Choi v QBE Insurance (Australia) Limited

[2025] NSWPICMP 651

DETERMINATION OF REVIEW PANEL

CITATION:

Choi v QBE Insurance (Australia) Limited [2025] NSWPICMP 651

CLAIMANT:

Yunseo Choi

INSURER:

QBE Insurance (Australia) Limited

REVIEW PANEL

MEMBER:

Gary Victor Patterson

MEDICAL ASSESSOR:

Shane Moloney

MEDICAL ASSESSOR:

Drew Dixon

DATE OF DECISION:

28 August 2025

CATCHWORDS:

MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; assessment of treatment and care dispute; claimant was a learner driver who was being supervised by her mother who was the front-seat passenger; the insured vehicle collided with the rear passenger side of their vehicle; claimant reported experiencing pain in her neck, wrists, lower back, ankles, and jaw; Medical Assessor certified that various surgical procedures for right wrist proposed do not relate to the injury caused by the subject accident nor are reasonable and necessary; issue as to causation of claimant’s right wrist injury; whether due to subject accident or her nursing placement; Held – Review Panel satisfied as to causation because of immediate complaint of pain in right wrist following subject accident; Review Panel satisfied that proposed right wrist arthroscopy and TFCC debridement are reasonable and necessary; Review Panel not satisfied that proposed right wrist ulna shortening is reasonable and necessary; certificates revoked.

DETERMINATIONS MADE:  

CERTIFICATE

REVIEW PANEL ASSESSMENT OF TREATMENT AND CARE - CAUSATION

Certificate issued under s 7.23(1) of the Motor Accident Injuries Act2017 (the Act)

1.     The Panel revokes the certificate dated 13 January 2025 and issues a new certificate determining that:

(a)    the following treatment and care:

·         right wrist arthroscopy requested by Professor Smith;

·         right wrist Triangular Fibro Cartilage Complex (TFCC) debridement requested by Professor Smith; and

·         right wrist Ulna shortening osteotomy requested by Professor Smith,

DOES RELATE TO THE INJURY caused by the motor accident.

CERTIFICATE

REVIEW PANEL ASSESSMENT OF TREATMENT AND CARE – REASONABLE AND NECESSARY

Certificate issued under s 7.23(1) of the Motor Accident Injuries Act2017 (the Act)

2.     The Panel revokes the certificate dated 13 January 2025 and issues a new certificate determining that:

(a)    the following treatment and care:

·         right wrist arthroscopy requested by Professor Smith; and

·         right wrist TFCC debridement and right wrist requested by Professor Smith,

IS REASONABLE AND NECESSARY in the circumstances.

(b)    the following treatment and care:

·         right wrist ulna shortening osteotomy requested by Professor Smith,

IS NOT REASONABLE AND NECESSARY in the circumstances.

STATEMENT OF REASONS

INTRODUCTION

1. Yunseo Choi (the claimant) was involved in a motor accident on 30 January 2024 in the morning. The claimant was a learner driver who was being supervised by her mother who was the front-seat passenger. As they were travelling along a main road, the insured vehicle, coming from a side street on the left, collided with the rear passenger side of their vehicle. Neither Ambulance nor Police Officers attended the scene. Following the exchange of information with the insured driver, the claimant’s mother attempted to drive home. However, due to her residual anxiety stemming from a prior motor vehicle accident, the claimant’s mother found it challenging to drive. Consequently, the claimant drove home. The claimant reported experiencing pain in her neck, wrists, lower back, ankles and jaw later that day. The claimant scheduled an appointment with her treating GP within a week of the accident date.

2. QBE (the insurer) indemnifies the owner and/or the driver of the at-fault vehicle for liability to pay to the claimant any damages and/or statutory benefits under the Motor Accident Injuries Act 2017 (the Act). The insurer admitted liability for the claim but declined to fund a Right Wrist Arthroscopy, TFCC Debridement Ulna Shortening Osteotomy recommended by Professor Nicolas Smith. The stated reason for refusal was that a MRI report dated 26 February 2024 indicates that chronic changes and interstitial tears in the right wrist are pre-existing and not causally related to the subject accident. By letter dated 23 April last, the insurer’s lawyers maintained the insurer’s position that the requested treatment is neither reasonable nor necessary in the circumstances. Also, that the claimant has not exhausted conservative treatment options, prior to considering surgical intervention.

ASSESSMENT UNDER REVIEW

1. As there is a dispute between the parties about:

   (a)whether any treatment and care relate to an injury caused by the accident; and

   (b)whether any treatment and care provided is reasonable and necessary in the circumstances

   under Schedule 2, cl 2(b) of the Act, the dispute was referred to Medical Assessor David McGrath for determination.

2. Medical Assessor McGrath certified on 13 January 2025 as follows:

The following treatment and care:

• whether right wrist arthroscopy request by Professor Smith relates to the injury caused by the motor accident;
• whether right wrist TFCC (Triangular Fibrocartilage Complex) debridement and right wrist request by Professor Smith relates to the injury caused by the motor accident; and
• whether right wrist Ulna shortening osteotomy request by Professor Smith relates to the injury caused by the accident

DOES NOT RELATE TO THE INJURY caused by the motor accident.

The following treatment and care:

• whether right wrist arthroscopy request by Professor Smith is reasonable and necessary in the circumstances;
• whether right wrist TFCC (Triangular Fibrocartilage Complex) debridement request by Professor Smith is reasonable and necessary in the circumstances; and
• whether right wrist Ulna shortening osteotomy request by Professor Smith is reasonable and necessary in the circumstances

IS NOT REASONABLE AND NECESSARY in the circumstances.

THE REVIEW

1. The claimant sought a review of Medical Assessor McGrath’s certificate, on the grounds that the medical assessment was incorrect in a material respect, under s 7.26 of the Act. The claimant relied upon the particulars set out in the application and supporting documentation.

2. The claimant brought the application within the time prescribed by s 7.26(10)(a) of the Act and cl 34 of Procedural Direction PIC 7 (28 days).

3. The claimant submitted that Medical Assessor McGrath failed to provide sufficient reasons for his determination that the proposed treatment was not related to the injury caused by the subject accident. The claimant notes that the Medical Assessor acknowledged that the claimant complained of right wrist pain immediately after the accident. The claimant submitted that, despite evidence indicating that the claimant suddenly turned the steering wheel when the collision occurred, the Medical Assessor failed to provide reasons why he did not consider that this action may have caused the claimant’s right wrist injury, or contributed to her current condition.

4. The claimant notes that the Medical Assessor determined that her right wrist injury was aggravated by work as an enrolled nurse, and that “the contribution from the MVA is not more than negligible as a cause for major wrist surgery.” The claimant submits that the Medical Assessor did not provide sufficient grounds for that conclusion. The claimant also submitted that Medical Assessor failed to provide explanations as to why he determined that the physical demands of the nursing placement put greater stress on the claimant’s right wrist than the physical impact sustained in the subject accident.

5. The claimant submitted that the Medical Assessor failed to provide sufficient explanation, nor provided his path of reasoning, in reaching his opinion that the tears in the claimant’s right wrist TFCC, were not caused by the accident, contrary to Professor Smith’s diagnosis of “acute ulnocarpal abutment injury”. The claimant submitted that the Medical Assessor failed to provide sufficient reasoning for his determination that the proposed treatment was not related to the injury caused by the subject accident.

6. The claimant submitted that Medical Assessor McGrath failed to provide sufficient reasons for his determination that the proposed treatment was not reasonable and necessary. In support of that submission, the claimant firstly said that the Medical Assessor’s determination was based on an erroneous causation analysis (see previously). Secondly, in relation to the Medical Assessor’s suggestion of alternative therapies that could be tried before surgery, the claimant submitted that the Medical Assessor failed to provide any basis or evidence for that opinion, particularly given that Associate Professor Smith determined that four weeks of hand therapy was sufficient to decide whether surgery was necessary.

7. The claimant’s application for review was opposed by the insurer on various grounds. As those submissions were not accepted by the President’s delegate, it is not necessary to state them in detail.

8. In relation to the first alleged error, the insurer submits that the Medical Assessor considered the totality of the evidence and formed a correct assessment on the issue of causation. Particulars are given in support of that submission. The insurer says that the Medical Assessor clearly stated that the requested treatment was not indicated having regard to a MRI right wrist that revealed findings of chronic changes in the TFCC that may reflect and result in instability given there is minimal subluxation and distal radioulnar joint and a small joint effusion. There was certainly no acute abnormality seen anywhere throughout the right wrist joint (insurer’s emphasis).

9. The insurer submitted that the medical evidence and pathology made clear there was evidence of degenerative pathology within the right wrist and any need for surgical intervention arose as a result of the degenerative pathology, as supposed to any distinct injury sustained as a result of the subject accident. The insurer submitted that any minor aggravation of the claimant’s pre-existing degenerative condition, caused by the subject accident or nursing placement, did not give rise to a need for surgery.

10. As to the second alleged error, the insurer submitted that the Medical Assessor did not err in his determination that the requested treatment is not reasonable nor necessary in the circumstances, given the evidence. The insurer referred to the Medical Assessor’s indication that:

    (a)    there are reported long-term adverse osteoarthritis complications from the suggested procedure and there is risk for a need for further surgical intervention in the future, and

    (b)    the claimant’s right wrist required strengthening in “three dimensions over at least a six-month period”, before any surgery could be considered, which had not been done. The insurer submitted that the claimant has not tried appropriate conservative treatment to justify a need for surgical intervention. The insurer says that failure was fully considered by the Medical Assessor.

11. President’s delegate, Ratula Gupta, issued a Determination of an Application for Review of a Medical Assessment on 6 March 2025 which stated the satisfaction of the President’s delegate that there is reasonable cause to suspect that Medical Assessor McGrath’s assessment was incorrect in a material respect. The basis of that decision was stated to be that the Medical Assessor failed to provide sufficient reasons for his determination that the proposed treatment was not related to the injury caused by the motor accident.

12. Accordingly, the claimant’s review application was accepted. The Panel is to reassess all of the treatments referred to Medical Assessor McGrath for assessment.

13. Pursuant to cl 128(1) of the Personal Injury Commission Rules 2021 (PIC Rules), the Panel is to conduct and determine the proceedings, in accordance with procedures determined by the Panel.

STATUTORY PROVISIONS

1. A medical assessment matter is determined in accordance with Division 7.5 of the Act. The matter is determined at first instance by a Medical Assessor and, on review, by a Review Panel consisting of two Medical Assessors and a Member assigned to the Motor Accidents Division of the Personal Injury Commission (Commission).

2. Part 5 of the Personal Injury Commission Act 2020 (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.[1]

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

3. Rules 127 to 130 of the Personal Injury Commission Rules 2021 (the 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.[2]

   [2] Rule 128 of the PIC Rules.

4. The review of the medical assessment is by way of new assessment of all the matters with which the medical assessment is concerned.[3]

   [3] Section 7.26(6) of the Act.

5. All members of the Review Panel had no previous involvement with the claimant or with this matter.

CAUSATION OF INJURY

1. Causation of injury is addressed in the Guidelines as follows:

   “6.5   An assessment of the degree of permanent impairment is a medical assessment matter under cl 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 AMA 4 Guides, as well as the common law principles that would be applied by a court (or the Personal Injury Commission) in considering such issues.

   6.6    Causation is defined in the Glossary at page 316 of the AMA 4 Guides as follows:

   Causation means that a physical, chemical or biological 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 contributed to the worsening of the impairment, which is a non-medical determination.

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

   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.”

2. See Briggs v IAG Limited t/as NRMA Limited.[4] See also Insurance Australia Limited t/as NRMA Insurance v Trkulja [2023] NSWSC 956,[5] wherein his Honour Justice Wright stated at (35):

   “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 principes were intended to be applied when a medical assessment was being made in relation to causation of minor injuries.”

   [4] Briggs v IAG Limited t/as NRMA Insurance [2022] NSWSC 372.

   [5] Insurance Australia Limited t/as NRMA Insurance v Trkulja [2023] NSWSC 956.

3. Wright J then described the Panel’s role in a medical review which is to:

   “Consider whether the motor accident did cause or contribute to (the claimant’s condition). This requires, not a consideration of material derived as a result of an internet search… but rather a consideration of the material referred to in 5.6 of the Guidelines, namely all the evidence available to the Panel, including all relevant findings derived from:

   (1)    a comprehensive, accurate history, including pre-accident history and pre-existing conditions;

   (2)    a review of all relevant records available at the assessment;

   (3)    a comprehensive description of the injured person’s current symptoms;

   (4)    a careful and thorough physical examination;

   (5)    diagnostic tests available at the assessment, noting that imaging findings that are used to support the assessment should correspond with symptoms and findings on examination.”

BUNDLES OF DOCUMENTS

1. The parties have presented their respective bundles of documents upon which they rely. The Review Panel (Panel) has read all the documentation. If a particular document is not referred to by the Panel, this does not mean that the Panel, or a Panel Member, has not read it, nor taken it into consideration. The same principle applies to parties not referring to, nor specifically relying upon, a document in their own bundle and submissions.

2. The fact that evidence is not referred to in these reasons does not mean it has been overlooked. It is not required that each piece of evidence be mentioned. The Panel is not required to “analyse every piece of information from every opinion contained in a document with which it was provided”. The Panel has come to its own conclusions and has taken its own history.

MATERIAL BEFORE THE REVIEW PANEL

1. The claimant relied upon the following material which the Panel has considered:

Document	Author	Date	Page
Claimant’s review submissions (see previously)	Littles Lawyers	06.02.2025	1
Claimant’s submissions made to Assessor McGrath	Littles Lawyers	11.09.2024	6

The claimant made the following submissions:

(a)    the proposed surgeries are reasonable and necessary treatment and care incurred in connection with the injuries sustained in the subject accident;

(b)    the claimant complained of right wrist pain immediately after the accident but did not complain of right wrist pain before the accident;

(c)    Dr Smith stated in his report dated 15 August 2024 that the right wrist injury resulted from the subject accident and that the proposed surgeries are directly related to treating the symptomatic ulnocarpal abutment caused by the injury. The mechanism of injury is consistent with the type of wrist injury sustained by the claimant when the steering wheel caused her wrist to twist;

(d)    as to appropriateness of the treatment, Dr Smith stated that the proposed surgeries are standard treatments for ulnocarpal abutment, a condition caused by the subject accident. The proposed surgeries aim to alleviate the claimant’s ongoing symptoms, restore functionality, and prevent further deterioration;

(e)    as to necessity of the treatment, the proposed surgical procedures are aimed at helping the claimant return to her usual activities by addressing the root cause of her pain and disability. Given the chronic nature of her condition and the failure of conservative management to relieve her symptoms, these surgeries are deemed necessary by the treating specialist, and

(f)    as to the insurer’s ground for refusal, the claimant submitted that was based primarily on the insurer’s interpretation of the MRI findings and the perceived lack of an acute abnormality. The claimant submitted that the insurer’s contention is contradicted by Dr Smith’s expert opinion, based on his clinical findings and the claimant’s symptoms, that her injuries are consistent with the mechanism of the accident.

29.	PIC Medial Assessment Certificate (see previously)	Medical Assessor David McGrath	13.01.2025	9
30.	Certificate of Capacity	Dr Ajeong Lee	07.02.2024	17
31.	Application for personal injury benefits	Claimant	09.02.2024	20
32.	Allied Health Recovery request	Jiho Han	26.02.2024	27
33.	MRI cervical spine and right wrist report	Dr Lin Enn Yapp	27.02.2024	32

Conclusion:

There is no spinal canal or foraminal stenosis seen throughout the cervical spine.

There are some chronic changes and interstitial tears at the triangular fibro cartilage complex as described which may reflect and result in a degree of instability given there is some minimal subluxation of the distal radio ulna joint and a tiny joint effusion. Certainly, no acute abnormality is seen here or elsewhere throughout the right wrist joint.

Certificate of Capacity	Dr Ajeong Lee	05.03.2024	34
Referral to Dr Nicholas Smith	Dr Ajeong Lee	05.03.2024	38
Allied Health Recovery request	Jiho Han	23.03.2024	39
Certificate of Capacity	Dr Ajeong Lee	27.03.2024	44
Report to Dr Lee	Associate Professor Nicholas Smith	17.04.2024	48
She had a right wrist injury when she was involved in a motor vehicle accident. She feels the steering wheel caused her wrist to be twisted. The whole presentation is consistent with an acute ulnocarpal abutment injury. If she is not settling, she would most certainly benefit from an arthroscopic debridement and ulna shortening osteotomy.
Referral to Wester Sydney Hand Physiotherapy	Associate Professor Nicholas Smith	17.04.2024	49
Certificate of Capacity	Dr Ajeong Lee	23.04.2024	50
Allied Health Recovery request	Jiho Han	17.05.2024	54
Certificate of Capacity	Dr Ajeong Lee	17.05.2024	59
Certificate of Capacity	Dr Ajeong Lee	08.06.2025	63
Allied Health Recovery request	Jiho Han	22.06.2024	67
Surgery approval request	Associate Professor Nicholas Smith	24.06.2024	72
Certificate of Capacity	Dr Ajeong Lee	02.07.2024	73
Letter declining surgery	QBE	05.07.2024	77
Pre-MBA GP record	My Health Meadowbank	22.07.2024	75
Letter/report	Associate Professor Nicholas Smith	15.08.2024	95

Associate Professor Smith opines that the proposed surgical treatment would be the appropriate treatment for symptomatic ulnocarpal abutment which began at the time of injury and that this is standard treatment for ulnocarpal abutment.

Internal Review Certificate QBE 16.08.2024 97

In declining to fund the requested surgery, QBE relied upon the MRI scan right wrist and highlighted the conclusion findings which states:

“Certainly, no acute abnormality is seen here or elsewhere throughout the right wrist joint.”

Report Dr Ajeong Lee 23.01.2025 104

Dr Lee opined that the injury to the right wrist being interstitial tears the triangular fibro cartilage complex torn of a cartilage which support and connects surrounding structures is a non-threshold injury.

Certificate of Capacity Dr Ajeong Lee 30.01.2025 110

1. The insurer relied upon the following material which the Panel has considered:

Doc No.	Documents	Date	Page
R1	Insurer’s submissions (see previously)	20.02.2025	2
R3	Police card	08.02.2024	17
R4	Photographs from accident scene	Undated	18
R5	Report of Rehab Dynamics	28.03.2024	20
R6	Insurer’s treatment approval	26.05.2024	35
R7	Invoice of Western Sydney Hand Physiotherapy	22.05.2024	36
R8	Allied Health Recovery request	14.08.2024	37
R9	Certificate of Capacity	30.07.2024	42
R10	Certificate of Capacity	24.08.2024	46
R11	Clinical records of Associate Professor Nicholas Smith	22.10.2024	52
R12	Letter to Littles Lawyers	24.10.2024	66
R13	Insurer’s further submissions	23.04.2025	67

·        The insurer maintains the position that the requested treatment is neither reasonable nor necessary in the circumstances.

·        The insurer submits that the claimant has not exhausted conservative treatment options prior to considering surgical interventions. The insurer references hand therapy.

·        The insurer submits it is evident that the claimant has not made any meaningful attempts to undergo conservative treatment prior to considering surgical intervention.

REASONABLE AND NECESSARY IN THE CIRCUMSTANCES

1. The claimant is required to establish that the treatment and care is both “reasonable and necessary”. This test differs from the worker’s compensation legislation which requires a worker to establish that the treatment and care is “reasonably necessary”. There is a stricter requirement under the Act because there is no moderation of the requirement that the treatment and care is “necessary”.

2. When discussing the meaning of “reasonably necessary” under s 60 of the Workers Compensation Act1987 in Clampett v WorkCover Authority of NSW,[6] Grove J stated:[7]

   “22. I return to the expression ‘reasonably necessary’ in s 60. Dictionaries stipulate that ‘necessary’ as relevant definition as ‘indispensable, requisite, needful, that cannot be done without’ – (shorter Oxford English Dictionary, 3^rd Edition) and ‘that cannot be dispensed with’ – Macquarie.

   23.    The essential issue is what effect flows from conditioning such qualities as ‘reasonably’. The consequence is to moderate any sense of the absolute which might otherwise be conveyed by the word ‘necessary’ if it stood alone. In order to contemplate such moderation, it is apt to consider surrounding circumstances, but the question to be addressed is whether modification of a worker’s home, having regard to the nature of the worker’s incapacity, is reasonably necessary. In contemplation of what may be ‘reasonably necessary’, there is these statutory obligations specifically to have regard to the nature of the worker’s incapacity. It provides emphasis towards moderating the meaning of ‘necessary’ in this context.”

   [6] [2003] NSWCA 52.

   [7] Clampett at (22) – (23), Meagher and Santow JJA agreeing.

3. Similar observations have been made subsequently by the Court of Appeal on the meaning of “reasonably necessary” under other legislation.[8]

   [8] See ING Bank (Australia) Limited v O’Shea [2010] NSWCA 71 at (48); Moorebank Recyclers Pty Limited v Tanlane Pty Limited [2012] NSWCA 445 at (113).

4. Factors relevant to, but not determinative of, the criteria of reasonableness in the context of the worker’s compensation legislation are well-settled.[9] They include:

   (a)    the appropriateness of particular treatments;

   (b)    the availability of alternative treatments;

   (c)    the costs of the treatment;

   (d)    the actual or potential effectiveness of the treatment, and

   (e)    the acceptance by medical experts of the treatment as being appropriate or likely to be effective.

   [9] See Diab v NRMA Limited [2014] NSWWCCPD 2 at (88) (Diab).

5. Whilst the observations in Diab were directed to the test of “reasonably necessary” in the worker’s compensation legislation, we adopt it in so far as they have relevance, although not determinative, of the stricter test of “reasonable and necessary”.

6. The words “in the circumstances” in the context of whether the treatment is “reasonable and necessary” must refer to the particular circumstances of the claimant. This is because Schedule 2 of the Act refers to treatment “provided or to be provided to the claimant”.

7. The test of “reasonable and necessary in the circumstances” does not direct attention to the relationship between the accident and the treatment. That issue arises from consideration of whether treatment “relates to the injury caused by the accident”.

EXAMINATION REPORT

1. The examination report of Senior Medical Assessor Drew Dixon is as follows:

   “Yunseo Choi (R-M26170/24)

   Examination by Drew Dixon

   MVA: 30.1.24

   8 July 2025

   (Korean Interpreter present – Bok Soon Yang) Naati: 51905

   This 20 year old claimant was involved in a motor vehicle accident on the 30 January 2024 when she was travelling at 50 km/h when her vehicle was t-boned on the left side by another car travelling at the same speed. She was clenching the steering wheel on impact, and this caused her right wrist to be twisted and she subsequently had ulnar sided wrist pain due to a wrenching injury on impact of the wrist.

   She subsequently had an MRI of the right wrist which showed some chronic changes and interstitial tears at the triangular fibro cartilage, which was thought to reflect a degree of instability, given that there was some minimal subluxation of the distal radial ulnar joint and a tiny joint effusion. No acute abnormality was seen throughout the right wrist joint.

   X-ray of the right wrist on 17 April 2024 showed minimal ulnar plus variance and no evidence of ulnar impaction. There was some deformity of the trapezium and perhaps a trapezoid query old fracture.

   Despite having physiotherapy treatment and taking simple analgesia such as Panadol and no splintage, the claimant complained of ongoing pain in the distal ulnar carpal joint region of her right wrist.

   She had review by a hand specialist, Associate Professor Nicholas Smith, on 17 April 2024, who commented that the MRI scan demonstrated a bi-convex lunate as well as TFCC change and that radiologically, she had a positive ulnar variance.

   He diagnosed the whole presentation was consistent with an acute ulnar carpal abutment injury and that if she not did not settle, she would benefit from an arthroscopic debridement and an ulnar shorting osteotomy.

   In the subject accident she also sustained neck and back strain injuries which have resolved.

   On presentation at the Hornsby rooms on 8 July 2025 there was mild stiffness of her right wrist with dorsi flexion 50 degrees, palmar flexion 50 degrees, ulnar deviation was 30 degrees but with some pain on abutment and radial deviation was 20 degrees without pain. Pronation and supination (rotation) were full. There was a prominent distal ulnar radial styloid and there was a reducible subluxation of the distal radial ulnar joint on the right. There was tenderness in the distal radial ulnar joint and some proximal tenderness to the ulnar styloid. At the left wrist there was normal prominence of the distal ulna styloid.

   The claimant has had over 18 months to recover from this injury, however, in view of the ongoing symptomatology and the above physical findings and radiological findings, it does appear that it is reasonable and necessary to repair the triangular cartilage with arthroscopic appraisal.

   In general, TFC lesions without instability (type 1) can be managed conservatively with splinting and physiotherapy. Acute ones with instability can be managed with casting with the wrist fully supinated but this requires concentric reduction be maintained.

   In this claimant, there has been progression with distal radial ulnar subluxation and a known disruption of the triangular cartilage and arthroscopy for better visualisation of the tears plus or minus debridement and removal of any loose bodies and repair can be addressed.

   When there is ulnar neutral or ulnar negative variance, debridement and repair gives relief of symptoms. When there is positive ulnar variance on static or dynamic views in patients with triangular TFC tears, correction is recommended by doing open diaphyseal (shaft) ulnar shortening. The reason for this is that there are less favourable results in patients with TFC tears who have ulnar positive variance, where the ulnar variance is not addressed.

   The distal radial ulnar joint is a synovial joint where there are rotational (supination and pronation) and transitional movements with a radioulnar articulation. Stability is provided by the TFCC, the fibro cartilage disc which is attached to the sigmoid notch of the radius and inserts into the sigmoid notch with a fovea of the ulnar styloid. Clinically, this TFCC has been significantly disrupted.

   Review of the hard copy of the MRI right wrist dated 26 February 2024 showed disruption to the attachment as well as surface tears with subluxation of the distal radioulnar joint.”

FINDINGS

1. The Panel conducts a new assessment of all the matters with which the medical assessment is concerned.[10]

   [10] Section 7.26(6) of the Act

2. The Panel is not required to choose between medical opinions and is required to form its own opinions.[11] The Panel adopts the findings and opinions of Senior Medical Assessor Drew Dixon with which Medical Assessor Shane Moloney concurs. The Panel reconvened on 14 August 2025 to confirm its findings and decision.

   [11] Insurance Australia Group Limited v Keen [2021] NSWCA 287 and Insurance Australia Group Limited v Marsh [2021] NSWCA 31

3. The Medical Assessors have explained the basis for their assessments and findings. The Medical Assessors note the views expressed by Dr Rimmer in relation to causation, with which they respectfully disagree because, upon examination, there was a particularly prominent distal ulnar radio styloid and there was a reduceable subluxation of the right distal radio ulnar joint. The prominence of the styloid cannot be explained without significant ligamentous disruption. Upon questioning, the claimant denied any past trauma, apart from the subject accident, as a caused of the observed condition. The claimant demonstrated to Senior Medical Assessor Dixon the mechanism of her injury as described in the examination report.

4. The Panel is satisfied it is unlikely that the condition found upon examination would present in a young woman absent trauma. The Medical Assessors respectfully disagree with the views expressed by Medical Assessor McGrath and prefer the views of Associate Professor Smith on causation.

5. The Medical Assessors also respectfully note the radiological opinion of Dr Yap that no acute abnormality was shown in the right wrist upon MRI scanning. The Medical Assessors note that imaging studies are not sufficient to make a diagnosis, especially where the imaging findings are not concordant with clinical symptoms and signs, and the history of injury. The Medical Assessors prefer to rely upon the clinical findings made upon examination and their clinical judgment.

6. Whilst the Panel accepts that the condition of the claimant’s right wrist could have been aggravated by her work as a nurse, as Medical Assessor McGrath thought, the Panel is satisfied the subject accident made more than a negligible contribution to the condition found upon examination by Senior Medical Assessor Dixon. The claimant’s treating GP recorded “painful wrists” within one week and ordered a MRI scan within three weeks of the motor accident. The Panel accepts that the claimant’s immediate complaint of pain, in her right wrist, absent pre-existing symptoms, establishes the necessary causal link.

7. The Panel is satisfied, as a matter of medical determination and as a matter of factual non-medical determination, that the referred requests for treatment and care relate to the injury caused by the motor accident.

8. The Panel accepts that the requested right wrist arthroscopy and right wrist TFCC debridement are reasonable and necessary.

9. However, as ulna variant is very minor and the ulna shortening is minimal, the Panel is not satisfied that the requested right wrist ulna shortening osteotomy is reasonable and necessary in the circumstances.

CONCLUSION

1. For the above reasons, the Panel concludes the Certificates dated 13 January 2025 should be revoked. The new Certificates appears at the commencement of these reasons.