Cic Allianz Insurance Limited v Savic
[2024] NSWPICMP 347
•29 May 2024
| DETERMINATION OF REVIEW PANEL | ||
| CITATION: | CIC Allianz Insurance Limited v Savic [2024] NSWPICMP 347 | |
| CLAIMANT: | Borivoje Savic | |
| INSURER: | CIC Allianz | |
| REVIEW PANEL | ||
| MEMBER: | Hugh Macken | |
| MEDICAL ASSESSOR: | Wayne Mason | |
| MEDICAL ASSESSOR: | Melissa Barrett | |
| DATE OF DECISION: | 29 May 2024 | |
| CATCHWORDS: | MOTOR ACCIDENTS – Review of medical assessment; degree of permanent impairment; persistent depressive disorder with anxious distress; medical dispute; medical material to be considered; pre-accident psychological and physical injuries; consideration of medical material; persistent depressive disorder with anxious distress; psychiatric impairment rating; Held – Panel revokes the Certificate of Medical Assessor Alexey Sidorov. | |
| DETERMINATIONS MADE: | CERTIFICATE OF DETERMINATION The assessment made by the review panel under s 63(4) is as follows: 1. The Panel revokes the Certificate of Medical Assessor Alexey Sidorov dated 22 March 2023 and issues a new certificate determining that:
| |
STATEMENT OF REASONS
INTRODUCTION
Borivoje Savic (the claimant) is a 64-year-old man who was injured in a motor vehicle accident on 29 February 2016. Following the accident the claimant sought a concession that his injuries, including psychological injury gave rise to an impairment of greater than 10%. The insurer declined to make this concession and consequently the claimant referred the matter to the Personal Injury Commission (Commission) to have the issue of whole person impairment assessed.
Ultimately the claimant was examined by Medical Assessor Sidorov on 7 March 2023 and a certificate was issued dated 22 March 2023 finding that the claimant suffered a depressive disorder with anxious distress which was caused by the accident and which gave rise to a permanent impairment of 13%.
The insurer sought a review of this certificate which was considered by the President’s delegate Catherine Freeman, who, in a decision dated 20 April 2023, determined that she was satisfied that there is a reasonable cause to suspect that the medical assessment was incorrect in a material respect. Specifically, she considered that Medical Assessor Sidorov failed to have regard to the insurer’s original submissions regarding causations of the claimant’s psychological symptoms given the available evidence. That is, there was demonstrated lack of contemporaneous psychological complaints, delays in obtaining treatment and a lack of treatment between April 2018 and September 2022.
The Medical Panel met on 14 February 2024 at which time it was determined that additional material needed to be considered. This material was then uploaded and the Panel considered the material noting that the clinical notes were quite out of date with nothing further from about 2018. The Panel directed the updated clinical notes be loaded on to the portal.
Clause 14F of Schedule 1 of the Personal Injury Commission Act 2020 (the PIC Act) provides that the new review provisions apply in relation to a decision of a new decision-maker. A “new decision maker” is defined in cl 14A(1) of the Schedule 1 of the PIC Act. As the medical assessment, the subject of the review, was made on or after 1 March 2021, the new review provisions apply.
The new review provision provide that a review panel consists of two Medical Assessors and a Member assigned by the Motor Accidents Division of the Commission.
Part 5 of the PIC Act enables the Commission to make rules with respect to its practice and procedure including proceedings before a panel reviewing a decision of a Medical Assessor.
Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the PIC Act. A review panel determines how it conducts and determines the proceedings and may determine the matter solely based on the written application.
The review of the medical assessment is by way of a new assessment of all the matters with which the medical assessment is concerned.
STATUTORY PROVISIONS/GUIDELINES
Section 57 of the MAC Act defines a “medical dispute” as a disagreement or issue to which Part 3.4 of the MAC Act applies.
Sections 58 and 60 of the MAC Act together with cls 1.5-1.7 of the Guidelines set out the procedures for referral to one or more Medical Assessors and the principles to be applied at such assessments.
MEDICAL MATERIAL
The Panel considered a significant amount of medical material in respect to the assessment. In respect to the physical injury the claimant has been examined by the Medical Assessment Service on a number of occasions. Firstly, the certificate of Medical Assessor Paul Meyers dated 13 March 2018 in respect to his physical injuries. The Medical Assessor noted the claimant’s alleged injuries to his cervical, thoracic and lumbar spine as well as his left upper extremity. His certificate determined that the claimant did not suffer an injury to either his left or right upper extremity nor his lumbar spine. He suffered a soft tissue injury to his cervical spine and thoracic spine which gave rise to a whole person impairment of 0%. Secondly, the claimant made a further application to the Medical Assessment Service and was examined by Medical Assessor Rosenthal on 17 July 2019 who, in a certificate dated 24 July 2019, determined that the claimant sustained a 9% whole person impairment consequent on an injury to his cervico-thoracic spine, as well as both shoulders. He confirmed there was no lumbar spine injury but did identify restriction in the claimant’s shoulder movements persisting following this motor vehicle accident as well as a strain to his cervical spine which gave rise to a whole person impairment of 5%.
Thirdly, there was an examination by Medical Assessor Robert Payton who, in a certificate dated 25 July 2019, found a further whole person impairment of 6% consequent on hearing loss and tinnitus. This finding was the subject of a review and it was ultimately determined that this was not an injury arising from the motor vehicle accident and accordingly the claimant, in respect to physical injuries, was found to be below the 10% whole person impairment threshold.
The claimant was examined for an alleged psychological injury and was assessed by Medical Assessor Alexey Sidorov on 7 March 2023 who, in a certificate dated 22 March 2023 found the claimant suffers a persistent depressive disorder with anxious distress consequent on the motor vehicle accident and a whole person impairment of 13%. This is the certificate which was the subject of a review. The Panel, having considered all additional material including clinical notes of his treating psychiatrist Dr Kuljic, examined the claimant on
1 May 2024.
EXAMINATION
The claimant was assessed by videoconference via Microsoft Teams. He attended and was examined by Medical Assessors Barrett and Mason, unaccompanied.
HISTORY
Psychosocial history and pre-accident history
The claimant is a 64-year-old man who has been living alone, in Kemps Creek, for the last year and a half. He remains married to his wife but has preferred to live separately while she lives in their home in Bondi. He supports himself on income from investment properties.
The claimant was born in Serbia and reported normal birth and achievement of milestones. He is the middle of three brothers. His father was a shopkeeper in Serbia. The family migrated to Australia when Mr Savic was about 9 or 10-years-old for better opportunities. He denies exposure to any trauma.
Of migration to Australia, he stated, “It wasn’t easy”. There was some bullying at school, but he was not a particular target due to his height. He attended special English language classes. His parents were hardworking, and his father got a job in a factory.
He attended Fairvale High School, where he completed up to Year 10. He commenced a trade but did not complete it. In 1979, he and his older brother returned to Serbia to join the army, feeling a sense of responsibility to serve their birth country. He was in the army for about 13 months, which he described as a good experience. He did not see any active service. He met his wife and married when he was about 21 or 22-years-old.
In 1988, he returned to Australia with his wife. He then began working at Tetra Pak in quality control prior to injuring his lower back in 1989 or 1990. This was the subject of a previous workers’ compensation claim. There was no associated psychiatric claim. He attempted to return to work on light duties but was unable to continue and was eventually terminated.
He acknowledged he was then off work for a few years, due to his ongoing back pain. At that time he and his wife were living with his in-laws in Canley Heights and they provided support. He then found a job in insurance sales, in which he worked for two or three years. Prior to the Olympics, in the context of expected tourism opportunities, he opened a coach business in 1999. His business was successful, holding number of government contracts.
He and his wife have two daughters, aged 38 and 40-years-old. He has no grandchildren.
Aside from the workers’ compensation claim in 1989 or 90, he denied any other workers’ compensation claims. He denied any CTP claims. He denied any forensic history.
He is a nonsmoker who uses one or two standard drinks per week. He denied any history of daily alcohol use. He denied any other drug use history. He denied any history of stimulant use.
He denied any family psychiatric history.
He acknowledged that, at the time of the subject accident, the 1989/1990 back injury persisted but stated he, “had to learn to live with it”. He could not perform some activities. He acknowledged there were a few episodes a year where he would have flares of pain, lasting a few days, during which he could not drive long distances. Otherwise, he was able to sit to drive long distances if necessary and the back injury was not impacting him most days. He was not using any regular analgesics.
In 2013 or 2014, he injured his right knee. He denied any persisting pain and other than inability to jump from heights, he was not restricted.
He had cholecystectomy about 30 years ago. Otherwise, he states his health was “good” prior to the accident.
He denied any pre-accident psychiatric history. He acknowledged he did tend to be somewhat perfectionistic but stated, “work was like that, had to be 100%”, “very punctual, accurate”.
In the period before the accident, he was living in Canley Heights, in the family home with his wife. His wife performed the household chores. He showered daily and took pride in his appearance, “had to be a 100% appearance-wise” and shaved daily. He acknowledged that his work hours meant that he had limited time for recreation, “main focus was to make sure business was secure” and to achieve financial security for him and his family. He occasionally went to the pub but could not estimate how frequently, “couldn’t say, depends on business”. He was able to drive without restriction. He and his wife worked together in the business, with his wife running the administrative tasks. His relationship with his wife was “good”. He described a positive relationship with his adult daughters who were living independently. He was primarily occupied with working in his business, stating he worked 15 to 16 hours a day, 7 days a week. The business owned five or six full-sized coaches and six or seven mini buses. He employed up to 20 to 30 people. He drove the vehicles, if the planned driver was unable to do so, took the vehicles for service, washed and cleaned the coaches and took them for registration. The business had number of government contracts which were renewed every three to five years. The business was profitable.
As a result of profits in the business, he had invested in a number of properties. He had previously been an owner builder of his home in Canley Heights and he and his wife had purchased a property in Bondi with view to develop it into four apartments and a shop. He had engaged a builder and project manager.
History of the motor accident
The subject accident occurred on 26 February 2016. Mr Savic was driving his Mercedes Benz E class, which was then only two or three years old. He was travelling with his wife, who was in the passenger seat. They were looking for the driveway of a shop and so he was travelling at only about 15kmph. They were suddenly hit from the rear by a Ute, “never expected”. He was able to self-extricate and the driver was apologetic. They exchanged details. Neither police nor ambulance were called. The airbags did not deploy but his headrest, “disengaged”. It was difficult to understand what he meant by that term, as he appeared to be describing some change in headrest having been activated by the accident or breakage of the headrest. He drove the car home and it was subsequently repaired.
History of symptoms and treatment following the motor accident
Physical symptoms
Mr Savic reported injuries to his neck, shoulder and arm. As a consequence, he experiences pain in his neck, shoulder and arm. He experiences headaches, “buzzing in head”, experienced from his left ear into his head, “everyday”, “nonstop”. The sound is worse in the quiet.
In regards to treatment he has seen an ENT surgeon in regard to the, “buzzing”. He stated, “Nobody tells me what it is”. He was trialled on valproate by a neurologist, but stated he was “scared” to continue this medication, having read that it was used for epilepsy.
Prior to the accident, he had not been regularly driving, but was doing so if the driver was unavailable. However, after the accident, he states he could not drive at all. He stated, “There are lot of things I cannot do”. He states he could not lift or push and was therefore restricted to working only a few hours a day. When he had pain, he would rest to “sleep it off”. He states his pain was impacting his sleep overnight, causing him to wake overnight. He also reported his pain was impacting his mood, stating he would become “grumpy and angry”, particularly when under pressure. He stated when he felt pressured, he would also leave work and lie down.
Psychiatric Symptoms
Mr Savic stated that the psychiatric symptoms began a few months after the accident, from about mid-2016. There was no specific trigger, “I don’t know why”, but it, “started building up”, “more and more”. He described himself as increasingly irritable, triggered by the pressure of having to do a lot of emails or talk to the drivers. He started shouting and yelling at the drivers and his behaviour extended towards his wife. He denied any incidents of physical violence and would feel remorseful afterwards. His concentration was impacted by his headaches and “buzzing” after being woken by pain overnight. He then started worrying about his business, thinking, “What’s going on?” In total he was achieving only five to seven hours of broken sleep a night.
He was delegating more tasks to others, “feeling like he couldn’t do the tasks”, “psychologically and physically”. He needed to reduce work hours due to an increasing sense of being unable to cope which led to the need to employ more people to work for him to perform the roles he could not perform. He was avoiding meetings and talking with the drivers.
Between 2016 and 2019, he had gradually reduced his work hours, to three to five hours a day. In 2017 and 2018, he and his wife had moved to Bondi and he was running the business from there. From late 2017 or 2018, he started selling the full-sized buses to reduce the demands of the business. He was continuing to run his minibus fleet, which served the government contracts. He, “Couldn’t step in with driving if required”, stating he was fearful when driving that he was going to have another accident, “Am I going to be hit in the car?” and was avoiding driving. He could not perform the vehicle repairs and was struggling due to the, “way I felt in my mind”. As a result, the business’ profitability was declining.
The government contracts were due to expire in 2019. He put in a tender for the new contracts but he was surprised that the contract was awarded to a different company. The feedback he received is that they were overpriced compared to the successful contractor. However, if he would have been successful in the contract, he considers that he would have had significant difficulty continuing running his business at a profit. He stated he does not know how he would have managed to fulfil the contract if he had been successful. He was forced to close the business in September 2019, “despite, never wanted to close it".
He reports gradually worsening mood. He avoids people, stating he feels better, “away from everyone”. He avoids perceived pressures. His concentration is impacted and he has to re-read material multiple times to understand it. He had negative thoughts thinking, “Everything bad”, including thinking he is going to be hit by a car when he drives. He describes the lack of, “will to do anything”, poor motivation, and has limited social contact. He has lost all his former connections. He worries about the impact on his relationship with his children. He feels a sense of loss of support from former friends and that he is, “On my own”. He can still enjoy being around his children and seeing his wife on occasion.
His appetite has been reduced. He tends to skip meals, “couldn’t be bothered”. He had initially lost 26 kg but subsequently regained 10kg. His energy is low. He described passive suicidal thoughts, wishing he was dead and thinking, “I am useless”. He denied active suicidal thoughts.
In regard to treatment, he has seen a psychologist, Zoran Protulipac between 2017 and 2018. He stated these sessions were “a bit helpful”. He has been referred to psychiatrist,
Dr Kuljic, whom he has seen once a month for the last two years. He does not recall previous medications trialled but states they were associated with side effects of weight gain. He could not recall the name of the antidepressant he is currently using but the records indicate he has been prescribed the SSRI antidepressant fluoxetine, 20 mg daily, from about May 2023. He states it is, “A bit helpful”, “Calms me down”.
Details of any relevant injuries or conditions sustained since the motor accident
There have been no new injuries or conditions. He had cataract surgery on one eye. He had a detached retina in the right eye four or five years ago, treated successfully with surgery.
Current symptoms
He continues to report low mood. He reports a gradual worsening of his pain symptoms and persisting low mood. He described worrying and rumination about the effect of the accident, “It has affected me so much”. He reported poor self-esteem, perceiving himself as “useless” and described some hopelessness, “Don’t know what’s going to make it better”. He has persistent disturbed sleep, averaging five to seven hours of broken sleep per night, reduced to three or four hours prior to a stressful event, such as on the evening prior to this assessment. He has persistent loss of appetite, loss of interest, low energy and poor motivation. He can enjoy seeing his family, but otherwise reports a lack of interest in socialising.
Current and proposed treatment
He continues to see his treating psychiatrist Dr Kuljic once a month. He uses fluoxetine 20 mg daily, Progout, Diabex 500 mg daily and Glyxambi.
Clinical examination
Mental state examination
Mr Savic was assessed by video conference. He was punctual for the assessment.
He was casually dressed and appeared freshly shaven but his hair was somewhat dishevelled. There were no signs of psychomotor retardation or agitation. His speech was normal in rate, volume and rhythm. He tended to be somewhat overinclusive.
His affect was dysphoric and at one point during the assessment, when asked about suicidal ideation, he became anguished and tearful. He appeared embarrassed by the display of emotionality and after a period of time was able to collect himself and continue the assessment. He was able to contain his emotions and continue the assessment. He did not smile spontaneously, nor with prompting. His mood was described as depressed.
He experiences a negative view of himself, “I’m useless” and he is preoccupied by his loses, “I lost everything”. He worries about the impact on his relationships. He feels isolated. He continues to worry about the risk of another accident. He continues to fear another accident and stated, while talking about the accident, “Now I got trauma just thinking about it”. He did not describe re-experiencing symptoms, nightmares or flashbacks. There were no delusions reported. There is no formal thought disorder. He did not describe any perceptual abnormalities.
He described a sense of hopelessness and reported some passive suicidal thoughts, that he wished he was dead, but denied any active suicidal thoughts. He did not express any risk to others and denied any incidents of physical violence.
He was able to concentrate for the assessment, but could not recall some aspects of his history, such as previous antidepressants trialled or the name of his current antidepressant and had difficulty recalling the names of his other medications.
He has some insight in his condition, continuing to see his treating psychiatrist, and reports compliance with his antidepressant medication.
Current functioning
Mr Savic reported that he and his wife had bought a property in Kemps Creek two years ago as an investment, on the advice of his accountant. A year and a half ago he took the opportunity to move to one of the homes on the property, as he felt he should, “go and live on my own”. He does not know how to cook. He can make simple meals but tends to skip meals. His wife and daughter visit him and bring him pre-prepared meals but even then, he will sometime skip meals and needs to be reminded to eat the meals by his daughter. His daughter predominantly does the cleaning, although he does some cleaning tasks. He showers only every few days. He stated, “I feel I don’t have to”, “on my own”, that there is no one to see him.
He stated he now shaves only once a week, “what’s the point”, although he acknowledges he shaved prior to the assessment.
He spends his time sitting on the back veranda, enjoying, “peace and quiet”. He waters some plants, feeds his chickens and collects some eggs. Once every few weeks, he will mow the lawn using his ride-on mower. When encouraged by friends, he will go out for a meal infrequently, about once every few months. His daughter will take him to the club for a meal if there is no other food available at home, once every few months. He will have birthday dinners at their home in Bondi.
He is able to drive locally. He can drive to Bondi and finds the journey painful and stressful.
He has a good relationship with his adult daughters. One lives in Dubai but will visit occasionally. His eldest daughter lives locally and visits him a few times a week. He states that he and his wife were arguing and, “couldn’t get along”. He stated, “I offended her so many times”, so he preferred to live separately, although he states the marriage remains intact. He sees his wife now about once or twice a month. He has lost friends, “not many friends at all”. The friendships that remain intact are limited and he has only short conversations with them. He has contact with his brother now less frequently, only once a year, because there is “nothing to talk about”.
He has never enjoyed reading for pleasure. He will sometimes watch a movie or TV but states it is, “sometimes too much”.
He was forced to close his business in 2019 due to the loss of government contracts. He continues to have a number of investment properties; these are managed by property agents.
Comments of consistency
Mr Savic presented as an open and straight-forward historian. The reported symptoms were consistent with those contained in the documentation. His mental state examination findings were consistent with the reported symptoms and those expected in the diagnosis.
Conclusion on issues raised by the parties
The panel considers that in the context of the subject accident, from about mid-2016 and ongoing, Mr Savic has developed a persistent depressive disorder with anxious distress.
Although there has been differing opinions about accident-related physical conditions by our Medical Assessor colleagues, the most current certificate by Medical Assessor Rosenthal in July 2019 determined there were accident-related physical injuries which are permanent and cause impairment.
The panel thus accepts that Mr Savic’s physical restrictions impacting his ability to perform previous duties at work were causally related to the subject accident.
In addition to, and independent from the impact of pain and the physical restrictions, he reported increased anxiety, reduced stress tolerance and irritability after the accident, including anxiety when driving, impacting his ability to function in his role in his business and his work and non-work relationships. The panel accept that the accident was of a sufficiently serious nature to plausibly cause symptoms of anxiety, noting his description of his emotional experience of the accident, the effect of the impact upon the seat headrest and physical injuries sustained in the accident.
The resultant reduced work capacity, in regard to work hours and duties and in particular his ability to manage staff and stress, were thus reduced. The panel accepts that these restrictions to his work role, work hours and resilience had a gradually and cumulative impact upon his ability to run his business. He responded to this by attempting to delegate work, employ more people to do the work, and eventually by reducing the demands of the business by selling the coaches.
The panel accepts that Mr Savic’s capacity to continue to work in the business was progressively deteriorating from 2016, resulting in gradually reduced profitability and gradual contraction in the size of business, and which would have eventually resulted in loss of his capacity to run the business, even if he was successful in winning the government contract tender.
Considering Mr Savic’s pre-morbid perfectionism and the high level of importance he had placed on work and financial success, the panel considers the loss of roles caused the onset of chronic symptoms of depression, low mood, loss of self-worth, poor appetite with weight loss, low energy, reduced motivation and hopelessness, as well as heightened anxiety, fearing negative events including having another accident, and anxious worrying about his future.
As the triggering stressors have been chronic and gradually worsening, his symptoms of depression and anxiety have also been chronic and progressively worsening. Considering the persistence of his symptoms for more than two years, without remission, the panel considers he fulfils DSM-5 diagnostic criteria for persistent depressive disorder with anxious distress.
Mr Savic has no past history of any psychiatric conditions and he denied any relevant drug and alcohol history or family psychiatric history which would have represented risk factors for psychiatric condition.
The insurer submitted there was a lack of contemporaneous complaints of psychological symptoms and noted the delay to referral for treatment with the psychologist. Further they note the gap in treatment between when he last saw the psychologist in 2018 and when he was referred to a psychiatrist in 2022.
The Panel considered that in circumstances where there was a gradual accumulation of losses, it is not unusual for there to be a delay to the development of psychological symptoms. Mr Savic acknowledges that his psychological symptoms did not begin until a few months after the accident, which would be plausible and understandable in circumstances where the gradual and cumulative effects of the accident related anxiety symptoms, causing insomnia, impatience and reduced persistence with tasks and irritability, and restriction to his ability to drive, each impacting his role, would have gradually impacted on Mr Savic’s psychological state. In the context of a gradual contraction of his work capacity, role and subsequently business, his symptoms have gradually worsened. It is, therefore understandable that he was not initially referred to treatment, but only referred to treatment with a psychologist when his symptoms worsened, and later to a psychiatrist, when symptoms further worsened.
Mr Savic presents as a stoic and conscientious man, who did not feel he particularly benefitted from psychological treatment and therefore, the gap in seeking further treatment is not necessarily surprising and is understandable.
We note the insurer refers to the outcome of combined certificate of August 2019, assessing whole person impairment at 14% and points to the fact that Medical Assessor Payten’s certificate for ENT was overturned on review, so that the combined certificate is 9%. From a psychiatric point of view, whether or not the permanent impairment due to physical condition is above or below the 10% threshold, does not exclude that the physical impairment would have substantially impacted on the person’s work and non-work roles and self-image and could still be plausible cause of a psychiatric condition.
We note that the financial documents provided indicate a progressive reduction in income year to year.
The panel note the report of Dr Graham George, 5 December 2017, almost two years after the subject accident. In this report, Dr George reported Mr Savic described working reduced hours compared to prior to the accident, although he was still working 55 hours a week, that his business income had dropped by 30% or 40%. The reduction in income had caused financial stress. He reported the development of pain in his neck, both shoulders and headache after the accident, as well as buzzing. He was woken by pain. He was finding it more difficult to concentrate due to pain. He described his mood as “variable”, with good and bad days, and that he was worrying a lot about the reduced profitability of the business.
He had seen a psychologist Dr Protulipac about seven or eight sessions at that time. His GP prescribed diazepam and an antidepressant. He was sleeping five or six hours a night and was less physically active. He was not socially active, and his libido had declined.
The panel noted that Dr Geoge did not diagnose a psychiatric condition at that time. It is the panel’s opinion that Mr Savic’s psychiatric condition has begun gradually, six months after the accident and had been progressively and gradually worsened from late 2016 until the current time. Therefore,
Mr Savic’s symptoms were not as severe at the time of assessment by Dr George, although it is noteworthy that the symptoms are consistent in type and character. This is consistent with the history provided and the expected progression of the condition, noting the continued impact of the chronic stressors, and in the panel’s opinion is consistent with the natural history of Mr Savic’s condition.
Review of Documentation
Instructions for summary of relevant documentation
Summary of relevant documentation
The Panel considered all documentation available in relation to the claimant. The documentation supports his allegations of physical injury arising from the motor vehicle accident and associated continuing impairment consequent on those injuries. In particular the clinical notes as recently as
8 April 2024 note the claimant’s psychological treatment, medication use and management. The claimant has no changes in mental state continued observations that he is pessimistic, depressive ruminations of mood and unstable mood. The Panel notes the medical material supports the finding of a development of a significant psychological disability consequent on the motor vehicle accident.
Permanency of impairment
Statement about permanent impairment
The determination as to permanent impairment is made in accordance with the American Medical Association’s Guides to the Evaluation of Permanent Impairment (Fourth Edition) (AMA 4) and The Motor Accident Guidelines Version 4 15 January 2019 Permanent impairment is defined in the AMA 4 (p.315) as follows:
“Permanent impairment is impairment that has become static or well stabilised with or without medical treatment and is not likely to remit despite medical treatment.
A permanent impairment is considered to be unlikely to change substantially and by more than 3% in the next year with or without medical treatment.”
Determinations
Summary of injuries referred by the parties
The following injuries WERE caused by the motor accident:
· persistent depressive disorder with anxious distress.
Psychiatric Impairment Rating Scale
| Psychiatric diagnoses | 1. Persistent Depressive Disorder with anxious distress. | 2. |
| 3. | 4. | |
| Psychiatric treatment description | Two previous trials of antidepressants, current SSRI antidepressant, fluoxetine 20 mg. Previous psychological treatment between 2017 and 2018. Continuing treatment under a psychiatrist, Dr Kuljic, once a month. | |
| Category | Class | Reason for Decision |
| 1. Self Care and Personal Hygiene | 3 | Although Mr Savic lives alone, as a result of symptoms of his condition impacting motivation and appetite, he skips meals, even though they are prepared for him by his wife and daughter. He does very limited cleaning and showers infrequently, once every few days, and shaves once a week, which is vastly different from his pre-accident habit of taking care with his appearance. Considering the need for his wife and daughter to provide meals to him and to prompt him to not skip the meals, requiring his daughter to visit him a few times a week to maintain minimum hygiene by cleaning and providing him meals, this is consistent with PIRS definition of a moderate impairment. His appearance of being somewhat dishevelled on mental state examination was objective evidence of this determination. |
| 2. Social and Recreational Activities | 3 | Although prior to the accident Mr Savic was predominantly involved in business-related activities, he could go out on his own to clubs and engage socially with friends. Now he rarely socialises, only going out with friends once every few months when encouraged by friends or to the club every few months when encouraged by his daughter. He, otherwise prefers to spend time on his own in solitary and low demand pursuits of watering the garden or feeding his chicken. Condisidering his inability to go out without the encouragement and support of a friend or his daughter, this is consistent with a PIRS definition of a moderate impairment. |
| 3. Travel | 2 | He continues to avoid driving, fearful of another accident. He can drive locally on his own or the familiar area of Bondi despite experiencing this as stressful. He avoids driving longer distances and disclosed that he bought a motorhome four years ago but he has not driven it. His restriction to driving only in the local area or familiar places, is consistent with a mild impairment. |
| 4. Social Functioning | 2 | There was significant tension in his relationship with his wife, with frequent arguments, which he accepts relates to his irritability, which has caused him to live separately, and visit each other now only once or twice a month, although the relationship endures. He has very limited contact with his enduring friends and has lost many friends. He has reduced frequency of contact with his brother. However, he does maintain a good relationship with his adult daughters, one of whom live locally and who provides regular support to him throughout the weeks. Noting the strain in his relationship with his wife, loss of friendships and distance in his relationship with his brother, but persistence of the relationship with his wife, the panel considers this consistent with a class 2 impairment. |
| 5. Concentration, Persistence and Pace | 2 | Mr Savic reported reduced capacity to concentrate. He sometimes watches television or a movie but loses interest and finds it, “sometimes too much”. It was the clinical opinion of the panel that his poor motivation and reduced interest would impact his persistence with tasks. The panel, therefore assigned a mild impairment. |
| 6. Adaptation | 5 | Mr Savic currently has no capacity to work. His work capacity has gradually reduced from late 2016 until 2019 and has continued to decline until the current time. Although he owns a number of investment properties, he states they are managed by property agents. He does not participate in non-work roles, noting his very limited engagement in household chores and activities of daily living and reliance upon support from his daughter. The panel, therefore considers there was a class 5 impairment in work and adaptation. |
| List classes in ascending order: 2 2 2 3 3 5 | ||
| Median Class Value: 2.5 = 3 | ||
| Aggregate Score: 17 | ||
| % Whole Person Impairment: %19 | ||
19%WPI = Percentage Whole Person Impairment
Psychiatric impairment rating scale
Pre-existing/subsequent impairment
There is no pre-existing or subsequent impairment.
Apportionment
Effects of Treatment
Although Dr Protulipac reported some improvement with treatment, Mr Savic does not report psychological treatment as being beneficial and, in any case, any temporary treatment effect would have been lost with the progression of symptom. Mr Savic reports some benefit from fluoxetine, calming him down, but there is no substantial improvement in his symptoms, which the symptom severity and functioning in fact progressively worsening despite the use of fluoxetine for the last two years. The clinical notes of treating psychiatrist, Dr Kuljic support the absence of any significant improvement in symptoms despite treatment. Thus, the panel considers there is no objective evidence of improvement in his condition or functioning and thus, considers there is no adjustment for the effects of treatment.
Conclusion
Degree of final permanent impairment caused by the motor accident 19%
Final percentage of permanent impairment 19%.
Current percentage of permanent impairment 19%.
Pre-existing subsequent percentage of permanent impairment 0.
Adjustment percentage for effects of treatment 0.
0
0
0