Allianz Australia Insurance Limited v Mansour
[2025] NSWPICMP 322
•8 May 2025
| DETERMINATION OF REVIEW PANEL | |
CITATION: | Allianz Australia Insurance Limited v Mansour [2025] NSWPICMP 322 |
CLAIMANT: | Alice Mansour |
INSURER: | Allianz Australia Insurance Limited |
REVIEW PANEL | |
MEMBER: | Hugh Macken |
MEDICAL ASSESSOR: | Sharon Reutens |
MEDICAL ASSESSOR: | Melissa Barrett |
DATE OF DECISION: | 8 May 2025 |
CATCHWORDS: | MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; review of Medical Assessment Certificate (MAC); whole person impairment; exacerbation of post-traumatic stress disorder (PTSD); previous treatment in respect to psychiatric injuries; prior motor vehicle accident; previous PTSD claim; relevance of severity of accident; mental state examination; assessment of current functioning; minimise her persisting psychiatric symptoms; criteria for PTSD; previous relapse of PTSD; psychiatric impairment rating scale (PIRS); Held – MAC revoked; new certificate issued. |
DETERMINATIONS MADE: | CERTIFICATE OF DETERMINATION ASSESSMENT OF DEGREE OF PERMANENT IMPAIRMENT Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017 The Panel revokes the certificate of Medical Assessor Yu Tang Shen dated exacerbation of post-traumatic stress disorder. · |
STATEMENT OF REASONS
BACKGROUND
The claimant is a 55-year-old woman who was injured in a motor vehicle accident which occurred on 14 April 2020. Following the accident the claimant lodged an application for personal injury benefits and thereafter sought a concession from the insurer that she had sustained non-threshold injuries. Following a review the insurer declined to make this determination and accordingly the claimant lodged an application for assessment of threshold injury.
In a certificate dated 20 November 2021 Medical Assessor Michael Hong determined that the claimant had sustained a non-threshold injury. Thereafter, the claimant sought to have the degree of permanent impairment assessed noting that the insurer declined to concede that the injuries caused by the motor accident were greater than 10% whole person impairment.
What is relevant to this Panel is that the claimant was examined by Medical Assessor Yu Tang Shen who, in a certificate dated 28 September 2023 determined that the claimant had sustained a permanent impairment of 20% consequent on a post-traumatic stress disorder sustained in this motor vehicle accident.
Noting that the claimant has had previous treatment in respect to psychiatric injuries and in particular arising out of a 2016 motor vehicle accident, the insurer sought a review of the determination of Medical Assessor Chen. In a certificate dated 6 December 2023 the President’s delegate, Ratula Gupta, certified that there is a reasonable cause to suspect that the medical assessment is incorrect in a material respect. Thereafter the matter was referred to this Medical Panel.
The material before the Panel was insufficient to allow the Panel to determine the appropriate steps to take. Accordingly, on 5 November 2024 directions were made for the parties to upload to the portal all the material which was before Medical Assessor Shen at the time of making his assessment. This material is now before the Panel.
The Panel met on 11 December 2024 to further review the matter. It was noted that the clinical notes from Dr Lim, the claimant’s pre-accident general practitioner, were not before the Panel nor was there any material from Centrelink noting that the claimant has been in receipt of Centrelink benefits, and there had been a reference to a disability support benefit being paid to the claimant prior to the subject motor vehicle accident. The Panel is of the view that this material was required so as to ascertain what pre-existing whole person impairment, if any, the claimant suffered from. Thereafter the Panel was of the view that a re-examination would be required following the uploading of this material.
Clause 14F of Schedule 1 of the Personal Injury Commission Act 2020 (the PIC Act) provides that the new review provisions apply in relation to a decision of a new decision-maker. A “new decision maker” is defined in cl 14A(1) of the Schedule 1 of the PIC Act. As the medical assessment, the subject of the review, was made on or after 1 March 2021, the new review provisions apply.
The new review provision provide that a review panel consists of two Medical Assessors and a Member assigned by the Motor Accidents Division of the Personal Injury Commission (Commission).
Part 5 of the PIC Act enables the Commission to make rules with respect to its practice and procedure including proceedings before a panel reviewing a decision of a Medical Assessor.
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 matter solely based on the written application.
The review of the medical assessment is by way of a new assessment of all the matters with which the medical assessment is concerned.
STATUTORY PROVISIONS/GUIDELINES
Section 57 of the MAC Act defines a “medical dispute” as a disagreement or issue to which Part 3.4 of the MAC Act applies.
Section 58 and s 60 of the MAC Act together with cls 1.5-1.7 of the Guidelines set out the procedures for referral to one or more Medical Assessors and the principles to be applied at such assessments.
The claimant was assessed by Medical Assessors Melissa Barrett and Sharon Reutens by TEAMS on 9 April 2025.
The claimant was assessed via videoconferencing. She was located at her home and was assessed unaccompanied.
The interpreter engaged by the Commission, Lamia Abada, National Accreditation Authority for Translators and Interpreters CPN41L29R was present during the assessment.
Introduction
Mrs Mansour is a 55-year-old widow, who lives on her own in a unit in Fairfield. She has remained single since her husband died in 2008. She has two adult children, who live independently, and four grandchildren. She supports herself on Jobseeker, and recently commenced part-time work, about three weeks ago, 15 hours a week, in a carwash café as an employee of a friend.
Personal history
Mrs Mansour was born in Iraq. She described her childhood as, “Not great”, having been impacted by the war, restricting free movement as a child outside. She could not recall direct exposure to fighting and stated, “Got used to it”. She denied other childhood trauma.
She had attended school up until 16 years old, when she married a remote relative. The marriage was happy. Her husband served in the Army, and she and their two children lived with her in-laws whilst he was away fighting. The family moved to Turkey in 1990, to escape further war, applied to migrate to Australia, as her father was an Australian citizen, and moved to Australia in 1993.
She and her husband started a cleaning business in 1997. Her husband took a second job running a repair business.
Mrs Mansour denied any family history of psychiatric conditions.
She is an ex-smoker, who denied any history of alcohol or other substance use.
In 2008, her husband tragically died as a passenger in a car accident. Mrs Mansour described this loss as having sustained impact upon her, stating, “Until now, still hard. Start to cry”.
Mrs Mansour denied any history of psychiatric illness prior to her husband’s death.
After her husband’s death, she described symptoms of post-traumatic stress disorder. Although her predominant symptoms were of low mood, sadness, a sense of emptiness, initial insomnia, increased appetite, poor energy, “mentally exhausted”, on direct questioning she also reported nightmares about the accident and flashbacks, visualising an image of the impact of the accident and hearing her husband’s voice, especially when attempting to initiate sleep. Mrs Mansour said that she still cried when she spoke of the accident.
She was unable to work in the cleaning business, so employed staff, but she was losing contracts and closed the business about three months after her husband died.
She sought treatment from her general practitioner (GP) who prescribed her an antidepressant medication. She could not recall its name, but estimates she used it for about four months before cessation. She denied treatment with a psychologist or psychiatrist at that time.
She was motivated to improve for the sake of her children and travelled to USA for a holiday to stay with her sister.
By 2016, she was working casually as a cleaner, variable hours, and was a carer for her aunt, requiring her to visit her aunt five days a week, clean her aunt’s home and take her aunt shopping.
In 2016, she was driving on the M4, either to or from a job interview, when she was hit from the rear. Emergency services were called, but she felt she was, “alright” and was not conveyed by ambulance to the hospital, although the other driver was.
She sustained physical injuries to her back and shoulder in the 2016 accident. Although initially she reported the pain had resolved by the time of the subject accident, when the inconsistency with the documentation was raised with her, she accepted that she still had back pain and was continuing to use analgesics including the neuromodulator Lyrica (pregabalin), prior to the 2020 accident.
She reported psychiatric symptoms after the 2016 accident, including nightmares, a fear of driving, a fear of leaving the house and a fear that her children could become involved in an accident. Her mood was affected and she reported a period of suicidal thoughts.
Her children were a strong motivator for improvement and she sought treatment. She saw
Dr Lim and was prescribed an antidepressant, possibly desvenlafaxine, for about a year. She saw a number of psychologists at the practice, for about four sessions.
She reported that by the time of the 2020 motor accident she was, “doing well”. She reported that she was taking care of herself, that she had returned to driving and was more stable.
Mrs Mansour received the Jobseeker payment. She studied a Diploma of make-up and hairdressing, three days a week for six months, completing in late 2019.
It was put to her that this account was inconsistent with the history of symptoms, treatment and functioning recorded by Erin Carmody, the treating psychologist, in May 2018, who wrote she had “7/10 anxiety driving”, was sleeping two hours a night and having nightmares and flashbacks, and the records of Dr Lim, who recorded that she was still taking desvenlafaxine in August 2018, and the entry by the treating GP, Dr Guirgis in January 2020, who recorded persisting pain and wrote that she needed to see a psychologist. She accepted the content of the notes but added that she was determined to improve.
History of the motor accident
Mrs Mansour reported that she was driving a Mercedes Benz, 2009 model, when she was hit by the at-fault driver in similar circumstances to the 2016 accident. Her car spun and she was nearly hit by another car. She remained in the car for about 30 minutes before self-extricating, describing fear causing a dissociative state, “felt like not able to move” and her legs shaking. She called her son, who collected her from the scene. Emergency services were not called.
History of symptoms following the motor accident
She had no pain initially. However, by the second day post-accident, she felt back and neck pain.
She remains on Panadeine forte, on a prn basis, about once a week.
Currently, her pain has improved but she still needs to pace herself and has reduced mobility. She accepted the evidence in the records of the GP that she was working 30 hours/week as a carer in August 2020, until about 2021.
After the subject accident, she reported a worsening of her mental health, with a resurgence of memories about her husband’s 2008 motor accident. She was fearful of having another motor accident, causing her to avoid driving for about five or six months, which prevented her from going out. Her mood, sleep and energy levels were reduced and her appetite increased, although she denied a return of nightmares or suicidal thoughts.
She reports attending her GP for treatment and commenced the SSRI antidepressant, escitalopram 20mg. She saw a psychologist, Medhat Metry, for about nine sessions.
Details of any relevant injuries or conditions suffered after the 2020 motor accident
She had weight loss surgery in October 2020, without complication. She is satisfied with the outcome, having lost 51kg since.
About six months ago, and again three weeks ago, she experienced shortness of breath and was taken by ambulance to hospital for assessment.
Current symptoms
Mrs Mansour reported improvement in her symptoms, describing herself as, “better”. She tries not to reveal her mental state to others, although she explained her history to her new employer. Her mood and sleep are, “little bit better”. Her energy remains impacted. She has resumed driving but remains restricted from driving long distances due to fear.
Current and proposed treatment
Mrs Mansour has ceased treatment with the psychologist.
She now uses escitalopram intermittently, “when not feeling comfortable, feeling low”, on average, once every two weeks.
Mental state examination
Mrs Mansour was assessed via videoconferencing.
She was casually dressed and she had long curly hair in a ponytail. She interacted in a warm and animated style. She displayed a full range of facial expression and gestures. There were no psychomotor features. Her speech was normal in rate, volume and rhythm.
Her effect was bright, cheerful and reactive. She could smile warmly when appropriate and even smiled whilst describing her worsening mental health symptoms after the accident. Her effect was sad and wistful when talking about the loss of her husband.
She denied re-experiencing symptoms of nightmares and did not report flashbacks. She identified her children as providing an important sense of purpose and meaning. She continued to express a sense of loss following her husband’s accident, explaining, “A man is like a back to us”. She continues to fear driving and the risk of another accident. She did not report any delusions, there was no formal thought disorder and she did not report any abnormal perceptions.
She denied suicidal ideation. She did not express any risk to others.
She was able to participate in the assessment for its duration of more than 1.5 hours, answering questions and managing the complexity of the use of an interpreter. She could not recall some aspects of her history, including most of her childhood.
She has some insight into her condition and has sought treatment previously and after the subject accident but has since discontinued treatment with the psychologist and takes an antidepressant tablet very infrequently.
Current functioning
Up until about three months ago, she was living with a friend. However, the friend has formed a new relationship and Mrs Mansour moved out, to live on her own. She reported she was happy for her friend. She is showering daily.
She prefers to stay at home, never goes out and prefers being alone. She described this as a personal preference and explained that she had never enjoyed going out. Nevertheless, she does attend church for mass and friends come to visit her. Her daughter lives in Wollongong and visits Mrs Mansour once every two weeks. Her son lives locally to her and she sees him once every one to two weeks.
She is able to drive locally on her own, which she reports is an improvement from last year. She explained that she has no need to travel outside of the local area and that she would be restricted by her fears of driving. She has not been overseas since the accident.
At the time of the 2020 accident, she had been planning on starting a business in make-up and hairdressing. After the 2020 accident, she was prevented from doing so due to back pain. She accepted the evidence from the GP notes that, despite her pain, she was working 30 hours a week as a carer for her aunt by August 2020, but that it caused worsening of her pain and she stopped in about 2021. She was then reliant upon Jobseeker and did not perform paid work up until the last two to three weeks - she has commenced a job in a carwash café, 15 hours a week. She does not provide any unpaid care of her grandchildren.
Comments on consistency
Mrs Mansour tended to minimise her physical symptoms prior to the 2020 accident, but accepted that she still had pain, requiring the use of analgesics, when the evidence from the contemporaneous records of her GP was put to her.
She tended to minimise her persisting psychiatric symptoms in the period prior to the 2020 accident, although when the documents were raised with her, she accepted the persistence of symptoms, albeit at mild severity.
The absence of any psychiatric symptoms in the post-accident records of the treating GPs was raised with Mrs Mansour. She did not provide any explanation and could not recall which GP referred her to the psychologist, Medhat Metry.
Review Panel deliberations
The panel determined that Mrs Mansour developed post-traumatic stress disorder after her husband’s accident in 2008. DSM 5 criteria A for post-traumatic stress disorder includes the trauma learning about the death of a family member in an accident. Mrs Mansour would have been at increased risk of developing post-traumatic stress disorder, due to her exposure to the trauma of war in her childhood and later, migration stress. She developed criteria B, re-experiencing symptoms of nightmares and flashbacks, criteria C, avoidance, with social withdrawal, criteria D, negative affect and mood, noting her feelings of emptiness and low energy, and criteria E, sustained heightened arousal and reactivity, noting her initial insomnia and use of overeating to supress her symptoms. These symptoms resolved with period of treatment with an antidepressant, support from her sister overseas and through
Mrs Mansour’s motivation to resume her roles as a dedicated mother. Noting her reported improvement in symptoms and return to part-time work, plus a formal carer role for her aunt, the panel consider the 2008 accident-related post-traumatic stress disorder reached partial remission, although she continued to prefer to socially isolate.
She experienced a relapse of post-traumatic stress disorder after the 2016 accident. Although the 2016 accident would not independently be sufficient to cause post-traumatic stress disorder, in a person with a history of post-traumatic stress disorder, for whom a car accident would be more salient due to its similarity to the circumstances of her husband’s death, it would have been a plausible and sufficient trigger for relapse. Although she reports improvement in symptom severity by the time of the 2020 accident, she did still have some persisting, though attenuated, symptoms. This is consistent with the history of symptoms and functioning recorded in the certificate of Dr Bhattacharyya dated 5 August 2019 and certificate of Medical Assessor Hong dated 20 November 2021.
Following the subject accident, she experienced an exacerbation of post-traumatic stress disorder . The subject accident does not need to independently fulfill DSM 5 criteria A to cause an exacerbation of a pre-existing post-traumatic stress disorder. Her initial response of dissociation is consistent with her experience of the accident as an immediate trigger of post-traumatic stress disorder symptomatology, due to its similarity to the 2016 and 2008 accidents. She then experienced a worsening of fear of driving, and a relapse of avoidance of driving for about six months. She experienced increased avoidance of going out, and worsening of mood, sleep and energy. Although none of the provided GP entries reference her psychiatric symptoms, the panel accept, based on the prescription of an antidepressant and referral to a psychologist, that she did report her symptoms to a GP post-accident.
As has been the case after the 2016 accident, with a period of treatment, the passage of time, resumption of driving and her determination to resume roles, Mrs Mansour’s post-traumatic stress disorder symptoms have improved, despite persistence.
Psychiatric Impairment Rating Scale
| Psychiatric diagnoses | 1. Exacerbation of pre-existing, chronic PTSD | 2. |
| 3. | 4. | |
| Psychiatric treatment description | Previous escitalopram, about 9 sessions with psychologist, Medhat Metry | |
| Category | Class | Reason for Decision |
| 1. Self Care and Personal Hygiene | 1 | Mrs Mansour lives alone. She acknowledged the evidence that by August 2020 she had been performing 30 hours a week of Carer duties for her aunt. Although she did not continue after about 2021, this was because her pain, excluded from assessment in the PIRS, was exacerbated by the duties, and was unrelated to her psychiatric condition. Objectively, she appeared of average grooming at assessment. Therefore, there is no impairment. |
| 2. Social and Recreational Activities | 3 | She prefers to stay at home. She does attend church and has her adult children and friends visit her. Therefore, there is a moderate impairment. |
| 3. Travel | 2 | She can drive locally on her own, but her fear of driving, due to PTSD, would prevent her from driving long distances. This is a mild impairment. |
| 4. Social Functioning | 1 | She maintained friendships and was living with a friend prior to the friend forming a new relationship. She has a good relationship with her children, whom she sees regularly. There is no impairment. |
| 5. Concentration, Persistence and Pace | 2 | Her energy remains reduced, which the panel accepted would impact her persistence and pace. Objectively, she participated in the interview without difficulty. The gaps in her memory, including for childhood experiences, is common in clinical populations who have survived trauma. |
| 6. Adaptation | 2 | The main restriction to work after the accident was her experience of pain, which cannot be assessed by the PIRS in accordance with Guidelines 1.24 and 1.25. She was formally working as a carer for her aunt, 30 hours a week, up until 2021, eventually ceased due to pain. She has recently commenced working part-time, 15 hours a week, at a friend’s carwash café. Excluding the impact of pain, her residual symptoms of PTSD causing social withdrawal and mild impacts upon concentration and energy, would result in the need to work part-time. |
| List classes in ascending order: 1, 1, 2, 2, 2, 3 | ||
| Median Class Value: 2 | ||
| Aggregate Score: 11 | ||
| % Whole Person Impairment: 5 % | ||
*%WPI = Percentage Whole Person Impairment
Psychiatric Impairment Rating Scale - Pre-existing impairment
| Psychiatric diagnoses | 1. PTSD, chronic, with persisting but attenuated symptoms | 2. |
| 3. | 4. | |
| Psychiatric treatment description | Previous treatment with psychologist, previous treatment with antidepressant, desvenlafaxine. | |
| Category | Class | Reason for Decision |
| 1. Self Care and Personal Hygiene | 1 | She was able to care for herself independently. Therefore, there was no impairment. |
| 2. Social and Recreational Activities | 2 | She preferred to be at home and alone but would go out with a friend for coffee. Given the relative withdrawal, but maintenance of some socialising outside the home, there was a mild impairment. |
| 3. Travel | 1 | She had resumed driving but was still anxious driving in 2018. However, she did not report any restrictions driving by the time of the subject accident and Dr Bhattacharyya’s certificate records the capacity to drive to Wollongong. There was no impairment. |
| 4. Social Functioning | 1 | She had enduring friendships and positive relationships with her adult children. There was no impairment. |
| 5. Concentration, Persistence and Pace | 1 | She had been able to successfully complete a Diploma in make-up and hairdressing, 3 days a week, over 6 months, in 2019. Therefore, there was no impairment. |
| 6. Adaptation | 1 | She was in a formal role of carer for her aunt, 5 days a week, and in addition performed some casual cleaning work. Considering the totality, there was no impairment. |
| List classes in ascending order: 1, 1, 1, 1, 1, 2 | ||
| Median Class Value: 1 | ||
| Aggregate Score: 7 | ||
| Pre-existing % Whole Person Impairment: 0 % | ||
Effects of treatment
She describes having only a brief period of treatment with the psychologist, Medhat Metry, which would be insufficient to produce effect.
Her current usage of the antidepressant, one tablet every two weeks, would not have any therapeutic effect.
CONCLUSION – PERMANENT IMPAIRMENT
The degree of permanent impairment caused by the motor accident is 5%.
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