Belevski v Allianz Australia Insurance Limited
[2023] NSWPICMP 453
•13 September 2023
| DETERMINATION OF REVIEW PANEL | |
| CITATION: | Belevski v Allianz Australia Insurance Limited [2023] NSWPICMP 453 |
| CLAIMANT: | Jessica Belevski |
INSURER: | Allianz Insurance Ltd |
| REVIEW PANEL | |
| MEMBER: | Ray Plibersek |
| MEDICAL ASSESSOR: | Gerald Chew |
| MEDICAL ASSESSOR: | Alexey Sidorov |
| DATE OF DECISION: | 13 September 2023 |
| CATCHWORDS: | MOTOR ACCIDENTS – Claimant was a front seat passenger in a car which collided at an intersection on its left-hand passenger side; injuries reported; left arm and wrist; post-traumatic stress disorder and other psychological injuries; Held – Review Panel revoked the original certificate of the Medical Assessor; finds that the claimant has not reached maximum medical improvement and so declined to make an assessment of the claimant’s whole person impairment (WPI); Review Panel recommended that the claimant be referred to a consultant psychiatrist for antidepressant therapy and ongoing treatment; parties have liberty to apply to the Panel after the claimant has commenced treatment and in the opinion of her treating doctors has reached maximum medical improvement; Panel declines to reassess the claimant’s WPI until after she had received psychiatric treatment and that her condition has stabilised. |
| DETERMINATIONS MADE: | CERTIFICATE OF DETERMINATION The Review Panel: 1. Revokes the certificate of Medical Assessor Paul Friend dated 9 February 2022. 2. Finds that the claimant has not reached maximum medical improvement. 3. Declines to make an assessment of the claimant’s whole person impairment because the claimant has not attained maximum medical improvement. 4. The parties are referred to the Panel’s conclusion about the claimant’s medical condition that she requires referral to a consultant psychiatrist for antidepressant therapy and ongoing monitoring of her mental state. 5. The parties will have liberty to apply to the Panel after the claimant has commenced treatment and in the opinion of her treating doctors has reached maximum medical improvement when she can then be reassessed regarding her whole person impairment. |
STATEMENT OF REASONS
INTRODUCTION AND BACKGROUND
On 15 April 2018 Ms Jessica Belevski (the claimant) was a passenger in the front seat of a car driven by her then fiancé (now husband). Her car was travelling along Botany Road Mascot when her husband attempted to turn right into Coward Street. A utility travelling in the opposite direction failed to stop at a red light and hit her car on the left-hand side where she was sitting.[1] Ms Belevski was taken to hospital where she complained of injuries to her left arm and wrist.
[1] Claimant's bundle AD 10 page 68
In an application for personal injury benefits dated 24 April 2018, Ms Belevski described her injuries as: abrasions to the left arm and left wrist; burn marks from the airbag on the left arm and wrist; bruising and swelling of the left arm left shoulder and left wrist; cut on the left ankle and soft tissue damage.
In the application for personal injury benefits dated 1 May 2018,[2] Ms Beleviski stated that she was taken to Prince of Wales Hospital after the accident.
[2] Claimant's bundle AD 10 page 79
Allianz Insurance Limited (the insurer) is the relevant insurer with liability to pay any damages to Ms Belevski under the Motor Accident Injuries Act 2017 (MAI Act).
In a decision dated 3 March 2021 the insurer did not concede that the claimant's degree of permanent impairment is greater than 10%.
Ms Belevski sought an Internal Review of that decision. On 25 March 2021 the insurer issued their Internal Review - Certificate of Determination and Statement of Reasons. This decision affirmed the insurer’s earlier decision that the insurer did not concede that the claimant's degree of permanent impairment is greater than 10%.[3]
[3] Insurer bundle AD 13 page 7.
Medical Assessor Paul Friend issued a certificate dated 9 February 2022. In that certificate he certified the claimant's current whole person impairment (WPI) at 19% with five class 3 impairments. His psychiatric diagnosis of the claimant was a finding of post-traumatic stress disorder with anxiety. Medical Assessor Friend then deducted 12% WPI for the claimant's postnatal depression. Thus, he attributed 7% WPI to the subject motor accident.
On 2 March 2022 the claimant’s solicitor filed an application with the Personal Injury Commission (Commission) seeking a review of the certificate of
Medical Assessor Friend dated 9 February 2022.Pursuant to Schedule 2, cl 2 of the MAI Act, various matters are declared to be a medical assessment matter, including:
1.“(a) the degree of permanent impairment of the injured person that has resulted from the injury caused by the motor accident (including whether the degree of permanent impairment is greater than a particular percentage),”.
A medical assessment matter is determined in accordance with Division 7.5 of the MAI Act by a Medical Assessor.[4]
ASSESSMENT UNDER REVIEW
[4] Section 7.20 of the MAI Act.
The dispute was referred to Medical Assessor Friend who assessed Ms Belevski and issued a certificate dated 9 February 2022.[5]
[5] Claimant’s bundle AD 10 page 18.
The injuries referred for assessment included: the psychological injury – post-traumatic stress disorder with anxiety caused by the motor accident.
Medical Assessor Friend medically examined the claimant on 27 January 2022. He referred to the history of the motor accident, the detailed history of symptoms and treatment following the motor accident, detailed the current symptoms and set out the current and proposed treatment.
Medical Assessor Friend determined that Ms Belevski reached the criteria to satisfy a diagnosis of post-traumatic stress disorder. He further found that she satisfies all of the categories from A to H. Medical Assessor Friend found that the motor accident was the cause of the condition of post-traumatic stress disorder as he described in his assessment. There was no other event that occurred either prior to or subsequent to the motor accident that would explain this condition.
Medical Assessor Friend found that the claimant became anxious and depressed following the birth of her son and her functioning had declined since. He found that the matter requires post-accident apportionment. He assessed her current WPI at 19%. He assessed her pre-pregnancy WPI at 7%. He then found her post-accident WPI to be 19-7 = 12% WPI. Thus in conclusion Medical Assessor Friend found the degree of WPI caused by the motor accident to be 7%.
REVIEW PROCEDURE
An application for review of the medical assessment of Medical Assessor Friend was lodged on 2 March 2022 which is within 28 days of the date on which the certificate was made available to the parties.
On 28 March 2022, the delegate of the President being satisfied there was reasonable cause to suspect that the medical assessment was incorrect in a material respect referred the medical assessment to the Review Panel (the Panel). The delegate’s reasons were that the delegate agreed with the claimant's submission that the Medical Assessor had erred in his approach to apportioning the level of WPI as there was no new injury and no new psychiatric diagnosis of the claimant.[6]
[6] Claimant’s bundle AD 10 page 17.
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 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 provisions provide that a review panel consists of two Medical Assessors and a Member assigned to the Motor Accidents Division of the Commission.[7] Accordingly, the President’s delegate referred the matter to this Panel to assess.
[7] Section 7.26(5A) of the MAI Act.
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 Medical Assessor.[8]
[8] Section 41(2) of the PIC Act.
Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the PIC Act. A review panel determines how it conducts and determines the proceedings and may determine the proceedings solely based on the written application.[9]
[9] Rule 128 of the PIC Rules.
The review is by way of a new assessment of all matters with which the medical assessment is concerned. However, s 7.25 of the MAI Act provides that the review of a medical assessment can be made on the basis of any agreement by the parties as to the degree of permanent impairment from a particular injury and whether a particular injury was caused by the accident, without those matters having to be the subject of assessment.
The Panel issued a Direction to the parties dated 25 April 2023 advising both parties that the claimant was to be medically examined on 19 June 2023.
THRESHOLD INJURY (formerly minor injury) – STATUTORY PROVISIONS
The Motor Accident Injuries Amendment Act 2022 (the MAI Amendment Act) was assented on 28 November 2022 with various amendments commencing on 1 April 2023. From
1 April 2023 the MAI Amendment Act provides that a “minor injury” is known as a “threshold injury” and “minor injuries” are known as “threshold injuries”.The definition of what constitutes a minor injury has not been amended and continues to apply to a threshold injury.
Any reference in these reasons to “minor injury” is taken to be a reference to a “threshold injury” and any reference to the word “minor” referring to the injury alleged to have occurred in the accident is a reference to “threshold”.
A threshold injury is defined in s 1.6 of the MAI Act and includes a “soft tissue injury” or a “psychological or psychiatric injury that is not a recognised psychiatric illness”.
Sub-section 1.6(2) of the MAI Act defines a “soft tissue injury” as:
“[A]n injury to tissue that connects, supports or surrounds other structures or organs of the body (such as muscles, tendons, ligaments, menisci, cartilage, fascia, fibrous tissues, fat, blood vessels and synovial membranes), but not an injury to nerves or a complete or partial rupture of tendons, ligaments, menisci or cartilage.”
Section 1.6 of the MAI Act provides that Regulations may be made to exclude or include a specified injury from being a threshold injury. Part 1, cl 4 of the Motor Accident Injuries Regulation 2017 (the MAI Regulation) further defines threshold injury as follows:
“4 Meaning of “threshold injury”, section 1.6(4) of the Act
(1) An injury to a spinal nerve root that manifests in neurological signs (other than radiculopathy) is included as a soft tissue injury for the purposes of the Act.
(2) Each of the following injuries is included as a threshold injury for the purposes of the Act—(a) acute stress disorder,
(b) adjustment disorder.
Note—
See section 1.6 (5) of the Act in relation to the making of Motor Accident Guidelines for or with respect to the assessment of whether an injury is a threshold injury.
(3) In this clause acute stress disorder and adjustment disorder have the same meanings as in the document entitled Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association in May 2013.”Thus, the MAI Regulation provides that an acute stress disorder and an adjustment disorder are both by definition classified as a threshold injury.
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 the motor accident is a threshold injury for the purposes of the MAI Act.
Version 9.1 of the Guidelines commenced on 1 April 2023 and applies to motor accidents occurring on or after 1 December 2017. In respect of the medical assessment of whether an injury is a threshold injury, the Guidelines relevantly 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 motor accident.
5.4 Insurers should not require injured persons to undergo diagnostic imaging for the purpose of the insurer determining whether the injury related to the claim is a threshold injury. 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.”
In respect of a threshold psychological or psychiatric injury assessment cls 5.10, 5.11 and 5.12 of the Guidelines provide:
“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, Fifth Edition, Text Revision (DSM-5- TR), 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.”
In Briggs v IAG Limited trading as NRMA Insurance[10] his Honour Justice Wright stated at [35]:
[10] Briggs v IAG Limited Trading as NRMA Insurance [2022] NSWSC 372.
3.“The question of causation of injuries was not dealt with in Part 5 of the Guidelines but causation was addressed in Part 6, which related to assessment of permanent impairment. There is no reason to think that different principles were intended to be applied when a medical assessment was being made in relation to causation of minor injuries. Clauses 6.5 to 6.7 provided:
‘Causation of injury
4.6.5 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 motor 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 claims assessor) in considering such issues.
5.6.6 Causation is defined in the Glossary at page 316 of the AMA4 Guides as follows:
6.‘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:
7.1. The alleged factor could have caused or contributed to worsening of the impairment, which is a medical determination.
8.2. The alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination.’
9.This, therefore, involves a medical decision and a non-medical informed judgement.
10.6.7 There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be a sole cause as long as it is a contributing cause, which is more than negligible. Considering the question 'Would this injury (or impairment) have occurred if not for the accident?' may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes.”
EVIDENCE BEFORE THE REVIEW PANEL
General observations on evidence
The Panel notes that there are extensive and voluminous medical records, reports and clinical notes describing the claimant’s psychological and physical injuries. The Panel has read, discussed and carefully considered all of these medical records, reports and notes before it. The Panel has not referenced or summarised the most of records relating to
Ms Belevski’s injuries or symptoms because of the conclusions reached by the Panel in its re-examination that the Panel’s reassessment of her WPI should be stayed until after she had received psychiatric treatment and that her condition and stabilised.SUBMISSIONS
Claimant’s submissions
The claimant’s solicitors provided submissions prepared by counsel dated 1 March 2022. [11]
[11] Claimant bundle AD 10 page 7-15.
The claimant submits that the there is no attributable psychiatric diagnosis in relation to any incident or event during the course of or subsequent to the claimant's pregnancy as is required by clause 6.213 of the Motor Accident Guidelines (Guidelines). Because there is no psychiatrically diagnosable condition it is not permissible to make a deduction for the subsequent impairment. The claimant does not have a new and separate post-traumatic stress disorder arising from her pregnancy. Pregnancy itself is not a psychiatric condition and struggling to cope with a post-traumatic stress disorder while raising a newborn child is not a new psychiatric condition.
The claimant’s solicitors also refer to section 11 of Medical Assessor Friend’s reasons. The submissions note that Medical Assessor Friend refers to the claimant being identified by other doctors as being depressed and anxious however Medical Assessor Friend does not identify any formal DSM diagnosis by any of those treating the claimant for her pregnancy. Nor does Medical Assessor Friend provide any psychiatric diagnosis of depression or anxiety attributable to her pregnancy by making any reference to DSM criteria.
The claimant further submits that deterioration in her functioning after becoming pregnant as additional life stressors occurred is not a new psychiatric injury or condition but rather a change in the degree of symptomology from the already established psychiatric condition namely the claimant's accident related post-traumatic stress disorder.
The claimant notes that Medical Assessor Friend attempted apportionment is in error. He attempted to treat the claimant's current impairment as 19% WPI, take off an apportionment of 12% and find 7% WPI. Under the Guidelines Medical Assessor Friend is not permitted to make a post-accident apportionment when there was no new psychiatric condition or injury but merely an increase in the level of symptoms experienced by the claimant related to the psychiatric condition caused by the motor accident.
Clause 6.34 of the Guidelines deals with subsequent injuries. The claimant emphasises that the Guidelines require that there be a subsequent and unrelated injury or condition.
Medical Assessor Friend’s own reasons deny that there is any subsequent injury or condition. In the absence of an actual subsequent diagnosable psychiatric injury
Medical Assessor Friend was not permitted to adopt the approach he did of making some pregnancy related deduction from the claimant's current WPI.
Finally, the claimant submits that because Medical Assessor Friend has clearly stated that there was no new psychiatric injury after the motor accident then he is not entitled to make any deduction for any undiagnosed new injury.
Insurer’s submissions
The insurer provided three written submissions dated 25 May 2021, 18 March and
28 June 2022.[12][12] Insurer bundle AD 13 pages1- 6; 15-20; and 21-27.
In the first written submissions dated 25 May 2021 the insurer submits that the claimant’s psychiatric symptoms are not consistent with the fact that she returned to work within weeks of the accident, resumed her studies, was married within months of the accident and then travelled overseas for one month for her honeymoon.
In its second set of submissions dated 18 March 2022 the insurer solicitors submit that Medical Assessor Friend’s certificate makes it clear that although he did not make a separate diagnosis post pregnancy he considered the claimant's post-traumatic stress disorder had been aggravated by her pregnancy and the birth of her son. The insurer submits that there was sufficient objective evidence of a decline in the claimant's functioning as a result of her pregnancy and the birth of her son to warrant the apportionment of her WPI undertaken by Medical Assessor Friend.
The third set of submissions from the insurer dated 28 June 2022 gave an extensive and detailed history of the claimant’s treating medical practitioners including her obstetrician
Professor Karantanis in relation to her pregnancy and her treating psychiatrist Dr George.The insurer submitted that Dr George noted that the claimant had experienced some anxiety in the context of her post-partum haemorrhage but at the time of consultation she advised that she felt as though she was coping at the same level as she had been prior to her pregnancy. Dr George considered that the claimant’s current mental health issues were related solely to the subject accident. In Dr George’s opinion the claimant has a good prognosis in relation to her employment noting that she had been able to return to work eventually without restriction. Dr George assessed a 7% WPI.
The insurer relies upon the findings of Dr George and submits that the claimant’s psychological injuries do not give rise to a greater than 10% WPI.
MEDICAL EXAMINATION
The medical re-examination took place on 19 June 2023 by videoconference.
Ms Jessica Belevski attended the assessment via audio-visual link from her home in Banksia, New South Wales. Ms Belevski was examined by Medical Assessor Gerald Chew and Medical Assessor Alexey Sidorov who were both in the Sydney rooms. The assessment took approximately one hour.
Psychosocial history and pre-accident history
Ms Belevski is a 31-year-old woman who resides with her husband and her 19-month-old son in Banksia, New South Wales. Ms Belevski is currently on maternity leave. Her husband works as a customs broker.
Ms Belevski was born in Liverpool, New South Wales. Both of her parents are still alive. They separated in around 2012 and both reside in Sydney. She has one younger brother. She is close with her family and regularly meets them. Her mother lives, together with her brother, on the same street as Ms Belevski. Her father is a hairdresser, and her mother works at a factory. Ms Belevski described a good childhood. She lived in Brighton‑Le‑Sands from the age of 11 or 12. She has always been close with her brother. She attended high school in Kogarah. She completed Year 10 and received her School Certificate. She then left school as she wanted to work and earn money. She had worked in various retail roles, including in Coles for a couple of years, and started working in the childcare industry from the age of 19 or 20. She was working in childcare until she went off on maternity leave in August 2021. She gave birth to her son in October 2021. She has been married for almost five years. She denied any history of trauma or abuse growing up. She identifies as Macedonian Orthodox but denied being overly religious.
Ms Belevski denied any problems with her mental health prior to the subject accident. She denied any periods of significant depression or anxiety. She also denied any history of mania or psychosis.
Ms Belevski stated that she consumes alcohol once a year on her birthday. She denied using any illicit drugs.
Ms Belevski was diagnosed with hypothyroidism in 2019 and has been following up with her general practitioner in relation to this since then. She takes replacement Thyroxine and has blood tests every six months.
Ms Belevski denied any family history of mental illness.
History of the motor accident
Ms Belevski could not recall the exact date of the subject accident but endorsed the documented date of 15 April 2018. She recalled that it was around midday. She was a front seat passenger and her fiancé at the time, who is now her husband, was driving. Some other family members were in the back seat. They were travelling along Botany Road towards Mascot. She stated that a few other family members were travelling in other cars near them. She described that, as her husband was turning right onto Coward Street at a traffic light intersection, a ute that was travelling in the opposite direction did not stop and, as a result, t-boned the vehicle that Ms Belevski was travelling in. She stated that the impact was primarily into her door, as well as the pillar between her door and the rear passenger door. She recalled shouting something to her husband to the effect of, “They are not going to stop.” She recalled that it was a powerful impact and that there was glass all over her legs and the floor. Airbags were deployed and there was a lot of smoke. She closed her eyes, thinking that it may be a dream, but after a few moments realised that she was not dreaming, and it was the reality. As a result of the damage, Ms Belevski was unable to open her door and needed to exit the vehicle through the driver’s side door.
History of symptoms and treatment following the motor accident
Ms Belevski stated that, after the accident, she was in shock and was crying and felt anxious. She stated that immediately after the impact, there were no sounds from the back seat and, for a short time, she thought that her aunt and nephew, who were seated in the back seat, were killed. When they shouted out, she realised that they were not dead. She described that that time was “all a blur”. She stated that the other relatives got out of the car and were attempting to move it out of danger as it was still on the road with traffic. She stated that her arm was bleeding, and it was difficult for her to get out of the car. Her relatives called emergency services and who arrived promptly. She was extricated from her car and carried to a grassed area. She was very scared, so she did not want to go to the hospital with the ambulance alone, so her fiancé came together with her. They were transported to the Prince of Wales Hospital in Randwick. In the hospital, various examinations, as well as X-rays and blood tests, were done. She stayed there for a few hours. She stated that she had some scratches and scrapes, but no fractures were identified. Her scrapes were bandaged, and she was discharged from hospital to follow-up with her general practitioner. Her mother and brother came to pick her up from hospital, but she was struggling to get into the car due to the severe anxiety that she was experiencing. She had to lay down when she was being transported from the hospital as she could not even bear to see other cars.
Subsequently, she continued to struggle to get into cars due to fear and anxiety and was even too anxious to get into a car to attend an appointment with her general practitioner. The anxiety and fear related to being in cars continued and, even after she gave birth to her son, she avoided going to the hospital as a result of this and nurses from the hospital attended her home to check on her child.
Since then, she has travelled with her husband overseas to Italy and England. She stated that she was very anxious on the flight and, whilst away on the holiday, she did not want to travel in buses or cars and, as a result, did a lot of walking and she stated that she could not really enjoy the holiday. She was prescribed Diazepam by her general practitioner to take overseas for her anxiety. She has not been on a holiday since then for about five years.
She described that her mood continued to be unstable as a result, and she has continued to be hypervigilant, irritable and on edge, with associated sleep disturbance. She also has had ongoing, recurrent nightmares and intrusive thoughts about the subject accident. Particularly being in a car has reminded her of the subject accident. She developed grinding of her teeth as a result and experiences tooth and jaw pain associated with this. She is unable to fall asleep until 2 or 3 a.m. Her mood had also become pervasively depressed most of the day, nearly every day. She has been unable to enjoy most of her activities, aside from being home with her son. Her appetite had generally been lower than it was in the past. Her energy levels had also become lower than they were before, with an associated lack of motivation to do most things.
She developed a generally negative outlook on life, with feelings of hopelessness. She is easily overwhelmed, and her energy levels are low and she is easily fatigued, particularly when she goes outside with a lot of people, at which point she becomes overwhelmed. Her self-confidence has been significantly eroded and she has become a lot less confident, often feeling that she is worthless. She has had previous thoughts of death and not wanting to be alive.
She was previously commenced on Escitalopram, an antidepressant medication, but stopped taking it as she was worried about her pregnancy. She stated that when she stopped, her depression had worsened and the feelings of not wanting to be alive intensified. She has not been trialled on any other antidepressant medications since then. She had previously seen a psychologist, Zoran Protulipac, but had not seen him since 2019 or 2020. She is not currently receiving any psychological or psychiatric treatment for her symptoms. There was no evidence of symptoms of an obsessive-compulsive disorder, mania or psychosis.
Details of any relevant injuries or conditions sustained since the motor accident
Ms Belevski explained that she had always wanted to have children and, therefore, stopped the Escitalopram as she was worried about her pregnancy and the effect that it might have on her child. She denied any worsening of depression since the birth of her son. She described that after the subject accident, she returned to work five or six weeks later. She had difficulties with her work as she could not travel to other centres due to her fear of travelling in cars. She also described that, at her workplace, she was in a room where she could see a road and a roundabout with lots of cars going through there and every time she would look at it, she would be reminded of the subject accident, with associated intense distress and anxiety.
Current symptoms
Ms Belevski stated that she continues to experience trauma related and depressive symptoms, as described under the heading of “History of symptoms and treatment following the motor accident”. There has been no significant improvement to her symptoms, and she is not receiving any treatment currently.
Mental State Examination
Ms Belevski was a well-presented woman appearing of stated age. There was no evidence of self-neglect or poor personal care. She was generally cooperative, pleasant and polite. She was teary at times and was particularly distressed recounting the subject accident and its impact on her psychological functioning. There was no evidence of psychomotor disturbance or abnormal movements. Her affect was depressed. She described her mood as “depressed”. There was no evidence of formal thought disorder. She denied any thoughts of self-harm, suicidal ideations or thoughts of harm to others. There were no psychotic symptoms present, such as delusions or hallucinations. She was oriented to time, place and person. She had good insight and a good degree of rational judgment.
Current functioning
Ms Belevski stated that she generally maintains her personal hygiene, including brushing her teeth and showering, but is less motivated than in the past. She generally takes care of her son but is worried that her son will pick up on her abnormal mental state. Her husband helps her with the housework. She stated that she feels bad as he both works and does a lot of housework. She described that her ability to perform housework is reduced due to reduced energy and motivation. She has not driven since the subject accident. She would only get into a car with her husband and her mother driving, as she would not feel comfortable with anyone else driving. She continues to experience significant anxiety and fear when riding in a car. She goes for walks with her son in the local park. She used to be a social person and did not like being at home, but now feels more comfortable at home and does not like going out as she feels unsafe. She sees her mother, brother and father regularly, but generally stays at home with her son most of the time. There have been some strains in her relationship with her partner and she feels bad for him as she does not feel like the same person that she was in the past. She stated that, “He’s trying his best to be supportive.” Her concentration is generally poor, and she easily loses her train of thought and forgets what happened in the recent past, including the day before. She is on maternity leave and has not returned to work yet as she feels safer at home with her son. She does not feel comfortable returning to work yet. She was previously completing a diploma of childcare. She has attempted to finish her studies, but was unable to focus and, therefore, deferred it for the time being.
Comments of Consistency
There were no inconsistencies present in Ms Belevski's history or presentation.
Diagnosis and Reasons
Based on the account presented by Ms Belevski, her presentation and review of provided documentation, she meets the diagnostic criteria for a post-traumatic stress disorder, as per the DSM-5. This is based on a history of Ms Belevski being involved in a serious motor vehicle accident where she had fear for her life, as well as the life of other occupants in her car who were close relatives. Subsequent to that, Ms Belevski developed intrusion symptoms, including recurrent, involuntary and intrusive, distressing memories, as well as nightmares regarding the subject accident, as well as a persistent avoidance of stimuli associated with the subject accident, negative alterations in cognitions and mood associated with the subject accident and marked alterations in arousal and reactivity associated with the subject accident, characterised by increased irritability, hypervigilance, exaggerated startle response, difficulties with concentration and sleep disturbance.
Ms Belevski also meets the diagnostic criteria for a major depressive disorder, as per the DSM-5. This is based on a history of Ms Belevski experiencing a depressed mood most of the day, nearly every day, associated with a markedly diminished interest and ability to derive pleasure from most of her activities, a significant reduction in appetite, significant sleep disturbance, feeling fatigued and low on energy nearly every day, feelings of worthlessness, a loss of self-esteem and a loss of confidence, as well as feelings of hopelessness, a diminished ability to think and concentrate and recurrent thoughts about death and dying.
Ms Belevski has only had a short period of treatment with a single antidepressant medication, Escitalopram, which she had stopped due to worries about the effects that it may have on her pregnancy. There have been no other trials of medications, and she has not been referred to a psychiatrist. She previously saw a psychologist for a period of time but had stopped that several years ago. She is not currently receiving any treatment. She is motivated to attend for further treatment.
Causation and Reasons
Ms Belevski’s post-traumatic stress disorder and major depressive disorder were caused by the subject accident. There were no other identifiable causes. There was no clear evidence that her major depressive disorder was exacerbated by her pregnancy and birth and the postnatal period.
CONCLUSION
Ms Belevski has not received sufficient treatment for her post-traumatic stress disorder and major depressive disorder. She is not currently receiving any treatment and is motivated to engage in further treatment, therefore, she has not yet reached maximum medical improvement. Assessment of whole person impairment should be deferred until such time that Ms Belevski has achieved maximum medical improvement in regard to her post-traumatic stress disorder and major depressive disorder. She requires referral to a consultant psychiatrist for institution and optimisation of her antidepressant therapy and ongoing monitoring of her mental state. After Ms Belevski has been commenced on treatment and the treatment has been optimised, she should be re-assessed regarding her whole person impairment.
The Panel met on 31 August 2023 and reviewed all of the evidence and clinical findings of the two medical members of the Panel. Based on all of the evidence before the Panel and the medical members clinical judgement, the Panel declines to make an assessment of
Ms Belevski’s whole person impairment until after she has had commenced her recommended treatment.The parties may reapply to the Commission for an assessment by a review panel after the claimant has commenced treatment and in the opinion of her treating doctors has reached maximum medical improvement. She can then have her whole person impairment reassessed.
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