Bojovic v Allianz Australia Insurance Limited

[2025] NSWPICMP 223

DETERMINATION OF REVIEW PANEL

CITATION:

Bojovic v Allianz Australia Insurance Limited [2025] NSWPICMP 223

CLAIMANT:

Petar Bojovic

INSURER:

Allianz Australia Insurance Limited

REVIEW PANEL

MEMBER:

Susan McTegg

MEDICAL ASSESSOR:

Margaret Gibson

MEDICAL ASSESSOR:

Adeline Hodgkinson

DATE OF DECISION:

31 March 2025

CATCHWORDS:

MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; review of Medical Assessment Certificate (MAC); claimant suffered injury in a motor vehicle accident as a pedestrian on 6 April 2021; the dispute related to the assessment of whole person impairment (WPI) of a mild traumatic brain injury; cervical spine, thoracic spine, lumbar spine, right knee, and left shoulder; Medical Assessor assessed 6% WPI arising out of traumatic brain injury; Held – impairments described by claimant affect complex high-level tasks such as completing PhD; given academic performance and ability to sustain attention for four hours and despite a relative decline from previous function no WPI can attach to higher intellectual functions; no impairment of activities of daily living caused by mild traumatic brain injury and non-displaced occipital skull fracture; soft tissue injury to cervical spine, thoracic spine, lumbar spine, right knee, and left shoulder fully recovered and do not give rise to assessable permanent impairment; MAC revoked and certified injures caused by accident gave rise to 0% WPI.

DETERMINATIONS MADE:  

MOTOR ACCIDENT INJURIES ACT 2017

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%

Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017

1.     The Review Panel revokes the certificate of Medical Assessor Lahz dated 1 May 2024 and issues a new certificate determining that the following injuries were caused by the motor accident and give rise to a whole person impairment (WPI) of 0%:

·        mild traumatic brain injury; and

·        head – non-displaced occipital skull fracture with extra cranial haematoma on the left side.

2.     The Review Panel finds the following injuries caused by the accident have resolved and give rise to no assessable permanent impairment:

·        soft tissue injury to the cervical spine;

·        soft tissue injury to the thoracic spine;

·        soft tissue injury to the lumbar spine;

·        soft tissue injury to the right knee; and

·        soft tissue injury to the left shoulder.

REVIEW PANEL REASONS FOR DECISION

INTRODUCTION

1. On 6 April 2021 Mr Bojovic (the claimant) was walking home when he was struck by a car at high speed (the accident). Mr Bojovic has no recall of the accident, but a video shows him being flung onto the car bonnet and then onto the ground.

2. Mr Bojovic was 33 years of age at the date of accident and is now 35 years of age.

3. Mr Bojovic has brought a claim for common law damages under the Motor Accident Injuries Act 2017 (the MAI Act).

4. Allianz Australia Insurance Limited (the insurer) is the relevant insurer with liability to pay any damages to Mr Bojovic under the MAI Act.

5. Section 4.11 of the MAI Act provides that there is no entitlement to damages for
   non-economic loss unless the degree of permanent impairment of the injured person as a result of the injury caused by the accident is greater than 10%.

6. The claimant commenced proceedings in the Personal Injury Commission (Commission) in respect of the dispute as to whether the degree of permanent impairment sustained as a result of the injury caused by the accident is greater than 10%. This constitutes a medical assessment matter pursuant to Schedule 2, cl 2 of the MAI Act.

7. A medical assessment matter is determined in accordance with Division 7.5 of the MAI Act by a Medical Assessor.[1]

   [1] Section 7.20 of the MAI Act.

8. The dispute as to permanent impairment of the psychological injury was referred to Medical Assessor Sidorov. He issued a certificate dated 27 March 2024 in which he certified Mr Bojovic had sustained a 7% whole person impairment (WPI) in respect of a major depression disorder.[2]

   [2] Insurer’s documents p 58.

9. The dispute as to permanent impairment in respect of the physical injuries was referred to Medical Assessor Sophia Lahz who issued a certificate dated 1 May 2024. It is that certificate which is the subject of this review.

DOCUMENTS BEFORE THE REVIEW PANEL

1. On 28 August 2024 the claimant uploaded to the portal an indexed bundle of documents paginated from pages 1 to 879 (claimant’s documents). 

2. On 17 September 2024 the insurer uploaded to the portal an indexed bundle of documents paginated from pages 1 to 68 (insurer’s documents).

RELEVANT LEGAL AUTHORITY

1. Section 7.21 of the MAI Act provides that the degree of permanent impairment of an injured person is to be assessed in accordance with the Motor Accident Guidelines (the Guidelines).

2. The Guidelines were issued pursuant to Division 10.2 of the MAI Act and adopt the American Medical Association’s Guides to the Evaluation of Permanent Impairment, Fourth Edition (AMA 4 Guides). The Guidelines are definitive with regard to the matters they address but where they are silent on an issue, the AMA 4 Guides should be followed.[3]

   [3] Clause 1.2 of the Guidelines.

3. Causation of injury is addressed under Part 6 of the Guidelines dealing with permanent impairment:

   “6.6   Causation is defined in the Glossary at page 316 of the AMA4 Guides as follows:

   'Causation means that a physical, chemical or biologic factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following:

   1.The alleged factor could have caused or contributed to worsening of the impairment, which is a medical determination.

   2.The alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination.'

   This, therefore, involves a medical decision and a non-medical informed judgement.

   6.7    There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be a sole cause as long as it is a contributing cause, which is more than negligible. Considering the question 'Would this injury (or impairment) have occurred if not for the accident?' may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes.”

4. Clause 6.138 of the Guidelines define radiculopathy as the impairment caused by dysfunction of a spinal nerve root or nerve roots. To conclude that a radiculopathy is present, two or more of the following signs should be found:

   (a)     loss or asymmetry of reflexes;

   (b)     positive sciatic nerve root tension signs;

   (c)     muscle atrophy and/or decreased limb circumference;

   (d)     muscle weakness that is anatomically localised to an appropriate spinal nerve root distribution, and 

   (e)     reproducible sensory loss that is anatomically localised to an appropriate     spinal nerve root distribution.

CERTIFICATE UNDER REVIEW - CERTIFICATE OF MEDICAL ASSESSOR LAHZ

1. Medical Assessor Sophia Lahz issued a certificate dated 1 May 2024.[4] The following injuries were referred to Medical Assessor Lahz for as assessment as to permanent impairment:

   ·        brain – mild traumatic brain injury;

   ·        cervical spine – minor cervical spondylosis centred upon C4/5 resulting in mild bilateral foraminal stenosis, mild facet arthrosis at C7/T1 on the left;

   ·        head – non-displaced occipital skull fracture with extra cranial haematoma on the left side;

   ·        knee – medical collateral ligament injury (tear of the ligament on the inside of his knee);

   ·        lumbar spine – discal injury/soft tissue injury with radiculopathy;

   ·        shoulder – soft tissue injury/rotator cuff injury; and

   ·        thoracic spine – discal injury/soft tissue injury.

   [4] Claimant’s documents p 11.

2. Medical Assessor Lahz found the mechanism of injury was sufficient to have resulted in a traumatic brain injury. She found the criteria for a traumatic brain injury were met given the claimant sustained a generalised seizure at the scene of the accident, he had a soft tissue injury to the scalp and a left-sided occipital fracture. His Glasgow Coma Score (GCS) fell to 11 after the seizure until it fell to 3 due to pharmacological sedation for agitation and combativeness. Over the initial 24 hours in hospital the claimant reported GCS 14-15 followed by neurological improvement. She concluded the traumatic brain injury was within the mild range given that he emerged from post-traumatic amnesia (PTA) within 24 hours of the accident. Medical Assessor Lahz reported further CT brain and MRI imaging were unremarkable. She noted he remained affected by cognitive difficulties affecting memory, concentration and attention although he now leads an independent life, has been able to complete a masters degree since the accident and works part time in his videography business. Medical Assessor Lahz assessed a 6% WPI for the traumatic brain injury.

3. Medical Assessor Lahz found the mechanism of accident was compatible with soft tissue injuries of the cervical, thoracic and lumbar spine and the left shoulder, notwithstanding the lack of complaints in the clinical records.

4. Medical Assessor Lahz noted the CT scan of the spine performed in hospital was suggestive of wedging (20% height loss) at T10-12 although there is no record of complaint of upper or mid back pain. She also noted the absence of paravertebral tissue swelling present on the films to confirm the presence of vertebral fractures. On the basis an acute vertebral fracture would not be present unless there was associated adjacent soft tissue swelling Medical Assessor Lahz concluded Mr Bojovic did not sustain any vertebral fractures in the accident.

5. She noted the neck and thoracic spine were asymptomatic on examination so concluded the soft tissue injuries in those regions had resolved.

6. Medical Assessor Lahz reported the lumbar spine soft tissue injury was complicated by symptoms in the right sacroiliac joint (SIJ) with referral to the ipsilateral right anterior thigh. She concluded the claimant had sustained a lumbar spine soft tissue injury with adjacent right SIJ soft tissue injury although she found there were no longer any symptoms in the lumbar spine. There were no clinical signs in the lower limbs to confirm the presence of lumbosacral radiculopathy. 

7. Medical Assessor Lahz found the claimant sustained a right knee injury caused by the accident. One examination she found the knee was stable with mild ongoing discomfort at the medial joint line with valgus strain. The impairment for the right medical collateral ligament strain/soft tissue injury did not exceed 0% WPI and she found no laxity of the injured ligament.

8. Medical Assessor Lahz reported there was a full active range of bilateral shoulder, elbow, wrist and hand movements not attracting any WPI. She found mild residual symptoms at the left shoulder which, given the violent mechanism, she accepted resulted from the accident, despite the lack of contemporaneous documentation.

9. Medical Assessor Lahz found the following injuries were caused by the accident:

   ·        mild traumatic brain injury (with single epileptic seizure at the scene)

   ·        right knee soft tissue injury, and

   ·        left shoulder soft tissue injury.

10. She found the following injuries have resolved:

    ·        cervical spine soft tissue injury;

    ·        thoracic spine soft tissue injury;

    ·        lumbar spine soft tissue injury; and

    ·        extracranial haematoma associated with un-displaced skull fractures.

11. Medical Assessor Lahz found the following injuries were not referred but caused by the accident:

    ·        right SI (sacroiliac) soft tissue injury with referred symptoms to the anterior thigh, and

    ·        vestibular injury with bilateral positive Hallpike tests (documented during the acute hospital admission).

12. She assessed a total 6% WPI arising out of the traumatic brain injury.

REVIEW PROCEDURE

1. On 30 May 2024 Mr Bojovic sought a review of the medical assessment of Medical Assessor Lahz.

2. On 23 July 2024 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).[5]

   [5] Section 7.26 of the MAI Act, AD2 p 6, AD7 p 189.

3. Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the Personal Injury Commission, Act, 2020 (PIC Act). A Review Panel determines how it conducts and determines the proceedings and may determine the proceedings solely based on the written application.[6] The review is by way of a new assessment of all matters with which the medical assessment is concerned.

   [6] Rule 128 of the PIC Rules.

4. On 22 October 2024 the Panel sought the consent of the parties to limit the dispute as to the assessment of permanent impairment to the thoracic spine and the left shoulder where the submissions provided by the parties only addressed the dispute in respect of those body parts. The claimant did not consent and sought a review of all injuries the subject of the assessment.

5. On 5 November 2024 the Panel agreed two medical examinations will be required.

6. The panel notified the parties Medical Assessor Hodgkinson will undertake an assessment of the following injuries:

   ·        Mild traumatic brain injury; and

   ·        Head – non-displaced occipital skull fracture with extracranial haematoma.

7. The panel notified the parties Medical Assessor Gibson will undertake an assessment of the following injuries:

   ·        thoracic spine;

   ·        left shoulder;

   ·        right knee injury;

   ·        cervical spine injury; and

   ·        lumbar spine injury.

EVIDENCE BEFORE THE REVIEW PANEL

Application for personal injury benefits (the application)

1. In the application for personal injury benefits dated 18 May 2021 he listed the injures as non-displaced occipital fracture with extracranial haematoma (left), vertigo and nystagmus and medial collateral ligament injury.[7]

   [7] Claimant’s documents p 106.

2. The medical certificate completed by Dr Kim; general practitioner (GP) described the following injuries:

   ·        left occipital fracture with extracranial haematoma complicated by tonic-clonic seizures; and

   ·        right medial collateral ligament strain.[8]

[8] Claimant’s documents p 198.

Treating medical evidence

NSW Ambulance Service

1. The NSW Ambulance Service received a call at 4.13pm on 6 April 2021. The Ambulance Officers were at the scene and with the claimant by 4.15pm. The Ambulance report states:

   “NSWA saw pt having tonic clonic seizure on the road. Bystanders state pt was hit by car travelling at approx 40km/hr and fell to the ground having a seizure. Unknown if damage to car. 0/e Pt actively having a tonic clonic seizure lasting approx 2minutes, Actively bleeding wound to occiput of head. Incontinent of urine. Post seizure pt became highly combative and agitated. GCS (Glasgow Coma Scale) 11 (e4v2m5). PEARL. Airway self-maintaining. Occiput wound actively oozing. C-spine inline-immobilisation. Nil obvious airway trauma. Trachea midline. Lungs clear. Nil obvious chest trauma. Abrasions to L posterior flank. Abdo SNT. Pelvis bound. Long bones intact….”[9]

   [9] Claimant’s documents p 230.

2. The Vital Signs Survey records the following:[10]

   [10] Claimant’s documents p 229.

Time	16.16	16.24	16.45	16.53
VSS Position	(L) Lateral	Sitting	Supine	Supine
CVS
Pulse	95	113	99
BP	121/81	130/80
RESP
RR	18	10	16
Sp02 %	95	95
Environment	Room Air	Room Air
ETCO2MMG	35	35
Waveform	Normal respiratory waveform	Normal respiratory waveform
CNS
Eyes	4 Spontaneous	4 Spontaneous	4 Spontaneous	4 Spontaneous
Verbal	2 Incomprehensible sounds	2 Incomprehensible sounds	2 Incomprehensible sounds	2 Incomprehensible sounds
Motor	5 Localises to pain	5 Localises to pain	5 Localises to pain	5 Localises to pain
GCS Score	11	11	11	11
Pupils (L)
Size	Normal	Normal	Normal
Pupils (R)
Size	Normal	Normal	Normal
BSL	(mm/l)	6.1
VSS Incomplete Reason	Pt Combative	Pt Combative	Pt Combative	Pt Combative

1. The Ambulance Report details the following management:[11]

   [11] Claimant’s documents p 230.

16:19	Midazolam 5 mg, IM
16:25	IV access, 18 g, (L) antecubital fossa
16:28	Ketamine 20 mg
16:30	Oxygen therapy, oxygen mask 151/min
16:32	Ketamine 20 mg
16:33	Spinal immobilisation other aids >> inline immobilisation
16:35	Pelvis
16:35	IV access (R) antecubital fossa
16:36	Ketamine, 20 mg
16:36	Ondansetron 4 mg
16:40	Ketamine 20 mg
16:45	Ketamine 20 mg
16:50	Midazolam 2.5 mg, IV

Royal Prince Alfred Hospital

1. The claimant was admitted to Royal Prince Alfred Hospital (RPAH) following the accident on 6 April 2021.[12] The discharge summary notes Mr Bojovic was a pedestrian hit by a car travelling at 40kph. At the scene there was a tonic clonic seizure witnessed by ambulance officers. He was combative and required sedation at the scene. He was given 7.5mg IV Midazolam and 100mg IV Ketamine at the scene.

   [12] Claimant’s documents p 201.

2. The Ambulance/Retrieval Transfer records:

   “GCS to 3

   Combative

   60mg Ket

   5mg Midaz

   ↓

   GCS 12.”[13]

   [13] Claimant’s documents p 232.

3. On arrival in the resuscitation bay Mr Bojovic was agitated and required 80mg Ketamine.[14] He was seen to move all four limbs strongly. He progressed to intubation by anaesthetics (G2 airway via video laryngoscope).

   [14] Claimant’s documents p 255.

4. There were initial concerns for neurological injury given GTCS (sic) and R eye lateral deviation, which was later confirmed to be longstanding.

5. A trauma CT disclosed a non-displaced left occipital skull fracture. The endpoint of the fracture line was around the left sigmoid sinus. No intracranial haemorrhage was detected.  

6. Mr Bojovic was noted to be experiencing vertigo and nystagmus.

7. On admission at 5.50pm on 6 April 2021 the GCS was 8 and both pupils were equal and reactive to light. Mr Bojovic was moving his limbs and localising to pain.[15]

   [15] Claimant’s documents p 206.

8. The admitting physician reported CNS retrograde amnesia to events.

9. There were no obvious deformities or injuries to the neck, no rib or clavicle tenderness, no visible injuries at the abdomen and no visible injuries at the pelvis other than a superficial left hip abrasion. There were no visible injuries of the upper limbs and the only visible injury to the lower limbs was a left knee abrasion.

10. A CT brain scan showed left parieto-occipital subcutaneous haematoma with underlying
    un-displaced fracture extending to the left parietal bone inferiorly, crossing the lambdoid suture into the occipital bone inferiorly and terminating around the left sigmoid dural venous sinus. No acute intracranial haemorrhage. 

11. The X-rays of the chest and pelvis were unremarkable.

12. The CT of the cervical spine did not disclose any traumatic findings. A CT Pan scan was unremarkable.

13. Mr Bojovic was commenced on Keppra and successfully extubated overnight. He received analgesia and DVT prevention.

14. At 6.54am on 7 April 2021 the ICU update reads:

    “Woke up appropriately

    Obeying commands 4 limbs

    C-spine clinical assessment

    Full power upper and lower limbs

    No sensory deficit upper limbs

    Collar removed

    Full ROM without nec pain

    Palpated posterior spine – no pain

    CT reviewed – no injury C-spine

    D/W NSx reg – happy to clear C-spine

    UDS clear

    Extubated uneventfully.”[16]

    [16] Claimant’s documents p 236.

1. At 9.40am on 7 April 2021 Lauren Wonders, occupational therapist recorded an Abbreviated Westmead Post Traumatic Amnesia Screen (AWPTAS) score of 15/18.[17]

   [17] Claimant’s documents p 242.

2. At 10.30am on 7 April 2021 a GCS score of 14 was recorded. It was noted Mr Bojovic was initially confused as to specific date but was not scoring 14/15 due to drowsiness and post Droperidol for nausea.[18] His pupils were equal and reacting at size four.  He was moving all four limbs with normal power. 

   [18] Claimant’s documents p 241.

3. The AWPTAS was readministered by Ms Wonders at 10.30am on 7 April 2021 when the claimant scored 18/18 and it was concluded the claimant cleared the AWPTAS indicating a mild head injury.[19]

   [19] Claimant’s documents p 240 and 242.

4. At 21.40pm on 7 April 2021 the GCS was 15, Mr Bojovic was orientated as to time, place and person. CN was intact, there were nil motor or sensory deficits in the limbs and nil midline spinal tenderness.[20]

   [20] Claimant’s documents p 246.

5. During admission Mr Bojovic was noted to experience vertigo and nystagmus. The neurology registrar thought there was bilateral BPPV (benign paroxysmal positional vertigo). Epley manoeuvres were performed, and he was advised to avoid sleeping on the right side for a week. Follow up in the Brian Injury Unit with Dr Jankelowitz and also in the dizziness clinic was recommended.

6. Mr Bojovic was discharged on 8 April 2021 on Keppra, Panadol and Ondansetron.

7. On 16 April 2021 Mr Bojovic attended the neurosurgery clinic for removal of the staples in the occipital region.[21] Two further stitches were inserted for better closure and to prevent oozing.

   [21] Claimant’s documents p 271.

Neuro-Otology clinic, RPAH

1. Mr Bojovic underwent a vestibular examination on 20 April 2021. Hallpike testing showed persistent right beating nystagmus. All position testing was negative for vertigo. Mr Bojovic was encouraged to increase head motion.[22]

   [22] Claimant’s documents p 222.

2. Mr Bojovic was reviewed on 5 May 2021. Mo Bojovic reported no vertigo since last seen in the clinic. Hallpike testing was negative for both vertigo and nystagmus.[23]

   [23] Claimant’s documents p 224.

Dr Jankelwitz, neurologist

1. On 5 May 2021 Dr Jankelowitz, neurologist noted an improvement since discharge and Mr Bojovic was no longer experiencing headaches or vertigo.[24] He experienced anxiety and had suffered an episode of tunnel vision lasting 20 minutes. He had resumed lectures for his Master’s degree.  She noted negative Romberg’s and observed Mr Bojovic could do a tandem gait. Eye movements were normal and there was no nystagmus. Head impulse was normal. Mr Bojovic scored 26/30 on the MOCA (Montreal Cognitive Assessment) with trouble recalling four items. He complained of fatigue, irritability, frustration, forgetfulness and poor concentration. Dr Jankelowitz suggested Mr Bojovic avoid screens and have an MRI brain. She recommended he say on Keppra and would likely improve.

   [24] Claimant’s documents p 215.

Dr Rowena Mobbs, neurologist

1. On 7 May 2021 Dr Kim referred Mr Bojovic to Dr Rowena Mobbs. Dr Kim reported Mr Bojovic had sustained a traumatic brain injury on 6 April 2021 after a car versus pedestrian accident.[25] Dr Kim reported this caused an un-displaced parietal occipital fracture. Dr Kim reported Mr Bojovic had a seizure at the time of the accident and was discharged on Levetiracetam 1g BD with a plan to wean to 500mg BD after four weeks. Dr Kim reported
   

   [25] Claimant’s documents p 199 and 640.

   Mr Bojovic had deficits including fatigue, irritability, difficulty concentrating for prolonged periods of time, and anxiety in public places. He reported Mr Bojovic was doing significantly reduced hours at Uni and not working his usual part time job doing photo shoots and editing. In relation to the cognitive tests undertaken at RPAH, Dr Kim reported the poor result was not an accurate reflection of his function where English is not Mr Bojovic’s first language, and he reportedly found the instructions vague and unclear. He reported Mr Bojovic found it easier to think in his native language, Serbian since the accident.

2. In a report dated 16 June 2021 Dr Rowena Mobbs noted the accident followed by seizure and agitation.[26] There was gradual improvement but with residual anxiety in open spaces due to affective cognitive change. This was exacerbated by Keppra. The headache had eased but Mr Bojovic had some mental clouding. Whilst he did not recall any significant concussions Dr Mobbs reported there had been head trauma from boxing during his teen years. There was no family history of seizure. She recorded a score of 23 on the Post Concussion Symptom Scale (PCS). Orientation was intact and there was overall some slowed processing. Recall was slightly less than baseline. Dr Mobbs reported the cranial nerve, limb gait and speech examination was normal.

   [26] Claimant’s documents p 611.

3. Dr Mobbs found Mr Bojovic had suffered a mild TBI complicated by an impact seizure. The MRI was normal, so she thought the ongoing seizure risk was low. She suggested the possibility of post-traumatic migraine and discussed perineural occipital nerve injections. She also reported numbness of the scar in the region suggestive of nerve injury. She recommended an EEG and planned to wean the Keppra. Dr Mobbs also discussed post vaccine headache without migraine features. She considered he had tension spectrum response to the Astra Zeneca vaccine.

4. On 7 July 2021 Dr Mobbs reported some withdrawal symptoms whilst reducing Keppra. She recommended he reduce the Keppra to 250 mg bd. Mr Bojovic had improved, and the headaches had eased. She thought the seizure was due to the head trauma, but the overall seizure risk was low.[27]

   [27] Claimant’s documents p 614.

5. An EEG report of 15 July 2021 referred to normal record without epileptiform activity.

6. In a report dated 15 July 2021 Dr Mobbs noted a mild TBI complicated by grand mal seizure on 6 April 2021. Mood and cognition had improved on Keppra and the EEG was normal. He was to cease the Keppra in one week. Mr Bojovic was not driving, not to consume alcohol and was aware of the need for work life balance.

7. On 5 August 2021 Dr Mobbs noted Mr Bojovic was asymptomatic off Keppra. She reported the MRI of the cervical spine showed minor degeneration only. She concluded the symptoms in the claimant’s neck were musculoskeletal.[28]

   [28] Claimant’s documents p 624.

8. In a further report also dated 5 August 2021 Dr Mobbs noted that the seizure on 6 April 2021 had been due to the head trauma and was not a true tonic clonic seizure. She concluded
   

   [29] Claimant’s documents p 623.

   Mr Bojovic was safe for a private driving licence given there had been no further events.[29]

9. Mr Bojovic was re-referred to Dr Mobbs on 14 September 2021 with headaches across the scalp and face of moderate intensity and responsive to over-the-counter analgesics. He was seeing a psychologist fortnightly for cognitive behavioural therapy (CBT) for anxiety.

10. On 30 September 2021 Dr Mobbs noted the headaches had subsided in the last two weeks.  They had been localised to the forehead and were constant with visual obscuration but no other aura features. She did not arrange follow up.  

11. On 18 November 2021 Dr Mobbs reported no restrictions regarding computer use were necessary. She reported there was post traumatic migraine which commonly caused mental clouding due to cerebral dysfunction. She noted pain also caused distraction. No particular strategies were advised given the symptoms had resolved.

12. On review on 20 January 2022 Dr Mobbs noted Mr Bojovic needed further clearance for driving and proposed a repeat EEG. She thought he displayed subtle short term recall impairment which may relate to either post-concussion or else post traumatic psychological phenomenon. 

13. On 27 January 2022 Dr Mobbs reported the EEG was normal and there had been no further seizures. Mr Bojovic was fit to hold a class C licence.

14. In a report dated 23 May 2024 Dr Mobbs reported Mr Bojovic had been well with no recurrence of seizure.[30]  He had maintained good self-care and avoidance of further head injury.

    [30] Insurer’s documents p 66.

General practitioner clinical records

1. Mr Bojovic saw Dr Matthew Kim, GP on 10 April 2021 when he noted the accident caused a non-displaced left occipital fracture with extracranial haematoma.[31] He also noted the presence of vertigo and nystagmus due to BPPV. He reported mood swings, irritability, and fatigue. He also reported right knee pain. Mr Bojovic was using a neck brace but reported there was no neck tenderness. Dr Kim reviewed the scalp wound and recommended dressing for a few more days. Dr Kim recommended psychology follow up, dizziness and TBI (traumatic brain injury) clinic follow up.

   [31] Claimant’s documents p 587.

2. On 16 April 2021 Dr Kim noted Mr Bojovic was feeling better. He had ongoing right knee pain and there had been some ooze from the head wound. A DASS 21 showed no depression, mild anxiety and mild stress.

3. On 19 April 2021 Dr Kim noted the staples had been removed from the head wound although to additional sutures had been applied. Vertigo was improving. He has some right thigh pain. The right knee pain was improving in the brace.

4. Dr Kim completed a medical certificate dated 30 April 2021 in which he described the injuries as, “left occipital fracture w extracranial haematoma complicated by tonic clonic seizures.
   

   [32] Claimant’s documents p 198.

   R medial collateral ligament strain.”[32] Mr Bojovic had attended university although he found it hard to concentrate.

5. On 7 May 2021 Dr Kim referred Mr Bojovic to Dr Altman psychiatrist regarding anxiety and panic attacks. There were no flashbacks, and he sought advice as to whether there was anxiety or post-traumatic stress disorder.

6. In a certificate dated 14 May 2021 Dr Kim listed occipital skull fracture, traumatic brain injury/ seizure and medial collateral ligament injury.[33]  There were no seizures. Bending and twisting of the right knee was difficult. He was certified unfit for work for a month.

   [33] Claimant’s documents p 112.

7. On 16 June 2021 Mr Bojovic was referred to Mr Crino regarding anxiety, panic attacks and short fuse.

8. In a medical certificate dated 29 June 2021 Dr Kim reported there were significant deficits with concentration and attention span. Mr Bojovic was still unable to resume his tertiary studies.

9. On 21 July 2021 Dr Kim noted he had undergone EEG clearing Mr Bojovic of seizure activity.  Keppra had been stopped.[34] There was improvements in his mood and concentration.

   [34] Claimant’s documents p 594.

10. On 17 August 2021 Dr Katherine Hogg, GP reported Mr Bojovic’s right knee was still not completely stable.[35] She also reported he was getting neck tingling post flexing and could not work on the computer for prolonged periods due to neck symptoms.

    [35] Claimant’s documents p 594.

North Ryde Medical Centre clinical records

1. Dr Kim reviewed Mr Bojovic at North Ryde Medical Centre on 9 November 2021.[36] He reported Mr Bojovic was significantly better, he had mild-moderate pain in the knee, and he had seen a psychologist Dr Isakovic and was undertaking daily reflection exercises. He reported Mr Bojovic saw Dr Mobbs one month ago and she believed he was better from his brain injury. She had no plan for follow up and Mr Bojovic was cleared from a seizure perspective. He noted Mr Bojovic was finishing uni that semester and was working three to four hours a day four to five days a week.

   [36] Claimant’s documents p 353.

2. On 18 November 2021 it was noted he was receiving psychological and chiropractic interventions. His driving licences were suspended. He was fit for suitable duties with some increase in push, pull and carrying ability.

3. At of 3 March 2022 Mr Bojovic was juggling work, rehabilitation and study and feeling stressed. 

4. Consultations on 1 April 2022, 14 April 2022, 12 May 2022, 11 June 2022 and 23 July 2022 addressing ongoing right knee pain.

Balmoral Medical Practice

1. The records disclose consultations on 21 March 2023 and 29 September 2023.[37] Only the latter consultation is relevant where Mr Bojovic presented in relation to his fitness to drive. It is noted he was cleared by Dr Mobb and had no further seizures since the first episode. He had full neck range of motion and good ankle coordination/power.

   [37] Insurer’s documents p 67.

Dr Rocco Crino, clinical psychologist

1. Dr Crino saw Mr Bojovic for five sessions in 2011 following a referral on 16 June 2021. In a report dated 31 July 2022 he reported Mr Bojovic presented with marked anxiety and excessive rumination following the accident. He stated his primary concerns focused on his return to his pre-accident levels of functioning and the unjust nature of the accident and its consequences. He said he instructed Mr Bojovic in rumination control strategies, attentional focus techniques and behavioural activation strategies.[38]

   [38] Claimant’s documents p 812.

Dr Merima Isakovic Clinical Psychologist/ Neuropsychologist

1. In an Allied health recovery request (AHRR) dated 14 October 2021 Dr Isakovic referred to post-traumatic stress disorder, post concussive syndrome and major depression affecting concentration and attention as well as sleep. Mr Bojovic had difficulties with study, organisation, creative thought and decision making.[39]

   [39] Claimant’s documents p 317.

2. In an AHRR dated 12 February 2022 it was noted there were difficulties concentrating, sleeping, irritability and cognitive/emotional fatigue. There was reduced performance at home and at work.

Neuropsychological report of Dr Isakovic[40]

[40] Claimant’s documents p 338.

1. In a report dated 24 January 2022 Dr Isakovic reported a history of frequent daily seizures after the accident lasting a few minutes. This history is not consistent with the available evidence which refers to a single seizure at the scene of the accident without recurrence.

2. Dr Isakovic also reported various post concussive symptoms such as nausea, balance difficulties, reduced orientation and light/sound sensitivity. She also reported right leg injuries.

3. She reported Mr Bojovic was a full time videographer in his own business and was doing a sociology degree.

4. Dr Isakovic reported difficulties with attention, concentration, fatigue, work finding difficulty (WFD), anxiety, mood lability, insomnia and irritability. He had problems in emotional function, anger management, cognition and executive function. Mr Bojovic was reported to describe difficulty expressing himself, finishing tasks, low sexual drive and planning and organisation.

5. Dr Isakovic undertook the assessment over zoom. She reported as follows:

   ·        he was well orientated and his speech detailed;

   ·        there was no indication of disordered thought;

   ·        he felt fatigued;

   ·        his ability to organise and manipulate visual information fell in the low average range, lower than expected;

   ·        verbally based attentional difficulties fell in the average range, lower than expected;

   ·        ability to comprehend and express himself was within expected levels

   ·        Reading fell in the average range;

   ·        phonemic verbal fluency was average but categorical verbal fluency fell in the extremely low range;

   ·        significant difficulties with word retrieval based on semantic attributes whilst he could retrieve them based on phonemic aspects;

   ·        visual abilities lower than expected, with visual abstract reasoning in the average range, visuo-constructional skills were low average and a relative cognitive weakness;

   ·        efficiency of tasks completed was lower than expected;

   ·        he struggled to sequence letters alternating with numbers;

   ·        he could quickly name words though colour naming was low average;

   ·        ability to attend to auditory information and calculation abilities were both average;

   ·        he could recall verbal information and hold attention as well as filter out irrelevant information;

   ·        he was in the extremely low range for learning new information through repetition and had difficulties recall information after interference and after greater than 20 minutes;

   ·        he could not use cues to spark memory;

   ·        he could recall visual information immediately and after delay (low average to average) and could use cues to spark memory (low average), and

   ·        executive functions were consistent though he had difficulties alternating between two mental sets on visually mediated speeded test, performing lower than expected.

6. Dr Isakovic concluded Mr Bojovoic’s overall cognition was intact though affected by reduced attention capacity, a common consequence of TBI. She reported difficulties with organisation and manipulation of visual information. His visuo-constructional skills were noted to reflect a cognitive weakness, and he had difficulty alternating between two sets on a task at speed. There were difficulties with verbal fluency, with retrieving words using semantic characteristics and ability to learn new information was below that of his peers. 

7. Dr Isakovic also noted emotional distress perpetuated by the functional changes particularly with symptoms of depression, anxiety and emotional regulation.

Dr Sophie Armstrong, sports and exercise medicine physician

1. Mr Bojovic saw Dr Sophie Armstrong on 12 July 2022 regarding his right knee.[41] She reported he sustained a traumatic brain injury and a skull fracture. He also had significant right knee pain and underwent three to four months of chiropractic treatment. During this time, he became aware of some right lower back and sacroiliac joint discomfort.
   

   [41] Claimant’s documents p 561.

   Dr Armstrong reported the MRI of the right knee of 8 April 2022 was unremarkable. She thought he had right sacroiliac joint dysfunction causing referral down his right leg. There was no complaint pertaining to either the left shoulder or the thoracic spine.

2. On 10 January 2023 Dr Armstrong reported an improvement in the previous sacroiliac joint symptoms although Mr Bojovic continued to complain of ongoing right knee stiffness.[42] 
   She diagnosed a right sacroiliac joint dysfunction and expressed the following opinion as to causation:

   “Yes I do believe that Petar’s complaints are consistent with the injury sustained due to the impact on his right thigh creating a shearing mechanism through his right side, leading to sacroiliac joint dysfunction. His knee pain is a consequence of altered mechanics related to his sacroiliac joint dysfunction.”

   [42] Claimant’s documents p 571 and 783.

3. On 16 March 2023 Dr Armstrong reported the right leg and knee symptoms had settled and the sacroiliac symptoms were stable. Mr Bojovic had started running and continued physiotherapy.

4. On 21 May 2024 Dr Armstrong reported Mr Bojovic had ongoing lateral right hip and buttock discomfort which refers to the proximal lateral thigh and medial knee.[43] She noted a normal gait, a full range of motion through the lumbar spine but with a sense of tightness through the right lower back and buttock region with right sided movement. She recommended ongoing maintenance physiotherapy.

   [43] Claimant’s documents p 874.

Greenlight Rehabilitation

1. In a letter to Dr Crino dated 11 August 2021 Greenlight Rehabilitation reported Mr Bojovic had resumed university but with reduced cognitive function and reduced ability to concentrate.

Sidney Guines, chiropractor

1. Mr Bojovic came under the care of Sidney Guines. In an Allied health recovery request (AHRR) dated 30 September 2021 Mr Guines diagnosed a right knee medial ligament sprain with associated patellofemoral pain syndrome.[44] In current signs and symptoms Mr Guines recorded since the accident when Mr Bojovic was struck by a vehicle on the right side of his body he had noticed pain increase with activity in the medial aspect of the knee and pain in the right upper leg and hip after walking and kayaking of 60+ minutes duration. 

   [44] Claimant’s documents p 312.

2. On 10 November 2021 Mr Guines reported he treated the claimant for the right subacute MCL strain and right upper quadricep contusion resulting in progressive improvement.

Matthew Hogan, exercise physiologist

1. On 24 January 2022 Matthew Hogan assessed the claimant in respect of his right knee.[45]
   

   [45] Claimant’s documents p 197.

   He reported injuring his right knee, tearing his MCL as well as ongoing concussion symptoms caused by the accident. He reported tenderness on palpation of the medial knee. Range of motion of both knees was 2-140 degrees. He was still lacking strength but should improve with rehabilitation. He reported Mr Bojovic was limited at work by his post concussive symptoms with foggy thoughts. 

Taso Lambridis of Spinal Synergy Physiotherapy

1. On 18 November 2022 Taso Lambridis assessed the claimant for his ongoing right knee pain with associated SIJ discomfort.[46] He concluded that his issues most likely related to a right SIJ dysfunction. On examination, he noted amongst other findings, when standing Mr Bojovic had back posture with a kyphosis in the thoracic region and mild scoliosis convex to the left in the low-thoracic region.

   [46] Claimant’s documents p 565.

2. On 24 January 2023 Mr Bojovic was reassessed by Taso Lambridis, physiotherapist.[47]
   

   [47] Claimant’s documents p 573.

   He reported Mr Bojovic had little to no discomfort from the right sacro-iliac region but still reported occasional tightness in his right thigh. 

3. On 13 December 2023 Mr Lambridis reported that static position such as prolonged standing aggravate the right anterolateral thigh pain which worsens throughout the day or with increased activity. Mr Lambridis noted increased stability through the right SIJ but concluded the current symptoms indicated a right psoas/hip flexor strain.[48] 

   [48] Claimant’s documents p 876.

Imaging

1. Trauma CT, 6 April 2020 - Mr Bojovic underwent a trauma (brain, cervical spine, chest, abdomen including pelvis) CT in hospital on 6 April 2021. The report of the radiologist
   Dr Cheng included the following:

   “BRAIN

   A left parieto-occipital subcutaneous haematoma is noted. There is an underlying undisplaced facture extending from the left parietal bone inferiorly, crossing the left lambdoid suture into the occipital inferiorly and terminating around the left sigmoid dural venous sinus. No hyperdensity is seen within the sinus to suggest an acute clot. No acute intracranial haemorrhage is detected.

   No mass effect and no herniation. The ventricles are not dilated. Grey-white matter differentiation is preserved.

   No mastoid or middle ear effusion.

   The orbits and their contents are normal.

   An endotracheal tube is noted. The nasal passages and nasopharynx is opacified.

   CERVICAL SPINE

   The spinal alignments are within normal limits. No fracture is detected. No facet joint dislocation. The craniocervical junction articulations are intact.

   …

   Conclusion:

   Undisplaced left parieto-occipital skull fracture. The inferior endpoint of the fracture line is around the left sigmoid sinus. No intracranial haemorrhage is detected….”[49]

   [49] Claimant’s documents p 210.

2. CT scan right knee, 19 April 2021 - the comment reads:

   “No fracture is evident within the right knee.

   There is thickening of the medial collateral ligament suggestive of ligament strain.”[50]

   [50] Claimant’s documents p 673.

3. MRI brain, 26 May 2021 – the report reads:

   “The ventricles are not enlarged. There is no restricted diffusion.

   No focal mass effect or oedema is evident. There is no haemorrhage or microbleed. No surface collection is evident.

   There is no cortical signal alteration.

   Flow voids are demonstrated in the intracranial vessels.

   There is linear low T2 signal in the subcutaneous tissues overlying the left parietal bone, in keeping with a healing laceration.

   Conclusion:

   There is no evidence of focal haemorrhage or encephalomalacia.”[51]

   [51] Claimant’s documents p 674.

4. Electroencephalography, 15 July 2021 – the report concludes:

   “Normal record. No definite epileptiform activity was seen.”[52]

   [52] Claimant’s documents p 834.

5. MRI Cervical spine, 22 July 2021 - the report concludes:

   “There is minor cervical spondylosis centred upon C4/5 where there is mild bilateral stenosis as a result. 

   Facet arthrosis is mild at C7/T1 on the left."[53]

   [53] Claimant’s documents p 304.

6. Electroencephalography, 27 January 2022 – the report concludes:

   “Normal record.”[54]

   [54] Claimant’s documents p 848.

7. MRI right knee, 10 April 2022 – the comment reads:

   “Intact ligaments and menisci.

   No bone or cartilage lesion seen.

   Minor extensor tendinopathy and small semimembranosus bursal effusion”.[55]

Medico-legal evidence

[55] Claimant’s documents p 774.

Dr Yajuvendra Bisht, psychiatrist

1. Dr Bisht assessed the claimant and provided a report dated 1 February 2023.[56] He noted nightmares, flashbacks, anxiety, sadness, lack of enjoyment, reduced sustained concentration, poor motivation, flat mood and irritability. He also reported hypervigilance and fearfulness. 

   [56] Claimant’s documents p 123.

2. Dr Bisht diagnosed major depression and post-traumatic stress disorder.

Dr Pauline Langeluddecke, clinical psychologist

1. Dr Langeluddecke assessed the claimant and provided a report dated 23 February 2023.[57]

   [57] Insurer’s documents p 12.

2. Dr Langeluddecke reported that the psychometric testing indicated results below the level reported on the earlier assessment for most tasks including memory, cognitive proficiency, attention and executive function. She noted severe and wide-ranging deficits in higher order cognitive functions at odds with intact function in the cognitive domain during November 2021.

3. Dr Langeluddecke stated:

   “The impairments greatly exceeded those expected for mild TBI and were difficult to reconcile with the normal neuroimaging, mild post injury cognitive changes described in reports and records of treating neurologist and GP.”

4. Dr Langeluddecke considered the cognitive test results were inconsistent with the ability to maintain independence in daily living, drive and study. She considered there had been exaggeration of complaints and problems.

5. She indicated the parameters indicated mild TBI with the only suggestion of more severe TBI being the seizure afterwards with the reduced GCS.

6. Dr Langeludddecke thought the TBI was mild and the risk of long-term cognitive impairment and neurobehavioral change extremely low.

Professor Ian Cameron, rehabilitation physician

1. Prof Cameron assessed the claimant for the insurer and provided a report dated 19 March 2023.[58]

   [58] Insurer’s documents p 30

2. He reported at RPAH Mr Bojovic was diagnosed as having an occipital skull fracture with traumatic brain injury and musculoskeletal injuries. 

3. Prof Cameron reported ongoing memory and concentration difficulties. Mr Bojovic anticipated completing the Masters in 2023 and was planning to do a PhD. He reported his score of 16/30 on MOCA was invalid because it was not compatible with pursuing work, educational activities and leading an independent life. 

4. Prof Cameron diagnosed a mild TBI and musculoskeletal injuries. 

5. He reported Mr Bojovic had ongoing psychological issues. He noted his inconsistent performance on cognitive testing.

6. Using the DCR (Clinical Dementia Rating) he assessed 0% WPI for the TBI. He reported all domains were 0 aside from memory of 0.5. However, he noted there had been a significant brain injury followed by impairment of emotional and behavioural function. He ascribed 5% WPI for emotional and behavioural impairment using Table 3 page 142 of the AMA 4 Guides.

7. Prof Cameron assessed the soft tissue pelvic injury with sacroiliac joint dysfunction as
   0% WPI given there is no established pelvic fracture with residual symptoms or signs.

Dr Wayne Mason, psychiatrist

1. Dr Mason provided a report dated 4 December 2023.[59] He noted the report of
   

   [59] Insurer’s documents p 37

   Dr Langeluddecke. Mr Bojovic reported anxiety, social withdrawal and subjective reduction of cognitive stamina. Mr Bojovic also described episodic low mood, emotional reactivity and anxiety symptoms.

2. Dr Mason concluded there has a post concussive disorder. He concluded there was a mild TBI with a diagnosis of adjustment disorder and depressed mood.  e assessed a 7% WPI for the psychiatric condition.

SUBMISSIONS

Claimant’s submissions

1. The claimant provided submissions in support of the application for review.[60]

   [60] Claimant’s documents p 1

2. The claimant notes Medical Assessor Lahz reported any vestibular injury (which was not referred for assessment) was outside her expertise to assess.

Shoulder

1. The claimant submits the Medical Assessor failed to take accurate loss of range of motion measurements with the result that her findings are inconsistent with the preponderance of the treating evidence. The claimant submits the circumstances in this case demand the use of a goniometer to measure range of motion of the upper extremity in accordance with clauses 6.48 to 6.57 of the Guidelines.

Thoracic spine

1. The claimant refers to page 40 of the certificate and notes the objective radiological evidence demonstrates that the claimant suffered wedging of the T10-12 vertebra with a significant 20% height loss which is not contradicted by any pre- or post-accident alternative cause evidence and as such attracts a DRE II impairment of 5% WPI. The claimant submits the findings of Medical Assessor Lahz on causation of the thoracic spine injury were speculative and not grounded on an evidentiary basis in breach of Insurer Australia Limited trading as NRMA Insurance v Brown.[61]

   [61] Insurer Australia Limited trading as NRMA Insurance v Brown [2019] NSWSC 1236.[61]

2. The claimant submits Medical Assessor Lahz asked herself the wrong question and that the mandated question in assessing the claimant’s impairment is what level of injury and impairment can be assessed, if any, based on all of the evidence.

Insurer’s submissions

1. The insurer provided submissions dated 21 June 2024.[62] 

   [62] Insurer’s documents p 2

Thoracic spine

1. The insurer submits the claimant’s submission as to the mandated question for the evaluation of impairment is not correct. The insurer submits the relevant question is set out at cl 6.17 of the Guidelines which states:

   “The medical assessor must evaluate the available evidence and be satisfied that any impairment:

   (a)    Is an impairment arising from an injury caused by the accident; and

   (b)    Is an impairment as defined in clause 6.9 (above).”

2. The insurer submits Medical Assessor Lahz asked herself the correct question in that she considered:

   (a)     whether the accident did cause the vertebral pathology detected on imaging – she opined it did not, given the absence of contemporaneous evidence of thoracic swelling, which would have occurred in the presence of fracture – the Medical Assessor is entitled to make that determination based on her clinical
   experience, and

   (b)    whether there was impairment as defined in cl 6.9 (an alteration of a person’s health status” – she opined there was not, as there was nothing in the clinical material to suggest symptomatology in the mid-back.

3. The insurer submits the claimant has misconstrued the reasoning in Brown. The insurer submits in Brown it was determined there was no requirement to engaged in a detailed analysis of causation in relation to a lumbar spine injury, because “it was never a real issue for determination of the Panel”. An additional factor that there was no “alternative hypothesis about causation of that particular injury that rose above mere speculation” reinforced the notion that causation was essentially a non-issue.

Shoulder

1. The insurer refers to the claimant’s submissions and submits there is no rule which mandates the use of a goniometer in every range of motion (ROM) assessment.
   Clause 6.50 of the Guidelines states; “a goniometer shoulder be used where clinically indicated”. 

2. Further the insurer submits there is no evidence a goniometer was not used, particularly where Medical Assessor Lahz provided very detailed examination findings (including ROM measurements in all of the areas referred for assessment at pages 11 to 13 of her certificate).

3. The insurer submits that range of motion was expressed qualitatively, that is, “there was full active range of bilateral, shoulder, elbow, wrist and hand movements not attracting WPI … “. The insurer submits this is not an error. Even if a goniometer was not used the insurer submits there is no error and the Medical Assessor’s examination findings were extremely detailed and based on her judgement and experience as a rehabilitation physician. 

Submissions in reply to permanent impairment dispute

1. Submissions dated 13 April 2023 were provided. 

2. Whilst the insurer does not specifically address the thoracic spine it is submitted that the discharge summary of RPAH contains no reference to pain/injury to the back. Furthermore, the claimant has complained of pain in the SIJ but having regard to the opinion of
   Prof Cameron it is submitted there is no impairment in the lumbar spine. 

3. The insurer submits there is no contemporaneous evidence of an injury to either shoulder aside from abrasions. The Trauma Survey on 7 April 2021 records “bruising to the ante-cubital fossa, otherwise no trauma, full ROM, NVI”. The insurer submits there is no reference to shoulder injury in the GP notes of Balmoral Medical Practice. The insurer submits there is no impairment in either shoulder.

MEDICAL EXAMINATION BY MEDICAL ASSESSOR HODGKINSON

1. Mr Bojovic was assessed by Medical Assessor Hodgkinson on 28 February 2025 at the medical suites of the Personal Injury Commission.

2. Medical Assessor Hodgkinson noted Mr Bojovic arrived on time and understood the purpose of the assessment. He was cooperative and engaged although his affect was anxious and at time reserved.

Background

1. Mr Bojovic was born in Serbia and emigrated to New Zealand aged 7. He was educated to University level in New Zealand, obtaining a Bachelor degree in Spanish, political science and media.

2. He then travelled to Germany where he did an internship managing a database. His duties were predominantly data entry and review.

3. Mr Bojovic moved to Australia (Sydney) in 2011-2012. He was working in datamining and studying a Master of Arts – Sociology

4. At the time of the accident, Mr Bojovic had commenced a Master of Research in Anthropology. He is now completing a PHD. He was working in his own business producing video and editing. He produced audio/visual material both promotional and communication for businesses.

5. At the time of the accident Mr Bojovic was living in Neutral Bay with his partner (now wife) and his sister. He and his wife are now expecting their first child.

The accident

1. Mr Bojovic’s last memory before the accident was of leaving the building where he had attended a work visit. He estimates this was about 5 minutes before the accident occurred. His next memory is of being in hospital and being told he had an accident.

2. His immediate symptoms were of headache, vertigo, blurred vision and pain in his right leg preventing him from moving. His recollections from his two days in hospital were patchy.

3. Mr Bojovic was discharged home after two days. He was referred to the vestibular clinic at RPAH and a neurologist. His GP later referred him to Dr Mobbs who weaned his anticonvulsant prophylaxis (Keppra). He noticed an improvement in his symptoms of irritability and anxiety after this medication was ceased.

4. Mr Bojovic was referred to a local psychologist but changed to a Serbian speaking psychologist providing support online. He stated that he felt more comfortable speaking about personal issues with someone who understood his cultural background despite his fluency in English. He took a semester off his studies and then returned after six months. He returned to work after eight months.

Current symptoms

1. Since returning to studies and work Mr Bojovic has experienced some ongoing symptoms. He describes these as - mental fatigue, requiring extra time for assignments and assistance in structuring or planning his studies and work. He has successfully completed several subjects, obtaining a pass in the first subject on his return to his studies and thereafter high distinctions. Despite this he believes he is less efficient in his studies than pre-injury and now requires more than ordinary support from his PhD supervisor. Additionally, he seeks support from his wife who will read over his assignments and prompt him in areas where he could more fully answer the assignment question.

2. Regarding his work, Mr Bojovic reports a reduced ability to perform the same volume of work as pre-accident. This is because of the need to check his work for errors or omissions and mental fatigue reducing his daily output. He has lost some clients but gained new, he has maintained his business and has a stable base of regular clients. When timeliness to complete work has been a problem, he has contracted others to help him.

3. From a psychological perspective he reports good days and bad. On bad days he will be anxious, moody and at times confrontational. His confrontations have been with strangers rather than family members. He has described times of depression when he becomes withdrawn and lacks energy. These times are less frequent than early post injury.

4. Mr Bojovic has maintained his relationship with his partner, now wife, and is expecting his first child. He has maintained wider family connections.

5. He described his mental fatigue as affecting him after four to five hours of concentration. Episodes of disorganisation are described as double booking himself and forgetting appointments. He uses memory aids such as a whiteboard planner and a digital calendar.

Treatment

1. He is on no medication other than vitamins. He remains in contact with his treating psychologist, but contact is now less frequent and on request.

Assessment

1. Neuropsychological assessments have been performed, and the results are discussed elsewhere.

2. Mr Bojovic’s affect was anxious and somewhat reserved. He was cooperative with the interview and became more relaxed towards the end of the assessment. He appeared to put in full effort to the assessment.

3. He was a logical and detailed historian.

Cognitive screen – MOCA

1. He admitted to having seen the test before. The score on this occasion was 24/30. He lost points in copying the line drawing of a cube. He made three attempts – on each occasion omitting a line but eventually was able to self-correct the missing line with a prompt to check. He demonstrated some word finding difficulty on naming the animals but used a description strategy to arrive at the name. Free recall was the task that lost most points. He demonstrated excellent attention and immediate recall of the memory task. His recall without a prompt was 1/5. His recall with a multiple-choice cue was an additional 3 items.

2. The orientation question resulted in an initial incorrect date (29th). When asked to reconsider, this resulted in flustered responses of 30th and 31st of February. When told the 28th he stated that this had been what he had first said. He had arrived on time and was otherwise fully oriented and demonstrated a good understanding of timeframes.

Diagnosis and causation

1. A score of 24/30 on a MOCA is normally considered mild impairment. As other Assessors have noted, an impairment of this nature is inconsistent with academic and work performance at a high level. A MOCA early post injury is reported as 26/30; Assessor Cameron found it 16/30 and Assessor Lahz found it 24/30. Assessor Lahz detailed where points were lost. Interestingly although delayed memory resulted in the most points lost other difficulties varied from those in the current assessment.

2. Effort tests in the neuropsychological assessment (both embedded and standalone) have shown reduced effort. Mr Bojovic reported he found medical assessments very challenging and upsetting. He reported wanting to walk out of interviews where he felt insulted, or his history ignored.

3. Mental distraction as a consequence of emotional reactions can affect learning and effort. Intentional failure is not always the explanation. However, the inconsistencies seen in the MOCA and the contrast with academic and work performance means these screening tests cannot be relied upon to assess severity.

1. Mr Bojovic suffered a blow to the head in the accident sufficient to cause an un-displaced fracture of the occipital bone but not to cause intracerebral contusions or other changes. There was an impact seizure at the time consistent with significant force. Vestibular disturbance also supports a significant force incurred in the head injury. A normal MRI Brain on 26 May 2021, six weeks post-accident excludes a severe traumatic brain injury. His diagnosis remains a mild traumatic brain injury. His period of confusion post injury was measured by the AWOPTAS. He was fully oriented and gained a full score on the first day. His discharge was delayed by his vestibular symptoms.

2. Overall, the history is consistent with mild changes to his higher-level cognitive functions and his emotional and behavioural functions. The changes in higher cognitive functions while consistent with a blow to the head are not of severity sufficient to rate on the Clinical Dementia Rating (CDR) scale set out in table 6.9 on page 115 of the Guidelines as follows:

   ·        memory – slight inconsistent forgetfulness – score 0;

   ·        orientation – fully orientated – score 0;

   ·        judgment and problem solving – manages household chores and the finances of his business – score 0;

   ·        community affairs – slight impairment of work performance and studies – score 0.5;

   ·        home and hobbies – life at home and hobbies well maintained – score 0, and

   ·        personal care – fully independent – score 0.

3. The mild impairments in work and study performance may contribute to the emotional and behavioural changes as assessed by Professor Cameron and Medical Assessor Lahz. The impairments described affect complex high-level tasks such as completing his PhD, finalising tax returns and work efficiency.

4. Given his academic performance and ability to sustain attention for four hours and despite this being a relative decline from previous function, no whole person impairment can attach to higher intellectual functions.

5. Mild impairment of emotional and behavioural functions has resulted in the need for ongoing psychological support, additional time and support in work and studies. Despite this, his work is maintained, and his studies have progressed. There is no permanent impairment of his activities of daily living or social and interpersonal functioning as this refers only to basic functions. He is independent in personal care, he drives and can use public transport independently, he can cook an evening meal and can exercise independently. His social relationships are maintained. For his work and studies there is a small but significant impact arising from the injury. There is no evidence that this affects his activities of daily living as defined in the Guidelines or at page 317 of the AMA 4 Guides. Additionally, impairment is assessed independently of disability or handicap. The claimant’s limitations and additional support required may affect productivity, and rate of progression through his studies. These functions are specific to his circumstances but do not represent activities of daily living.

6. Medical Assessor Hodgkinson found no impairment of the claimant’s activities of daily living.

7. The claimant sustained a non-displaced occipital skull fracture with an extra cranial haematoma and a mild traumatic brain injury caused by the accident. The claimant has sustained 0% WPI arising out of the mild traumatic brain injury.

MEDICAL EXAMINATION BY MEDICAL ASSESSOR GIBSON

1. Mr Bojovic was assessed by Medical Assessor Gibson at her rooms on 14 March 2024. He was unaccompanied to the assessment and had brought no imaging with him.

Pre accident medical history

1. Mr Bojovic denied having had any prior injuries or medical or surgical issues prior to the subject accident. He had been taking no regular medication nor having any regular treatment for any condition.

Relevant personal details

1. Mr Bojovic currently lives with his wife in a two-bedroom, one-bathroom apartment in Cammeray. At the time of the accident, they were living in Neutral Bay. He said there are three stairs to enter their apartment. He shares the household chores with his wife, estimating 50-50. When asked what tasks at home he would particularly be cautious about, he said that he would avoid lifting heavy objects, such as large pieces of furniture. He seemed to recall his general practitioner restricted his lifting capacity to 15kg some years back. He drives an automatic car but avoids travelling for periods in excess of about an hour, due to the SIJ discomfort.

2. Last year he completed a master’s degree in creative research. He previously completed a master’s degree in sociology. He is now undertaking a PHD.

3. Mr Bojovic is self-employed in a videography business which involves him filming on site and editing his footage. He said he was working on a full-time basis prior to the accident. Following the accident, he took between six and 12 months off work and he had a similar break off his studies towards his master’s degree.

4. He now only works 20 hours per week, due to both his accident-related physical issues and the sequelae of his head injury. His physical concerns were related to the strain to the right sacroiliac joint which this limits his work capacity as it restricts his tolerance for prolonged sitting or standing, he estimates to about two to three hours.

5. Insofar as his cognitive capacity is concerned, he feels he lacks the stamina he once had, and he has difficulty maintaining attention, describing suffering with brain fog. He also finds he needs to take more regular breaks. He added that he is visiting a neuropsychologist who provides specific exercises and strategies to assist in his rehabilitation.

History of the accident

1. Mr Bojovic confirmed he had no recollection of the accident and was only able to understand what happened as other people told him. He did recall that he had been walking home after a client visit. The video on file showed that he had been struck by a car, thrown onto the bonnet and then onto the ground.

2. Following the accident, he was conveyed to Royal Prince Alfred Hospital by ambulance and remained there as an inpatient for several days.

3. The ambulance report from the day of the accident recorded bleeding from his head and abrasions over his left posterior flank. He was noted to be combative and agitated after having a seizure. His Glasgow Coma Score (GCS) was 11. His neck was placed in a cervical collar.

4. The records from Royal Prince Alfred Hospital predominantly dealt with the head injury, but he also was found to have normal upper and lower limb power on review the following day with no sensory deficits and a full range of motion of the neck. He was noted to have abrasions to the left flank and posterior hip and posterior shoulder regions but there was no bony tenderness or midline tenderness. There was right hip and upper thigh tenderness but a full range of motion. The discharge summary of 8 April 2021 recorded that a CT brain scan showed a left parieto-occipital subcutaneous haematoma with underlying un-displaced fracture extending to the left parietal bone. Imaging of chest and pelvis were unremarkable, and a CT scan of the cervical spine showed no relevant abnormalities. A CT scan of the spine had shown “… an impression of mild loss of vertebral body height by less than 20% at T10 to T12 vertebrae with no paravertebral soft tissue oedema. This is non-specific, and correlation with tenderness in this region is recommended to exclude an acute injury.” He was discharged on Keppra, paracetamol and ondansetron and was to visit his general practitioner in three to five days. He was also not to sleep on his right side for seven days.

5. Dr Matthew Kim completed a medical certificate on 30 April 2021, diagnosing left occipital fracture with extracranial haematoma complicated by tonic-clonic seizures and right medial collateral ligament strain.

6. On specific questioning, Mr Bojovic indicated that his neck and back had been initially a bit stiff and he had noticed this in the hospital, but that these symptoms had resolved over about a month. He was really uncertain whether he had had any upper back pain at all. He could recall having some left shoulder stiffness, and he indicated the trapezius and infrascapular region as the area affected. He said he had physiotherapy treatment for these symptoms which had settled over several months. His right knee was his main ongoing problem at that stage, and he recalled it had taken several days after the accident before he could fully flex the knee. Then, over time the knee pain had spread towards his right hip area.

7. A CT scan of the right knee performed 19 April 2021 showed some thickening of the medial collateral ligament which was suggestive of ligament strain. An MRI scan of the knee on 10 April 2022 had demonstrated intact ligaments and menisci, no bony or cartilage injury but there was minor extensor tendinopathy and a small semimembranosus bursal effusion.

8. Imaging of the cervical spine performed 22 July 2021 had shown minor cervical spondylosis, particularly around C4/5, with mild bilateral foraminal stenosis. There was C7 to T1 facet osteoarthritis.

9. Mr Bojovic came under the care of orthopaedic surgeon, Dr Gooden who organised the MRI scan of the knee. He said that Dr Gooden after reviewing the MRI had included his knee ligaments were intact, so no further treatment was required for the knee.

10. Mr Bojovic was referred to sports physician, Dr Sophie Armstrong, who he first visited on 12 July 2022. She had noted that he had significant right knee pain and after three to four months of chiropractic treatment he had become aware of right low back and sacroiliac joint discomfort. She diagnosed right sacroiliac joint dysfunction causing referral down into his right leg. She noted on further review on 21 May 2024 that he had long-standing right sacroiliac joint dysfunction with ongoing low-grade symptoms which he was managing with exercises. On examination she had noted normal gait, and found his lumbar spine was non-tender with a full range of motion.

Current complaints

1. Mr Bojovic denied any current neck, upper or lower back complaints, right knee complaints or left shoulder complaints.

2. His only ongoing physical issue is his right sacroiliac joint symptoms. He finds if he exerts himself or does not perform his regular stretching exercises, the right hip becomes stiff, and he has difficulty with hip flexion. At its worst he can develop a limp due to pain over the right gluteal region. The last episode of these symptoms was four months ago. He said this had followed a daylong shoot. He said that he had not expected the workday would go as long as it had. He said he was very uncomfortable over the next few days.

3. He said that he can walk for a maximum of 30 minutes. He said last year he managed a walk of 45 minutes but had noticed the flaring of the right sacroiliac joint symptoms. He said at home he has ergonomic equipment including a footrest and a sit/stand desk. He said he has reduced a basic kit of under 10kg whereas before he would have equipment weighing anywhere from 20-40kg although he did say that he uses a trolley.

4. He said he generally sleeps well so long as there is no pain in his right hip (sacroiliac joint).

Current treatment

1. Mr Bojovic stretches daily, with these exercises being specifically directed towards his right sacroiliac joint. He visits the physiotherapist as required, receiving massage when his symptoms become severe. He said the last time this had happened was early 2024. He takes no regular medication, and he said he is discharged from Dr Armstrong's care.

Physical examination

1. Mr Bojovic was left hand dominant. He was 174cm tall and weighed 89kg. He had a normal gait. He presented in a straightforward manner and was pleasant and cooperative throughout the assessment, and able to provide a clear and concise history.

2. On examination of the cervical spine, there was no neck tenderness. He had a full range of neck movement in all planes without any asymmetry, muscle spasm or guarding.

3. On examination of the upper limbs, his arms measured 30cm bilaterally (10cm above the olecranon) and 27cm bilaterally (10cm below the olecranon). Upper limb power, reflexes and sensation were normal and symmetrical.

4. On examination of the thoracic spine, there was no tenderness. Movements were to full range in all planes There was no asymmetry, muscle spasm or guarding.

5. On examination of both shoulders, there was no tenderness and no impingement. Measurements were taken using a goniometer and were as follows:

Shoulder Movements	Active ROM Measured RIGHT	Active ROM Measured LEFT
Flexion	180 °	180 °
Extension	50 °	50 °
Internal Rotation	80 °	80 °
External Rotation	80 °	80 °
Abduction	180 °	180 °
Adduction	50 °	50 °

1. On examination of the lumbar spine, there was normal posture. There was no local tenderness. There was a full normal range of movement There was no asymmetry, muscle spasm or guarding.

2. On examination of the lower limbs, circumferential measurements of thighs were 44cm bilaterally (10cm above the upper pole of patella) and maximal calf girth was 40cm bilaterally.

3. Lower limb power, reflexes and sensation were normal and symmetrical.

4. On examination of both knees, there was no local tenderness. There was no crepitus or instability although there was a click on extension of the right knee, and less so on the left knee. Knee flexion was 140° bilaterally and extension was 0° bilaterally.

5. There was tenderness in the vicinity of the right sacroiliac joint and right buttock. Hip movements were as follows:

Hip movements	Right	Left
Flexion	120°	120°
Internal Rotation	40 °	40 °
External Rotation	40 °	40 °
Abduction	30°	30°
Adduction	30°	30°

Diagnosis and causation

1. Mr Bojovic is a 36-year-old man who was involved in the accident as a pedestrian on
   6 April 2021 when he was struck by a motor vehicle. He was transferred by ambulance to Royal Prince Alfred Hospital where he was found to have a traumatic brain injury. Much of his time at the hospital was related to this injury.

2. He had imaging of cervical spine which was unremarkable for any accident-related trauma and scans of his thoracic and lumbar spine had also shown no traumatic features.

3. It is noted that the radiologist reporting on the imaging of the thoracic spine had commented on there being some suggestion of wedging T10 to T12, but in the absence of any paravertebral tissue swelling advised these imaging findings should be considered in the clinical context. Mr Bojovic had no record of any tenderness over the thoracic spine and there was no record of any thoracic symptoms after the accident. Therefore, these findings do not represent a thoracic spine fracture.

4. Mr Bojovic had sustained a soft tissue injury to his cervical, thoracic and lumbar spine, left shoulder, right knee and right sacroiliac joint caused by the accident. The Panel notes there was early mention of right loin symptoms in the hospital record, although the main sacroiliac joint symptoms appear sometime after the accident.

5. The only ongoing physical complaint relates to the right sacroiliac joint, all other physical injuries have now resolved. This history is consistent with the history recorded by Medical Assessor Lahz.   

Permanent impairment

1. The Panel finds the following injuries caused by the accident have resolved and give rise to no assessable permanent impairment:

   ·        soft tissue injury to the cervical spine;

   ·        soft tissue injury to the thoracic spine;

   ·        soft tissue injury to the lumbar spine;

   ·        soft tissue injury to the right knee; and

   ·        soft tissue injury to the left shoulder.

2. Whilst not referred for assessment the Panel notes the right sacroiliac joint would be rated at 0% WPI as there was no assessable restriction of hip movement in accordance with Table 40 on p78 of the AMA 4 Guides and now there was any assessable impairment of the right sacroiliac joint in accordance with paragraph 3.4 on page 131 of the AMA 4 Guides.

CONCLUSION

1. The Panel revokes the certificate of Medical Assessor Lahz dated 1 May 2024 and issues a new certificate determining that the following injuries were caused by the motor accident and give rise to a WPI of 0%:

   ·        mild traumatic brain injury; and

   ·        head – non-displaced occipital skull fracture with extra cranial haematoma on the left side.

2. The Panel finds the following injuries caused by the accident have resolved and give rise to no assessable permanent impairment:

   ·        soft tissue injury to the cervical spine;

   ·        soft tissue injury to the thoracic spine;

   ·        soft tissue injury to the lumbar spine;

   ·        soft tissue injury to the right knee; and

   ·        soft tissue injury to the left shoulder.