Florance v Star Entertainment Group
[2023] NSWPIC 662
•11 December 2023
| CERTIFICATE OF DETERMINATION OF MEMBER | |
| CITATION: | Florance v Star Entertainment Group [2023] NSWPIC 662 |
| APPLICANT: | Naomi Catherine Florance |
| RESPONDENT: | The Star Entertainment Group Limited |
| PRINCIPAL MEMBER: | Josephine Bamber |
| DATE OF DECISION: | 11 December 2023 |
| CATCHWORDS: | WORKERS COMPENSATION - Workers Compensation Act 1987; lump sum claim; primary psychological injury conceded; disputed claim for consequential gastrointestinal condition; issue as to application of section 65A as to whether lump sum compensation can be payable for both a primary psychological injury and consequential physical condition; Bell v The Mining Pty Ltd, Judge v Workforce International (Office Services) Pty Ltd and Tagicaki v Everwilling Cranes Pty Ltd followed; Held – award for the respondent in relation to the alleged gastrointestinal condition; the lump sum claim is remitted to the President for referral to a Medical Assessor to assess the permanent impairment for psychological injury with the deemed date of injury of 11 July 2016. |
| DETERMINATIONS MADE: | The Commission determines: 1. Award for the respondent in relation to the alleged gastrointestinal condition. 2. The lump sum claim is remitted to the President for referral to a Medical Assessor for assessment as follows: Date of injury: 11 July 2016 Body system: psychological. 3. The documents to be referred to the Medical Assessor are to include the Application to Resolve a Dispute and annexures and the Application to Admit Late Documents attaching the Reply and annexures. |
STATEMENT OF REASONS
BACKGROUND
Naomi Catherine Florance, the applicant, was employed with the respondent, The Star Entertainment Group Limited, as a croupier from about 2006. In the Application to Resolve a Dispute (ARD) the date of injury is pleaded as 11 July 2016. The injury description states:
“Our client sustained psychological/psychiatric injuries on 11 July 2016 from bullying and harassment during her employment with Star Entertainment Group. Due to stress and medication taken to treat her psychological injury, our client developed a consequential gastro-intestinal injury.”
The compensation sought in these proceedings relates to a claim for lump sum compensation pursuant to s 66 of the Workers Compensation Act 1987 (the 1987 Act) for 24% whole person impairment (WPI) comprising of 3% for gastrointestinal condition as assessed by Dr Greenberg and the balance for psychological injury as assessed by Dr Rastogi.
The claims for s 60 expenses were withdrawn because at the present time they are preluded due to the operation of s 59A of the 1987 Act.
The issues in dispute are:
(a) whether the applicant has a gastrointestinal condition as a result of the agreed primary psychological injury, and
(b) if so, whether for the purposes of the lump sum claim any impairment from the gastrointestinal condition can be combined with that of the primary psychological injury.
PROCEDURE BEFORE THE PERSONAL INJURY COMMISSION (Commission)
The matter was listed for conciliation conference/arbitration hearing before me on
11 September 2023. Mr Bill Carney, counsel, instructed by Ms Lazaris, solicitor, appeared for Ms Florance, who was present. Mr David Baran, counsel, instructed by Mr Van der Hout, solicitor, appeared for the respondent.6.
I am satisfied that the parties to the dispute understand the nature of the application and the legal implications of any assertion made in the information supplied. I have used my best endeavours in attempting to bring the parties to the dispute to a settlement acceptable to all of them. I am satisfied that the parties have had sufficient opportunity to explore settlement and that they have been unable to reach an agreed resolution of the dispute.
EVIDENCE
Documentary evidence
The following documents were in evidence before the Commission and considered in making this determination:
(a) ARD and attached documents, and
(b) Application to Admit Late Documents attaching the reply and annexed documents.
Oral evidence
There was no oral evidence. Both counsel made oral submissions, which were sound recorded, and a copy of the recording is available to the parties.
FINDINGS AND REASONS
It is common ground in the parties’ submissions that the determination of whether Ms Florance has developed a gastrointestinal condition as a result of her sustaining her work related primary psychological condition involves the application of the test of causation applying the principles in Kooragang Cement Pty Ltd v Bates.[1] These principles have been applied in many cases such as Kumar v Royal Comfort Bedding Pty Ltd[2] and Bouchmouni v Bakhos Matta t/as Western Red Services.[3]
[1] (1994) 35 NSWLR 452; NSWCCR 796, Kooragang.
[2] [2012] NSWWCCPD 8, Kumar.
[3] [2013] NSWWCCPD 4, Bouchmouni.
Ms Florance has the onus of proof to establish on the evidence before the Commission such a causal connection between her work place primary psychological injury and her gastrointestinal condition.
Despite the description of injury set out in her ARD, her counsel did not submit that the medication that Ms Florance has been taking had caused her to develop gastrointestinal symptoms and Dr Greenberg does support such a proposition.
Ms Florance has quite a complex presentation in terms of gastrointestinal symptoms so in order to consider both counsels’ submissions I have summarised the documentary evidence below.
Ms Florance’s statements
Ms Florance has provided statements dated 13 July 2018 and 30 August 2022. She describes her duties as a croupier for the respondent and also the development of her psychological symptoms. At [69] of her first statement she lists the physical symptoms she says she has suffered including but not limited to vomiting, constant diarrhea, stomach pains, extreme weight loss, loss of bladder control.[4] At [7] in her second statement she also refers to some of these symptoms.
[4] ARD p 9.
In neither of her statements does she refer to her prior medical history.
Dee Why Family Medical Centre
Records from the Dee Why Medical Centre commence from 3 April 2012 when Dr Valanju records Ms Florance having lethargy, malaise, chest pain, palpitations, vomiting and diarrhoea. On 25 August 2012 there is a record of diarrhoea explosion, pelvic pain, bloated with a temperature of 35.6. Fasigyn tablets were prescribed. On 23 October 2012 the doctor records the presence of gastro-oesophageal reflux disease ( GORD) and prescribes Nexium tablets and issued a referral to Dr Jamal Merei.[5] GORD is mentioned again on 5 November 2012. On 10 November 2012 it is recorded Ms Florance presented with anxiety due to work condition DASS anxiety and stress and a referral was given to Ms Charlotte Leung. On 11 November 2012 GORD, right disc degeneration, stress and counselled is recorded.
[5] ARD p 76.
On 20 November 2012 psychologist Julia Evecek has recorded in the clinical notes that Ms Florance attended with symptoms consistent with acute stress disorder due to workplace difficulties. On 26 November 2012 Dr Merei’s report to Dr Valanju is set out in the clinical notes in relation to her reflux symptoms as well as upper abdominal pain, fullness and bloating with occasional vomiting. He says she is taking Nexium 40mg once per day and uses NSAID (non-steroid anti-inflammatory drugs) to control neck pain. The doctor was to arrange an upper abdominal ultrasound to rule out gall stones.[6] On 6 December 2012 Dr Raju recorded that the ultrasound was normal and recommended bland food and a breath test. The helicobacter breath test was done on 21 December 2012. Throughout 2012 Ms Florance was also reporting of a variety of musculoskeletal symptoms.
[6] ARD p 78.
Throughout 2013 Ms Florance continued to experience symptoms of GORD and was prescribed Nexium. Diarrhea was recorded on 12 October 2013[7] and on 16 February 2014, the latter due to gastroenteritis.[8] On 21 March 2014 diarrhea is recorded. During 2014 she continued to be treated with Nexium for GORD symptoms. On 11 March 2015 she reported diarrhoea, abdominal cramps with the diagnosis made of gastroenteritis. On 14 July 2015 it is recorded that she had been actively trying to lose weight having been 80kg previously and now was 69.7kg.[9] On 28 November 2015 it is recorded she had diarrhoea overnight with no nausea or abdominal pain and she wanted a certificate for work.
[7] ARD p 86.
[8] ARD p 89.
[9] ARD p 93.
On 17 February 2016 it is recorded that she had recent stressors at work and in her personal life and a friend had recommended she see a psychologist. The psychologist Adena Silverstein recorded in the clinical notes about the stresses at work.[10] Further sessions are recorded on 9 and 23 March 2016 and 16 and 30 April 2016.[11] On 3 May 2016 Dr Gunasekera records details of her psychological issues and that she has increasing anxiety and loss of sleep and weight loss. She is now 50kg. On 16 May 2016 it is recorded that she had diarrhoea on the weekend, palpitations and chest pain and she was tearful. She was prescribed Alprax which is to treat anxiety.[12] This is the only record of diarrhoea in 2016 in these clinical notes which include details of seven sessions with psychologist Ben Gleeson.
[10] ARD p 95.
[11] ARD p 96.
[12] ARD p 99.
On 27 January 2017 Dr Gunasekera records that she has been having diarrhoea up to four times a day in the morning which she felt would interfere with a job. He suggested she try Imodium and he referred her to a gastroenterologist.
On 28 April 2017 the psychologist, Ben Gleeson, has written in the clinical notes that Ms Florance attended for her 30th session under the workcover arrangement and she was treated by CBT (cognitive behaviour therapy). She reported improved mood however continued to suffer with anxiety on the day of her rehabilitation appointments. He recorded, “She reported panic and gastro issues yesterday leading up to the appointment…”[13]
[13] ARD p 119.
On 23 May 2017 the doctor records that Ms Florance has intermittent diarrhoea and he queried irritable bowel syndrome (IBS) and notes she had poorly controlled bowel action and she had not completed the investigations he arranged previously and he again referred her for faecal testing.[14] Thereafter, various consultations are recorded and on 13 September 2017 Dr Gunasekera noted she was due to return to gastroenterologist to commence prophylactic therapy.[15] On 13 October 2017 Ben Gleeson recorded that she was taking medication to reduce stomach inflammation and it was helping.[16] On 20 October 2017 Ms Florance attended volunteer work and it is recorded that she felt and fatigue and diarrhea were worse due to the increased days.
[14] ARD p 121
[15] ARD p 129.
[16] ARD p 131.
Ms Florance had a consultation with a dietician at the practice on 14 November 2017. Her BMI (body mass index) was 18.5 with a weight of 51.5kg. In the notes there is mention of workplace bullying in 2016 with work stress exacerbating her diarrhea. A diagnosis was made of malnutrition related to anorexia and diarrhea secondary to ulcerative colitis. It was noted she had suboptimal food and protein intake.[17] There are many more entries up to the start of 2019 and reference to an attempt by Ms Florance to gain admission to the Northside Clinic for the treatment of anxiety but it was declined due to her low weight.[18]
[17] ARD pp 136-137.
[18] ARD p 148.
Dr Deepal Gunasekera provided a lengthy undated handwritten report to Ms Florance’s solicitors.[19] He refers to Ms Florance suffering from diarrhea and abdominal pain in the context of suffering stress at work.
[19] ARD p 56.
Dr Leach
Ms Florance has been treated by Dr Margaret Leach, gastroenterologist, who reported to Dr Gunasekera on 11 September 2017 that Ms Florance had a history of severe daytime diarrhea. A colonoscopy revealed a minor active colitis. She had a history of a hiatus hernia, asthma and anxiety. The medications she was taking at the time included Alprazolam, Eleva, fish oil, Imodium, Nexium EC, Panadol and Zoloft. She failed to make a follow up appointment to discuss management of her diarrhea.[20]
[20] ARD p 181.
In the report dated 18 December 2017[21] the doctor advised that “brain gut interactions are no doubt playing a role however she had proven colitis at colonoscopy and has ongoing raised inflammatory markers and iron deficiency- the latter no doubt a mixture of inflammation and nutritional etiology.” The doctor provided her advice about the treatment of the ongoing diarrhea.
[21] ARD p 55.
On 5 March 2020 Dr Leach reported to Dr Gunasekera that Ms Florance was having persistent diarrhea.[22] The doctor arranged for a colonoscopy to be performed.
[22] ARD p 162.
In the report dated 2 April 2020 Dr Leach advises Dr Gunasekera that Ms Florance had mild peripheral eosinophilia, which she explained can be associated with asthma, sinusitis, allergies, parasites, and worms. The doctor thought it was possible her diarrheal reaction may be related to food intolerances. Her colonoscopy was normal except for the removal of a polyp.[23]
[23] ARD p 153.
In the report dated 1 June 2020 Dr Leach reported that diarrhea is still an issue and that Ms Florance continued to be stressed and anxious. Dr Leach advises that stress management is paramount.[24]
[24] ARD p 152.
Dr Leach does not express an opinion whether her gastrointestinal symptoms are as a consequence of her workplace psychological injury.
Osana Medical Centre
On 12 February 2020 Dr Marco Doherty of Osana Medical Centre referred Ms Florance to Jennifer Rathjen for ongoing management of severe anxiety and PTSD with mood deterioration due to ongoing issues with her neighbour. Her past medical history was listed as including:
“colitis/IBS- Dr Margaret Leach, gastro; considering prednisone.
Hiatus hernia
C5/6 early degenerative changes
Exercise -induced asthma
2005 LLETZ procedure
Annual CST
FHx
Crohns
…
Stomach cancer- uncles.”[25]
[25] ARD p 204.
A clinical note on 19 February 2020 refers to her anxiety being dramatically increased due to bullying by a neighbour. There are various other entries including on 1 July 2020 which refers to her anxiety being more severe and that she was very stressed with her neighbour and strata. It is recorded she was taking Nexium which helped but she still had diarrhea, nausea and vomiting.[26] There are also detailed clinical notes about consultations in 2019 dealing with her psychological condition.
[26] ARD p 223.
Dr Greenberg
Dr Greenberg, general and gastrointestinal surgeon, provided Ms Florance’s solicitors with a medico-legal report dated 27 April 2021.[27] He listed her medications as Axit, Alepam and Circadian for sleep. He stated that she had no past history of gastrointestinal problems. He took a clinical history that Ms Florance current symptoms main relate to her lower gastrointestinal tract with chronic diarrhea. He also noted that she has persisting nausea, her stomach churns and she dry retches and projectile vomits.
[27] ARD p 23.
Dr Greenberg’s examination was conducted by video. He noted that Dr Leach had performed a colonoscopy on 1 April 2020 which apart from a polyp, that was removed, was essentially normal. It was noted that Dr Leach found no organic pathology to explain why Ms Florance had persisting diarrhea. Dr Greenberg referred to Dr Rastogi’s opinion that Ms Florance suffers from a post-traumatic stress disorder and anxiety.
Despite referring in the early part of his report to Ms Florance having symptoms relating to her lower gastrointestinal tract, Dr Greenberg assessed permanent impairment of the upper gastrointestinal tract of 3%. Under the heading “opinion” Dr Greenberg expresses his opinion that her symptoms are consistent with an intestinal motility disorder which is consequential to her mental health issues. He explains this phrase applies to abnormal intestinal contractions such as spasms and intestinal paralysis and is used to describe a variety of disorders in which the gut has lost its ability to coordinate muscular activity because of endogenous or exogenous causes. Dr Greenberg stated that “it is recognised that chronic anxiety stress and mood disturbance are associated with a chronic bowel dysfunction and consistent with the symptoms as described by Ms Florance.”
Dr Greenberg says he could not find an equivalent condition in “AMA5 or the WorkCover Guides”. He cites section 1.59 page 10 of the Guides (sic) to permit an assessor to select an analogous condition if no similar match can be found. The correct reference is chapter 1.23 page 5 of the NSW Workers Compensation Guidelines for the Evaluation of Permanent Impairment-fourth edition.
Dr Greenberg provided a supplementary report dated 15 May 2023 in which he answered a series of questions. He advised that he was not aware whether Ms Florance had a hiatus hernia or gastro-oesophageal reflux disease prior to her work injury. He also advised that Ms Florance’s mother’s diagnosis of bowel cancer is unrelated to her symptoms. Dr Greenberg was given a copy of Dr Sethi’s report and he states that he disagrees with his conclusions.
Dr Sethi
Dr Sethi, gastroenterologist and hepatologist, provided a medico-legal report for the respondent dated 11 February 2022.[28] He has a history that Ms Florance first developed gastrointestinal symptoms in December 2015 with reflux and Nexium was prescribed for this. He states this was associated with nausea and dry retching occurring several times a day. Dr Sethi also records a history of prominent bloating, excess gas with sharp abdominal pains and diarrhea with some fecal urgency. He records a past history as including a hiatus hernia. He notes she is taking Mirtazapine, Nexium and Syquet. He records he conducted a telehealth consultation with Ms Florance and so, like Dr Greenberg, did not physically examine Ms Florance.
[28] ARD p 63.
Dr Sethi expresses the opinion that Ms Florance has developed gastro-oesophageal reflux disease (GORD) and irritable bowel syndrome (IBS). He explains that her description of retrosternal burning sensation, nausea and dry retching are strongly suggestive of GORD, which is caused by laxity of the gastro-oesophageal sphincter valve and a common condition affecting 15-20% of the population. He notes that the past history of hiatus hernia is considered in the medical literature to contribute to the development of GORD.
The doctor also explained that the symptoms of bloating, excess gas, diarrhea, and fecal urgency are strongly suggestive of IBS, which he states is caused by visceral hypersensitivity of the gastrointestinal tract and is a common condition experienced by 15-20% of the general population. Dr Sethi opines that psychological distress, anxiety and mental health do not cause either GORD or IBS. He also states that the medication she has been prescribed has not contributed to these conditions. Dr Sethi is of the view that Ms Florance does not suffer work-related gastro-intestinal conditions.
In addition, Dr Sethi finds that the impairment of the gastro-intestinal tract is 0% with reference to the AMA 5 Guides. In relation to Dr Greenberg’s assessment he says that doctor has not followed the SIRA guidelines which clearly state that patients with only symptoms and no signs should be rated at 0% impairment. He says Dr Greenberg’s opinion about causation being as a result of her psychological injury is speculative as any such association has never been conclusively proved in clinical trials.
Submissions
Mr Carney made concise submissions relying on Ms Florance’s statements that she in fact suffers from gastrointestinal symptoms and also to the evidence in her treating doctors’ records. He also relied upon the medico-legal opinion of Dr Greenberg.
Mr Carney submitted that Ms Florance in her statement sets out her psychological symptoms and that she has had to deal with a range of physical symptoms including vomiting, constant diarrhoea, and stomach pains.
He referred to the clinical notes from the treating general practitioner and that there had been a referral to Dr Leach. He submitted there were only a few references to her gastrointestinal conditions in the clinical notes and gave as an example the reference on 28 April 2017. Mr Carney also submitted that Dr Leach in 2020 found that diarrhea was still an issue and that Ms Florance continued to be stressed and anxious with Dr Leach advising that stress management is paramount.
Mr Carney also recited the contents of the reports from Dr Greenberg including his reference to the fact that Ms Florance has a severe anxiety disorder and that her symptoms are consistent with intestinal motility disorder and are as a consequence of her psychological issues.
Mr Carney referred to Dr Sethi ‘s report and submitted that the symptoms he records such as bloating would be inconsistent with a finding of GORD and IBS. He submits the proximal cause of her gastrointestinal symptoms is the stress which Dr Leach has mentioned. He said the symptoms came on in the manner they did after the psychological injury and while there is mention in the notes of the earlier diarrhea that seems to have been a plain sort of diarrhea.
Mr Baran submitted that Ms Florance’s counsel only referred to the clinical notes from about 2017. Mr Baran argued that the clinical records show that Ms Florance has had gastrointestinal symptoms going back as far as 2012 involving bloating, diarrhea explosion, and gastrointestinal reflux disease (GORD). He noted she was prescribed Nexium and referred to Dr Merei, gastroenterologist, from whom no report is before the Commission, although there appears to be an entry in the clinical notes from that doctor in November 2012.
He submitted that these clinical notes do not support that there is a causal connection with the work injury and the gastrointestinal symptoms, because she has had those symptoms for so long.
Mr Baran further submits that Dr Greenberg, despite having the clinical notes, states that Ms Florance has no past history of gastrointestinal issues and Mr Baran argues this is not correct and, therefore, that no weight should be given to his opinion.
Mr Baran relies on Dr Sethi’s opinion and submits it should be accepted that Ms Florance’s gastrointestinal issues have been pre-existing and her symptoms are strongly suggestive of IBS and GORD and there is no causal connection to her psychological injury.
I find the respondent’s submissions are persuasive. I find I cannot accept the opinion of Dr Greenberg when he has not considered in any detailed manner the entire clinical notes which are before the Commission. I find it is abundantly clear from those notes that Ms Florance was diagnosed with GORD well before her psychological injury. It also seems that she suffered from a hiatus hernia and Dr Leach was concerned about whether food intolerances were causing her symptoms. Because Dr Greenberg has not considered this evidence and provided a detailed opinion about such evidence, I find I do not have confidence in the conclusions he has reached.
Dr Greenberg referred to symptoms such as nausea, stomach churning, dry retching and vomiting. I find from the clinical notes coupled with Dr Sethi’s opinion that it is more likely than not on the balance of probabilities that such symptoms are due to her GORD illness for which she has been treated with Nexium for many years. I prefer Dr Sethi’s opinion to that of Dr Greenberg because it is more detailed and he has details of Ms Florance’s earlier medical history.
While Dr Leach has referred to Mr Florance having stress, she has not provided an opinion relating to the issue in dispute and I find this is a significant omission in Ms Florance’s case, particularly as the doctor was concerned about food intolerances perhaps being causative and conditions such as colitis. I find Ms Florance has a complicated medical history and it is necessary for that to be considered rather than a “broad brush” approach taken, as seems to be Dr Greenberg’s approach.
I am not satisfied that on the evidence before the Commission that Ms Florance has discharged her onus of proof that the gastrointestinal conditions of which she has suffered are causally a result of her primary psychological injury.
Application of s 65A
However, in the event I am incorrect in the finding set out above, I will briefly consider the second issue as to whether she can aggregate for the purposes of a lump sum claim the impairment from a primary psychological injury and consequential physical conditions. There have been several decisions by Commission members finding there can be no such aggregation such as in Bell v The Mining Pty Ltd[29] and Judge v Workforce International (Office Services) Pty Ltd[30] and Tagicaki v Everwilling Cranes Pty Limited.[31] I agree with the determinations in those matters that aggregation is not permitted in this situation. I understand that the decision in Bell has been appealed, however it has not yet been determined and I consider I should not further delay in issuing my reasons in this matter, given the finding I have reached about the gastrointestinal condition.
[29] [2023] NSWPIC 295, Bell.
[30] [2023] NSWPIC 440, Judge.
[31] [2022] NSWPIC 203, Tagicaki.
In Bell, Member Homan at [55] referred to the decision of Keating P in NSW Police Service v Snape[32] as lending support for the conclusion that a worker who had sustained a primary psychological injury and a consequential physical condition (in that case the onset of diabetes) could not obtain lump sum compensation for both.
[32] [2008] NSWWCCPD 89, Snape.
Mr Carney said it is clear from s 65A(5) that a secondary psychological injury cannot be compensated. It was submitted that s 65A does not deal with a “secondary physical condition”. He referred to Tagicaki and acknowledged that it referred to an applicant only being able to be compensated for one injury, but not both for a psychological and physical injury. Mr Carney referred to the cases about consequential conditions, that s 4 injury test is not relevant and the test is that in Kooragang. He submitted that a consequential condition is not an “injury” and s 65A(3) deals with a physical injury and a psychiatric injury, so two s 4 injuries arising out of one incident means you can only be compensated for one of those injuries. It was submitted that Ms Florance’s situation is very different because she only has only one injury, being the psychological injury and because of that injury she has physical gastrointestinal symptoms and so s 65A does not preclude this.
Mr Carney’s submissions are similar to that considered and rejected in Bell and Judge.
Mr Baran submit the legislation is clear, that s 65A qualifies s 66 and the cases referred to support the proposition that a physical injury arising out of the same incident cannot be compensated together with a primary psychological injury.
While the decision in Bell is not binding on me, I consider it is correct and the same outcome was reached in Judge and Tagicaki. There is an unreported decision in the case of Buckland v Judicial Commission of NSW 4528/20 in which an Amended Certificate of Determination was issued on 18 December 2020 by Arbitrator Wynyard. He accepted a similar argument that was rejected in Bell, that a consequential physical condition results from a primary psychological injury is not an “injury” under s 4 of the 1987 Act and that s 65A only disentitles second psychological injuries not secondary physical conditions. However, with respect to my colleague, I prefer the reasoning in Bell, Judge and Tagicaki.
In Judge the applicant could not receive lump sum compensation for both her psychological and physical impairments and had to choose the greater entitlement. Ms Florance’s claim in respect to the gastrointestinal symptoms is only for 3% WPI. So if I had found she had a gastrointestinal condition as a result of her psychological injury, she would not have been entitled to have that separately assessed because it is below the greater than 10% WPI threshold. Mr Carney’s submissions sought to avoid such an outcome by arguing there could be aggregation of the assessments of psychological and physical, which I have rejected relying on the reasoning in Bell.
In summary, I find that pursuant to s 65A(4) of the 1987 Act, permanent impairment resulting from an applicant’s primary psychological injury cannot be aggregated with any permanent impairment resulting from consequential physical conditions.
0
7
0