BCX v AAI Limited t/as AAMI

[2023] NSWPICMP 102

DETERMINATION OF REVIEW PANEL

CITATION:

BCX v AAI Limited t/as AAMI [2023] NSWPICMP 102

CLAIMANT:

BCX

INSURER:

AAI Limited t/as GIO

REVIEW Panel

PRINCIPAL MEMBER:

John Harris

MEDICAL ASSESSOR:

Michael Hong

MEDICAL ASSESSOR:

Atsumi Fukui

DATE OF DECISION:

22 March 2023

CATCHWORDS:

MOTOR ACCIDENTS – Motor Accidents Compensation Act 1999; the claimant suffered injury on 10 March 2017 when a kangaroo jumped in front of and collided with her vehicle; the dispute related to the assessment of permanent impairment of the psychological condition; claimant re-examined; pre-existing psychological condition did not give rise to permanent impairment prior to motor accident; subsequent life difficulties did not cause further psychiatric injury; claimant’s psychological condition was in response to the direct effects of the motor accident and the  resultant physical injuries and pain; Held – claimant assessed at 7% permanent impairment; original assessment revoked. 

DETERMINATIONS MADE:  

Medical Assessment – Permanent Impairment

Whether the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident is greater than 10%.
The assessment made by the Review Panel under s 63(4) is as follows:

The Review Panel revokes the certificate of Medical Assessor Allan dated 5 November 2021 and issues a new certificate that the following injuries caused by the motor accident give rise to a whole person impairment which is not greater than 10%:

·        adjustment disorder.

REASONS

BACKGROUND

1. BCX (the claimant) suffered injury in a motor accident on 10 March 2017 when a kangaroo jumped in front of and collided with her vehicle (the motor accident).[1]

   [1] Claimant’s bundle, p 7.

2. AAI Ltd (the insurer) is liable to pay to BCX any damages under the Motor Accidents Compensation 1999 (the MAC Act).

3. The present dispute between the parties is whether the degree of permanent impairment as a result of the psychological injury caused by the motor accident is greater than 10%. This constitutes a medical dispute within the meaning of the Act.[2]

   [2] See ss 57 and 58 of the MAC Act.

4. Section 44(1)(c) of the MAC Act provides that the Authority may issue guidelines with respect to the assessment of the degree of permanent impairment of an injured person as a result of an injury caused by a motor accident.

5. The Motor Accident Permanent Impairment Guidelines (the Guidelines) were issued pursuant to s 44(1)(c) for the assessment of permanent impairment. The Guidelines adopt the fourth edition of the American Medical Association’s Guides to the Evaluation of Permanent Impairment (AMA 4). Where there is any difference between AMA 4 and the Guidelines, the Guidelines are definitive.[3]

   [3] Clause 1.2 of the Guidelines.

6. The present application is a review of a medical assessment pursuant to s 63 of the MAC Act. The medical assessment the subject of this review was conducted by Medical Assessor Allan dated 5 November 2021.

7. Medical Assessor Allan diagnosed an adjustment disorder with depressed and anxious mood and assessed the permanent impairment at 5% after making a two-thirds deduction due to the “difficulties and challenges associated with the care of her husband”.[4]

   [4] Claimant’s bundle, p 95.

8. The application for referral of a medical assessment to a Review Panel (the Panel) was made by the claimant within 28 days after the parties were issued with the original certificate for the medical assessment for which the review is sought.[5]

   [5] Section 63(7) of the MAC Act.

9. The delegate of the President referred the medical assessment to the Panel as they were satisfied that there was reasonable cause to suspect that the medical assessment was incorrect in a material respect having regard to the particulars set out in the application.[6]

   [6] Section 63(2B) of the MAC Act.

10. Pursuant to s 63(3) of the Act and Schedule 1, clause 14F(2) of the Personal Injury Act 2020 (the PIC Act), the Panel consists of two medical assessors and a member of the Motor Accidents Division of the Personal Injury Commission (Commission).

CONDUCT OF THE REVIEW

1. Part 5 of the 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 merit reviewer or a medical assessor.[7]

   [7] Section 41(2) of the PIC Act.

2. Rules 127 to 130 of the Personal Injury Commission Rules 2021 (the PIC Rules) are made pursuant to 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.[8]

   [8] Rule 128 of the PIC Rules.

3. The Panel requested the parties to provide bundles of documents for its consideration.

MEDICAL ASSESSMENT UNDER REVIEW

1. This review is from the assessment of Medical Assessor Allan dated 5 November 2021 who determined that BCX suffered a 5% permanent impairment due to psychological injury. Medical Assessor Allan diagnosed an adjustment disorder with depressed and anxious mood. The Medical Assessor assessed impairment at 15% and apportioned one-third to the motor accident and two-thirds to the challenges associated with the care of her husband.

OTHER MEDICAL ASSESSMENTS

1. Medical Assessor Home provided a Medical Assessment dated 1 June 2021.[9] The Medical Assessor assessed the impairment of the cervical spine at 5% based on an aggravation of underlying C5/6 discopathy with non-verifiable complaints and 1% for the right shoulder secondary to neck pain based on the Nguyen principle resulting in an overall permanent impairment of 6%.

   [9] Insurer’s bundle, p 328.

SUBMISSIONS

Claimant’s submissions dated 26 November 2021[10]

[10] Claimant’s bundle, p 1.

1. These submissions were filed seeking a review of the Medical Assessment. The claimant referred to various clauses of the Guidelines and submitted that there was no basis to find that the life difficulties associated with the care of her husband have caused some unrelated permanent psychiatric impairment.

2. The claimant further submitted that the Medical Assessor did not otherwise assess in accordance with the Guidelines.

Insurer’s submissions dated 25 November 2020[11]

[11] Insurer’s bundle, p 6.

1. The insurer referred to the certificate dated 6 April 2017 which diagnosed a whiplash injury and the police report which recorded that the damage from the motor accident “was not significant enough to require a tow”.

2. The insurer referred to the history recorded by Mr Prout dated 23 July 2012 that the claimant suffered from depression and was receiving treatment from a psychologist. It also referred to a report from Macarthur Health Service dated 14 January 1999 and from Dr Dent dated
   3 November 1998 that the claimant suffered from post-traumatic stress disorder in relation to a medical negligence claim.

3. The insurer disputed causation of injury and any assessment including a deduction for pre-existing condition and “apportionment”.

Insurer’s submissions dated 15 December 2021[12]

[12] Insurer’s bundle, p 1.

1. The insurer submitted that the history provided in the interview to the Medical Assessor constituted objective evidence of a subsequent and unrelated condition in accordance with cl 1.34 of the Guidelines. Accordingly, the history provided the basis for the Medical Assessor to find that one-third of the claimant’s impairment was attributable to the motor accident.

EVIDENCE

Pre-existing medical evidence

1. Ms Dean, psychologist, provided a report dated 6 February 1998[13] diagnosing post-traumatic stress disorder and depressive disorder directly related to traumatic childbirth in 1995. In a further report dated 29 June 1998 Ms Dean recommended weekly psychological treatment.[14]

   [13] Insurer’s bundle, p 75.

   [14] Insurer’s bundle, p 82.

2. In a further report dated 14 January 1999, Ms Dean opined that the claimant had ongoing symptoms of anxiety and depression and required further counselling sessions and ongoing medication.[15]

   [15] Insurer’s bundle, p 94.

3. Dr Malcom Dent, psychiatrist, provided a report dated 3 November 1998. The doctor diagnosed post-traumatic stress disorder by reason on the background of adjustment disorder with anxiety and depression.[16]

   [16] Insurer’s bundle, p 86.

4. Hospital notes in 1999 referred to depression and flashbacks associated with the 1995 incident.[17]

   [17] Insurer’s bundle, p 71.

5. Dr Anthony Smith, orthopaedic surgeon, provided a report dated 24 February 2012.[18] The doctor then noted a degenerative condition in the cervical spine with right arm symptoms which was temporarily aggravated by the 2010 motor accident.

   [18] Insurer’s bundle, p 46.

6. Ms Rosalie Prout, exercise physiologist, provided a report dated 23 July 2012.[19] Ms Prout noted that BCX suffered from ongoing depression, which, at times, affected her motivation to perform her exercises.

   [19] Insurer’s bundle, p 103.

7. Various medical reports in 2012 noted that BCX suffered from pain in the C6 nerve root distribution.[20]

   [20] Insurer’s bundle, p 114, p 138.

8. Medical Assessor Vickery provided a Medical Assessment dated 28 February 2012. The Medical Assessor found no objective clinical evidence of a diagnosable DSM psychiatric disorder in the examination and did not assess the degree of permanent impairment for any psychological condition.[21] 

   [21] Insurer’s bundle, p 269.

9. Medical Assessor Oates provides a Medical Assessment dated 14 April 2012 for the physical injuries. The Medical Assessor found permanent impairment of the physical injuries at 11% and diagnosed cervical spine injury with asymmetrical reflexes.[22]

   [22] Insurer’s bundle, p 300.

Histories following the motor accident

1. BCX attended Dubbo Base Hospital on 11 March 2017 with a “chief” complaint of neck pain radiating to the right shoulder. Pain was also mentioned in the lower back.  Neurological examination was normal save as weakness noted in flexion and extension of the right elbow which probably related to “pain as well”.[23]

   [23] Insurer’s bundle, p 16.

2. The CT scan of the cervical spine noted endplate osteophyte formation at C5/6 likely degenerative with no acute fracture.[24]

   [24] Insurer’s bundle, p 22.

3. The police report dated 22 March 2017 noted the motor accident and that BCX suffered pain in the neck and shoulder.[25]

   [25] Insurer’s bundle, p 10.

4. BCX attended her general practitioner on 30 March 2017 who noted the motor accident and a similar motor vehicle accident seven years previously.[26] The doctor noted “tingling sensation to the right hand similar to what she had in the past”.

   [26] Insurer’s bundle, p 215.

5. A certificate of capacity from Dr Kuku dated 6 April 2017 opined that BCX sustained a whiplash injury caused by the motor accident.[27]

   [27] Claimant’s bundle, p 16.

6. The claim form dated 10 October 2017 reported the motor accident as described earlier in these reasons. The claimant reported that the motor accident caused a whiplash injury with right arm pain and numbness in her right foot and big toe.[28]

   [28] Claimant’s bundle, p 7.

Qualified medical evidence

1. Dr James Bodel, orthopaedic surgeon, was qualified by the claimant and provided a report dated 1 June 2020.[29] The doctor noted a previous neck injury with right arm pain following a motor accident in 2010.

   [29] Claimant’s bundle, p 20.

2. Dr Bodel opined that BCX sustained an injury at the C5/6 level caused by the motor accident.

3. Dr Stephen Buckley opined that the claimant sustained an exacerbation of cervical disc disease with dysmetria and non-verifiable radicular pain from the motor accident.[30]

   [30] Claimant’s bundle, p 38.

4. Dr Graeme Doig, orthopaedic surgeon, opined that the motor accident aggravated the pre-existing neck injury particularly at the C5/6 level.[31]

   [31] Insurer’s bundle, p 35.

5. Dr Jonathan Phillips, psychiatrist, provided a report dated 29 October 2020. The doctor noted that the claimant’s husband suffered from an inoperable benign brain tumour, has suffered a number of seizures and is cared for by the claimant.

6. The doctor noted that the motor accident became the trigger for the onset of an adjustment disorder requiring psychotherapy. Dr Phillips assessed impairment at 15% and “apportioned” the impairment as 10% to events in earlier life, 20% to other stressors which preceded the motor accident and 70% to the motor accident.

RE-EXAMINATION

1. BCX was examined by the Medical Assessors on 20 December 2022. The joint examination report is as follows.

   “Who attended the assessment

Dr Fukui and Dr Hong were in their Sydney offices for the video assessment.
BCX was assessed on her own. She was at her daughter’s home (45 minutes from her home). Her husband and daughter were also at the same house.

History
Psychosocial history and pre-accident history

She was born in Australia and grew up with her parents and is the eldest of four siblings.

In terms of family history, her son has Asperger’s and ADHD and her daughter has depression, an aunt suffered bipolar disorder and a brother has ADHD.

She does not have epilepsy, cardiac, thyroid or liver disease.

In terms education and employment history, she left school after Year 11, then went to a secretarial college. She studied massage therapy and a Certificate 3 in teaching. She later started a teaching degree but did not finish it.

BCX experienced difficulties in her childhood, with the brother who is closest in age to her. She noted that he would suddenly become aggressive and would hit her. He has autism and after a while, his behaviour settled. She said that she has never sought help or had counselling in relation to him
In the 1990s, BCX recalled after giving birth to her third child, she was given an accidental overdose by the staff at Bankstown Hospital, and they had to pump out her stomach while she was still conscious. She started having flashback nightmares and described having significant psychological symptoms of posttraumatic stress disorder for the next two or three years. She took Zoloft and received counselling, and practised meditation and reported that she then recovered.
BCX married in 1990 and her husband was diagnosed as having cavernomas, which caused brain bleeding and grand mal seizures in 2001. He could not work anymore and has been on a Disability Support Pension from Centrelink since and she became his carer and received a carer’s pension. She reported at that time, she could no longer work in their business as she cared for him. She trained in massage therapy and worked from home for a while. She then started training in primary school education but never finished her training, she stated because of her responsibility in looking after her husband. BCX purchased and managed a takeaway shop. She then worked for Imagination Childcare Centre in Mudgee but eventually had to stop because of pain issues.
In 2010, BCX was in a car accident. Her husband was driving and hit a kangaroo and the car was written off. She developed C5/6 nerve impingement and was advised that she needed surgery, however, due to various reasons, she has never had surgery. She had help from an occupational therapist and adjusted how she performed home tasks. Eventually, pain improved to the point where she no longer needed analgesic medications. Her psychological health deteriorated after that accident, and then improved.
In 2016, when her son was 16 years old and previously healthy, he suddenly suffered a heart attack and was admitted to ICU for five days. She said it was quite a shock as she did not expect him to have a major health crisis. She was preoccupied with looking after her son. Her son has had a few minor episodes since then and developed myocarditis after his third Pfizer COVID-19 vaccine, and then when he was 18, he was found to have cavernoma. Her daughter also has cavernoma now.
In 2015, Ms Hellegers’ brother with autism passed away. She had one session with a psychologist online, who told her that she suffered an adjustment disorder. She said that even though further treatment was recommended, nothing was put in place for her, so she did not have further psychological/psychiatric treatment. She reported that at the time she had returned to work in the childcare centre doing special needs education two days a week. There was no problem with work stress, and she stopped working because she had to care for her brother who was in palliative care, and also cared for her mother with deteriorating health. That was her last paid employment.

In terms of Ms Hellegers’ psychiatric functioning before the subject accident, she reported she was unimpaired in her self-care. She ate and showered daily. She cared for her husband and attended to household chores. She normally enjoyed fishing and socializing with her family. She had no problem with her concentration and memory and could focus on crocheting. BCX was not working as she was caring for her family.
History of the motor accident

On 10 March 2017, BCX recalled that her husband was driving, and she was a front seat passenger. They were on their way home driving from Orange to Dubbo. It was 9 p.m. They had driven around a bend when a kangaroo jumped out and struck their car. The car’s ABS activated, and the car suddenly braked, and she said most of the damage occurred on her side. The airbags were not deployed, and the car was later repaired, but had incurred a cost of $8,000 in damages.
She remembered she had immediate pain affecting her right neck, shoulder and arm. Because they were close to home and because her husband could not be out for too long, they decided to go home. However, she had severe pain and could not sleep that night and went to Dubbo Hospital the next day and was investigated over a few hours.

History of symptoms and treatment following the motor accident

She has had pneumonia four times since the subject accident and said she also lost peripheral vision in her right eye, which she has been told is related to neck damage. She also reported a right-sided earache and headache.
BCX has been told that she suffered nerve impingement from whiplash and that she needs surgery but has not had surgery since the subject accident. She said that at one point, she almost had the surgery but then the focus became her husband's brain surgery in 2019. She said she has always been one to prioritise other people's needs over her own.

She is on a waiting list and said that she is hoping that with surgery and having less pain, her sleep should improve, and her psychological health will be better. She noted that on the occasional days when she wakes up with less pain, she has ‘an amazing day’ and her psychological symptoms subside.

BCX reported after the subject accident, she was angry and shocked. She felt that it was unfair that the accident happened when everything was going well in her life.
She said she tried to be strong and not disclose her emotional problems to other people, but she would cry in the shower. Pain is the main driver of her chronic depression and she explained that she cannot even rest at night because of pain.

Details of any relevant injuries or conditions sustained since the motor accident

BCX has not had further car accidents or sustained other psychological injuries.

Current symptoms
BCX feels guilty, because she cannot do things when she is in pain and has difficulties doing things with her family. She said she is expecting her 11^th grandchild very soon and really wants to be physically better, so she can hold her grandchild.

Ms Hellegers’ depressive symptoms ‘come and go’, generally in keeping with her pain level.
She has reduced enjoyment and motivation.

She described having reduced concentration and memory overall. If she has good sleep, her concentration would be fine the next day.

She gained 10kg after the subject accident and gained some weight in 2023 because she is an emotional eater.

She has passive suicidal ideation.
She feels anxious.
She has been irritable.
Current and proposed treatment
BCX has not consulted a counsellor, psychologist or psychiatrist since the subject accident. She has not taken any psychotropic medication.

She takes Lyrica 75 mg in the morning and night, Panadol, Ibuprofen and 75 anti-hypertensive medication.

Clinical Examination

Mental State examination
BCX engaged well with the assessment process. There was no psychomotor slowing or abnormal movements. She was moderately restricted in her affect range and reactivity. She spoke spontaneously and provided a cogent history. She was apologetic. She recalled a reasonable amount of detail and maintained a normal speed and pace in her speech. There was no overt cognitive impairment.
Current functioning

BCX is 57 years old. She is living with her husband and has four adult children. Her 21-year-old son lives at home with them, and he has attention deficit hyperactivity disorder and Asperger’s syndrome.

She goes to the shopping centre but reported that because of her eyesight problems, she would bump into people and this makes her anxious. She has been going to the shops less. She tends to buy groceries every two weeks and also shops at local small shops. She reported that even pushing the shopping trolley can cause pain and make her cry.
Her motivation varies and she does not always cook proper meals. Sometimes she will eat chips or biscuits for dinner and her husband will make a sandwich for himself.
She cares for her husband which predominantly involves supervision. He cannot be left alone due to his seizures. She helps with his meals.
She had friends when she was working but once she stopped working and she moved away from Mudgee she has not gained close friends. She still keeps in contact with them on Facebook.
BCX enjoys crocheting and making blankets for her grandchildren. She has to stop after ten minutes because of pain and she cannot be seated for long. She used to read books to her husband and also read for enjoyment but stopped reading due to eyesight problems.
She used to go fishing with her husband, but they have stopped all physical activity as it causes too much pain.
Comments of consistency

There was no inconsistency identified.

Determinations

Diagnosis and reasons
BCX described chronic anxiety and depressive symptoms as a result of the subject accident, with her physical injuries and pain as a perpetuating factor for her psychological symptoms. Her anxiety and depressive symptoms are consistent with an Adjustment Disorder.

Causation and reasons

BCX encountered many major life events and was injured in a previous MVA. She developed anxiety and depressive symptoms and re-experiencing symptoms and was previously treated for PTSD. Her psychological symptoms gradually resolved, and she was no longer on any psychological/psychiatric treatment and described being able to function well in the years before the subject accident.
Her current psychological symptoms developed immediately after the accident and have persisted. She continued to experience stress related to her husband and family, but these stressors were not significantly different after the subject accident.
The Panel concluded that the subject accident is a major causal factor to her current psychological injury.

BCX has not had psychological/psychiatric treatment. The Panel noted her psychological symptoms and functioning have not changed for a long time and her psychological injury is entrenched, and unlikely to change substantially, with or without medical treatment.

Degree of permanent impairment Psychiatric Impairment Rating Scale

Category	Class
1.   Self Care and Personal Hygiene (current)	2	BCX gained weight due to eating when stressed. She showers 2 times per week. She cooks and engages in home duties, within her physical limitations. She described difficulties using the bathtub to bathe due to her physical injuries. Sometimes she would wipe down instead of having a shower.
2.   Social and Recreational Activities	3	She used to go out with her family and enjoyed fishing with her husband. She no longer participates in her normal recreational activities, and her anxiety and depressive symptoms are part of the reasons.
3.   Travel	2	She drives on her own locally. She prefers to be accompanied when driving as her eyesight has deteriorated and is anxious
4.   Social Functioning	2	Ms Hellegers’ relationship with her husband, children and grandchildren is good. She has no local friends. She still has contact online with friends but are no longer close. There has been no separation or domestic violence.
5.   Concentration, Persistence and Pace	2	BCX can focus on reading books, crocheting and intellectually demanding tasks for more than 30 minutes. Her physical injuries and pain are not assessable in the PIRS.
6. Adaptation	3	BCX was not working at the time of the subject accident. She continues to perform similar life roles, more than 20 hours per week, but has reduced stress tolerance.
List classes in ascending order:  222233
Median Class Value:   2
Aggregate Score: 14
% Whole Person Impairment: 7 %

*%WPI = Percentage Whole Person Impairment

Psychiatric Impairment Rating Scale - Pre-existing impairment

BCX has not sustained a subsequent injury.

Category	Class	Reason for Decision
Self-care & Personal Hygiene (before the subject accident)	1	BCX had no impairment before the subject accident. She ate and showered regularly.
Social & Recreational Activities	1	No impairment before the subject accident. She enjoyed fishing and outings with her family.
Travel	1	No impairment before the subject accident. She could drive everywhere.
Social Function	1	No impairment before the subject accident. She described having good relationships with her husband and family. She had friends when she was working.
Concentration, Persistence & Pace	1	No impairment before the subject accident. She could focus on working in a child care centre.
Adaptation	1	She could work and even though she left her employment, she was caring for her family and husband.

List classes in ascending order:

1 1 1 1 1 1

Median Class Value:  Aggregate Score:

1 6

Whole Person Impairment:

0

Apportionment

Nil.

Effects of Treatment
0%
No treatment.

Final WPI = 7%.”

FINDINGS

1. The review is a new assessment of all matters with which the medical assessment is concerned.

2. The Panel, comprised of two specialist medical practitioners, is not required to choose between competing medical opinions and is required to form its own opinion: Insurance Australia Group Ltd v Keen[32] and Insurance Australia Ltd v Marsh.[33]

   [32] [2021] NSWCA 287 at [40], [41] and [45].

   [33] [2022] NSWCA 31 at [11], [21] and [64].

3. The Panel adopts the joint examination report of the Medical Assessors supplemented by the following further reasons.

4. The Panel is satisfied that the claimant’s ongoing psychiatric condition is causatively related to the motor accident. BCX sustained an aggravation of a cervical spine condition established by the qualified medical opinions set out earlier in these reasons, the opinion of Medical Assessor Home and the consistent history recounted by the claimant of an aggravation of physical symptoms following the motor accident. These physical symptoms are a perpetuating factor for the psychological symptoms of chronic anxiety consistent with an adjustment disorder.

5. In terms of the psychological injury caused by the accident, the Panel found BCX less impaired than Dr Phillips in social functioning, and noted she has a good relationship with her family, but she isolates herself from her friends.

6. The Panel found BCX less impaired than Dr Phillips in adaptation, and noted she was not working at the time of the accident but could perform other life roles. Since the subject accident, her capacity to engage in those life roles has deteriorated.

Pre-existing impairment

1. The insurer made submissions on various reports including medical evidence in the late 1990s of the pre-existing psychiatric condition. It failed to refer to and address the assessment undertaken by Medical Assessor Vickery in 2012 that BCX was not suffering from a diagnosable psychiatric condition at that time. It otherwise ignored the recent history prior to the motor accident.

2. The Panel applied the correct test applicable under the Guidelines which requires an assessment of pre-existing impairment at the time of the motor accident rather than vague notions of “apportionment” which is not the statutory text in the motor accidents legislation.

3. For the reasons articulated by the Medical Assessors, there is no pre-existing impairment.

Subsequent impairment

1. We agree with the claimant’s submission that there was and is no basis to find that the life difficulties associated with the care of the claimant’s husband have caused further permanent psychiatric impairment.

2. The insurer’s submission that the methodology of deduction undertaken by Medical Assessor Allan constituted objective evidence of a subsequent and unrelated condition in accordance with cl 1.34 of the Guidelines is misconceived.

3. Clause 1.34 of the Guidelines was discussed by Wright J in Slade v Insurance Australia Ltd.[34] His Honour determined that the principles discussed by Malcolm CJ in State Government Insurance Commission v Oakley[35] apply in the application of cl 1.34 of the Guidelines.

   [34] [2020] NSWSC 1031 (Slade).

   [35] (1990) Aust Torts Rep 81-003.

4. We are not satisfied that the difficulties faced by the claimant with respect to caring for her husband has caused a further psychiatric injury. In this respect, the Panel’s diagnosis is that the psychiatric condition and impairment was in response to the direct effects of the subject accident and the physical injuries and pain caused by the motor accident.

Conclusion

1. The certificate issued by Medical Assessor Allan is revoked. The new certificate is attached at the commencement of these Reasons.