughout the interview. She denied the presence of thoughts of self-harm or suicidal ideation. She denied the presence of psychotic features such as auditory hallucinations. There was no evidence that she was delusional. Responses to questions were often illustrated by dramatic examples.
Her memory appeared to be selectively impaired. She was unable to recall various details about previous admissions to psychiatric institutions or threats of suicide until specific examples were provided to her. On the other hand, she appeared to have perfect recall of events related to the accident.
The claimant was fully oriented in time, person and place and displayed no evidence of organic or psychotic psychopathology apart from the possibility of cannabis intoxication.
Current functioning:
·self-care and personal hygiene: Ms Abdul-Raouf said she showers weekly and changes her clothing only when someone comes to the house. She said she is scratching all the time. She does not cook, clean or do any housework. She relies on her husband and sons;
·Social and recreational activities: Ms Abdul-Raouf said a girlfriend has visited on Friday for the last two weeks. She said her husband had builders come to the house but she does not talk to people where she lives. She did attend a graduation ceremony for her son;
·travel: Ms Abdul-Raouf acknowledged she was able to drive after the accident but stated she cannot do so now due to fear. She denied this was to avoid testing positive for cannabis. She is unable to use public transport. She has not travelled by air;
·social functioning: Ms Abdul-Raouf acknowledged her family is intact. She said she sees only 1 girlfriend and does not talk to relatives;
·concentration, persistence and pace: Ms Abdul-Raouf said this is not good and she finds it difficult to persist with tasks. She acknowledged she did concentrate throughout the interview and was able to persist for two hours, and
·adaptation: Ms Abdul-Raouf said she is able to work less than 10 hours/week whereas in the past she worked between 40 and 80 hours/week. She does not do any housework.

Consistency of presentation

There were multiple inconsistencies in her presentation. Psychiatric problems both before and subsequent to the accident have been well-documented yet denied by Ms Abdul-Raouf. She noted being able to drive following this accident yet states she is unable to do so. She was not able to provide satisfactory explanations for these inconsistencies.

Diagnosis and reasons

Ms Abdul-Raouf has a lengthy and complex background history which begins with low birth weight and protracted neonatal intensive care. This was followed by enforced migration of the family under stressful circumstances from Afghanistan to Germany, the United States and eventually Australia, arriving here at 6.5 years of age. She described being virtually illiterate until age 9 years.
She was diagnosed with ADHD in childhood, her parents separated when she was nine years of age, and she described sexual abuse during childhood by two different perpetrators. She attended seven different schools, was bullied and harassed while at school, and reported she had no friends.
She developed severe, generalised chronic pain and dystonia following a fractured metatarsal bone in her right foot in 2007 and since then has received lengthy treatment with pain management specialists. This involved various polypharmacy approaches, participation in two pain management programs, and the use of spinal cord stimulators and ketamine infusions. before the accident, she had eventually achieved some degree of pain control using medicinal cannabis which she stated enabled her to function at work and as a parent and homemaker.
The Panel noted there were pre-existing psychiatric conditions consisting of a major depressive disorder in 2009 associated with her foot injury, and anxiety and depression in 2022 arising from her mother's terminal illness diagnosis. Ms Abdul-Raouf was reluctant to acknowledge these conditions. It was noted that as the claimant’s medical history was well documented so that the lack of acknowledgment could be explained by other reasons other than deception.
Her presentation at interview was suggestive of cannabis use disorder and her description of the amount of medicinal cannabis used, being 20 inhalations throughout the day, raised the question of cannabis intoxication.
In the opinion of the Panel the most likely pre-existing psychiatric diagnosis was complex post-traumatic stress disorder (ICD 11). While this was not acknowledged by Ms Abdul-Raouf, the history of trauma to which she has been exposed and her difficulties in adult life before the accident strongly indicate the presence of this condition. The Panel note her treating psychologist Ms Blackburn diagnosed post-traumatic stress disorder arising from past traumatic events.
The Panel notes the accident, while not exactly trivial, was not in itself particularly life threatening. However, given the pre-existing history of trauma and chronic pain, the difficulty associated with managing that pain over the years, and the pre-existing psychiatric condition, Ms Abdul-Raouf was a particularly vulnerable individual.
The Panel therefore diagnosed an exacerbation of a pre-existing post-traumatic stress disorder as a result of the accident. This diagnosis incorporates the traumatic impact of the accident and her subsequent experiences of anxiety and depression.
The Panel thus considers the accident did satisfy DSM-5-TR Criteria for post-traumatic stress disorder as follows:
·Criterion A. This is met because of the claimant's pre-existing physical and psychological vulnerability. The accident would have been experienced as life-threatening;
·Criterion B. She described distressing dreams and intrusive distressing memories;
·Criterion C. She described attempts to avoid internal and external reminders of the accident;
·Criterion D. She described a persistent negative emotional state, diminished interest and participation in significant activities, and feelings of detachment and estrangement from others;
·Criterion E. She described irritability and angry outbursts, problems with concentration and sleep disturbance;
·Criterion F. Duration is greater than one month;
·Criterion G. There is impairment of social and occupational functioning, and
·Criterion H. The condition is not due to a substance or another medical condition.
The Panel also notes the likely presence of an iatrogenic cannabis use disorder which has been exacerbated by the accident. It is acknowledged the cannabis is used for medicinal purposes of pain control. DSM-5-TR criteria are met as follows:
·Criterion A is met because cannabis is being required in larger amounts over a longer period. Efforts to cut down had been unsuccessful;
·in the opinion of the Panel the claimant has developed tolerance because of the need for markedly increasing amounts to achieve the desired pain control effect, and
·withdrawal symptoms have been experienced following attempts to reduce consumption while an inpatient in The Hills Clinic.
DSM-5-TR criteria for somatic symptom disorder with predominant pain are met as follows:
·Criterion A. Whole body pain with dystonia has been exacerbated by the accident;
·Criterion B. She has persistent thoughts about the seriousness of the pain, high levels of anxiety about the symptoms, and she develops excessive time and energy to controlling the pain levels, and
·Criterion C. The condition has lasted for many years.
In summary, the Panel has diagnosed an exacerbation of pre-existing post-traumatic stress disorder, exacerbation of a cannabis use disorder and exacerbation of a somatic symptom disorder (predominant pain).

Causation

The Panel is satisfied that Ms Abdul-Raouf was a vulnerable individual from a psychiatric point of view. On this basis the accident was capable of materially contributing to the diagnosed conditions. It is the opinion of the Panel that it did so.

Determination

The Panel agrees with and adopts the reasons given by its medical members in their re-examination report in support of this finding.
Ms Abdul-Raouf sustained non-threshold psychiatric injuries in the accident.
The Panel is satisfied that the claimant also suffered physical injury as a result of the accident.
The Panel has considered the evidence relating to the claimant’s pre-accident psychological history and her inconsistencies in recalling the past.
The Panel has given weight to its medical members’ opinions who, following a thorough examination of the claimant’s pre-existing functioning, were satisfied that while there were pre-existing psychiatric conditions at the time of the accident, the accident aggravated those conditions.
There is a plausible mechanism of injury from the circumstances of this accident and the development of these psychiatric injuries, and there is a temporal and thematic association with the psychiatric symptoms becoming more prominent and the accident, which maintains a nexus between this accident and the psychiatric injuries.
There was no other cause for these conditions being exacerbated other than the accident.

Conclusion

The Review Panel revokes the certificate of Medical Assessor Verma dated 1 January 2024 and certifies that the following injuries caused by the accident were not threshold injuries:
·        exacerbation of pre-existing post-traumatic stress disorder;
·        exacerbation of a cannabis use disorder, and
·        exacerbation of a somatic symptom disorder (predominant pain).

[2025] NSWPICMP 717

17 September 2025