Ghoz v Insurance Australia Limited t/as NRMA Insurance

DETERMINATION OF REVIEW PANEL
CITATION:	Ghoz v Insurance Australia Limited t/as NRMA Insurance [2025] NSWPICMP 443
CLAIMANT:	Ghoz
INSURER:	Insurance Australia Limited t/as NRMA Insurance
REVIEW PANEL
MEMBER:	Terence Stern OAM
MEDICAL ASSESSOR:	Dr Christopher Canaris
MEDICAL ASSESSOR:	Dr Matthew Jones
DATE OF DECISION:	23 June 2025
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; review of Medical Assessment Certificate (MAC); claimant suffered psychiatric injury in learning of the death of her son killed in a motor vehicle accident; Medical Assessor determined the claimant’s whole person impairment (WPI) as a result of the accident was 6%; claimant sought a review of the assessment under section 7.26 and the matter was referred to a Review Panel; the Review Panel conducted its own examination and found that WPI as a result of the psychiatric injuries sustained in the accident totalled 8%; MAC revoked; new certificate issued with 8% WPI.
DETERMINATIONS MADE:	CERTIFICATE OF DETERMINATION 1. The Medical Review Panel revokes the determination of Medical Assessor Roberts that Ms Ghoz sustained a 6% whole person impairment for her injuries: · persistent depressive disorder. 2. The Medical Review Panel substitutes its determination that the following injuries caused by the motor accident gave rise to a permanent impairment of 8%: · prolonged grief disorder.

PERSONAL INJURY COMMISSION

MOTOR ACCIDENTS DIVISION

REVIEW OF MEDICAL ASSESSMENT

Matter number:	M21039/24
Claimant:	Rima Ghoz
Insurer:	Insurance Australia Group Limited trading as NRMA Insurance
Review Panel:	Member Terence Stern OAM Medical Assessor Christopher Canaris Medical Assessor Matthew Jones
Date of determination:	23 June 2025

CERTIFICATE OF DETERMINATION

The Medical Review Panel revokes the determination of Medical Assessor Roberts that Ms Ghoz sustained a 6% whole person impairment for her injuries:
· persistent depressive disorder.
The Medical Review Panel substitutes its determination that the following injuries caused by the motor accident gave rise to a permanent impairment of 8%:
· prolonged grief disorder.

STATEMENT OF REASONS

INTRODUCTION

On 7 January 2021, the claimant Rima Ghoz (Ms Ghoz), suffered psychiatric injury as a consequence of her son being killed in a motor vehicle accident whilst she was in Lebanon (the accident).
At the time of the accident, the vehicle which Ms Ghoz alleges caused the collision, was insured by Insurance Australia Group Limited, (NRMA).
Ms Ghoz was assessed by Medical Assessor Samson Roberts (the Medical Assessor) on 24 January 2024, and on 13 February 2024 he certified that Ms Ghoz had a persistent depressive disorder caused by the accident and giving rise to a permanent impairment of 6%.
The claimant has applied for a review of the certificate.
The following injuries were referred by the Personal Injury Commission (Commission) for assessment:
(a)psychological injury (nervous shock);
(b)post-traumatic stress disorder;
(c)depression, and
(d)anxiety.

Review procedure

Ms Ghoz sought a review of the Medical Assessment under s 7.26 of the Motor Accident Injuries Act 2017 (MAI Act) (the Review). The application for referral of a medical assessment to a Review Panel (the Panel) was made by Ms Ghoz within 28 days after the parties were issued with the original certificate for the medical assessment for which the review is sought: s 7.26(10) of the MAI Act.
Clause 14F of Schedule 1 of the Personal Injury Commission Act 2020 (the PIC Act) provides that the new review provisions apply in relation to a decision of a new decision-maker. A “new decision maker” is defined in cl 14A(1) of Schedule 1 of the PIC Act. As the Medical Assessment which is the subject of the Review was made on or after 1 March 2021, the new review provisions apply.
A delegate of the President of the Commission determined there was reasonable cause to suspect that the Medical Assessment was incorrect in a material respect and referred the matter to the Panel.
The President’s delegate has convened this Panel to conduct the review of the Medical Assessment.
Part 5 of the PIC Act enables the Commission to make rules with respect to the practice and procedure before the Commission including proceedings before a panel reviewing a decision of a Medical Assessor: s 41(2) of the PIC Act.
The Review of the medical assessment is not limited to a review of only that aspect of the assessment that is alleged to be incorrect. The Review is by way of a new assessment of all matters with which the medical assessment is concerned: s 7.26(6) of the MAI Act. However, s 7.25 of the MAI Act provides that the review of a medical assessment can be made on the basis of any agreement by the parties as to the degree of permanent impairment from a particular injury and whether a particular injury was caused by the accident, without those matters having to be the subject of assessment.
Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the PIC Act. A review panel determines how it conducts and determines the proceedings and may determine the proceedings solely based on the written application: Rule 128 of the PIC Rules.

STATUTORY PROVISIONS

Permanent impairment

If there is a dispute about whether the degree of permanent impairment of an injured person is sufficient for an award of damages for non-economic loss, damages may not be awarded unless the degree of permanent impairment has been assessed by a Medical Assessor under Division 7.5: s 4.12(1) MAI Act.
The method of assessing the degree of impairment is dealt with in s 7.21, which is in the following terms:
“7.21 Assessment of degree of permanent impairment
(1)     The assessment of the degree of permanent impairment of an injured person for the purposes of this Act is to be made in accordance with the Motor Accident Guidelines. The assessed degree of permanent impairment is to be expressed as a percentage.
(2)     Impairments that result from more than one injury arising out of the same motor accident are to be assessed together to assess the degree of permanent impairment of the injured person.
(3)     In assessing the degree of permanent impairment, regard must not be had to any psychiatric or psychological injury, impairment or symptoms, unless the assessment of the degree of permanent impairment is made solely with respect to the result of a psychiatric or psychological injury.
(4)     A medical assessor may decline to make an assessment of the degree of permanent impairment of an injured person until the assessor is satisfied that the impairment caused by the injury has become permanent.”
Clause 6.35 of the Guidelines states that psychiatric impairment is assessed in accordance with ‘Mental and behavioural disorders’, found in cls 6.201- 6.228 of the Guidelines.

Pre-existing impairment

Pre-existing impairment is addressed in cls 6.31-6.33 as follows:
“Pre-existing impairment
6.31 The evaluation of the permanent impairment may be complicated by the presence of an impairment in the same region that existed before the relevant motor accident. If there is objective evidence of a pre-existing symptomatic permanent impairment in the same region at the time of the accident, then its value must be calculated and subtracted from the current WPI value. If there is no objective evidence of the pre-existing symptomatic permanent impairment, then its possible presence should be ignored.
6.32 The capacity of a medical assessor to determine a change in physical impairment will depend upon the reliability of clinical information on the pre-existing condition. To quote the AMA4 Guides (page 10): 'For example, in apportioning a spine impairment, first the current spine impairment would be estimated, and then impairment from any pre-existing spine problem would be estimated. The estimate for the pre-existing impairment would be subtracted from that for the present impairment to account for the effects of the former. Using this approach to apportionment would require accurate information and data on both impairments.' Refer to clause 6.218 for the approach to a pre-existing psychiatric impairment.
6.33 Pre-existing impairments should not be assessed if they are unrelated or not relevant to the impairment arising from the motor accident.”
Clause 6.35 of the Guidelines states that psychiatric impairment is assessed in accordance with “Mental and behavioural disorders” within the Guidelines, namely cls 6.201-6.228 of the Guidelines.
In order to measure impairment caused by a specific event, a Medical Assessor must, in the case of an injured person with a pre-existing psychiatric diagnosis or diagnosable condition, estimate the overall pre-existing impairment using precisely the method set out in the Guidelines, and subtract this value from the current impairment rating: cl 6.218.

Causation

The Guidelines state as follows with respect to causation of injury:
“Causation of injury
6.5    An assessment of the degree of permanent impairment is a medical assessment matter under clause 2(a) of Schedule 2 of the Act. The assessment must determine the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident. A determination as to whether the injured person's impairment is related to the accident in question is therefore implied in all such assessments. Medical assessors must be aware of the relevant provisions of the AMA4 Guides, as well as the common law principles that would be applied by a court (or the Personal Injury Commission) in considering such issues.
6.6    Causation is defined in the Glossary at page 316 of the AMA4 Guides as follows:
'Causation means that a physical, chemical or biologic factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following:
1.     The alleged factor could have caused or contributed to worsening of the impairment, which is a medical determination.
2.     The alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination.'
This, therefore, involves a medical decision and a non-medical informed judgement.’
6.7    There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be a sole cause as long as it is a contributing cause, which is more than negligible. Considering the question 'Would this injury (or impairment) have occurred if not for the accident?' may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes.”
It is necessary for the Panel to consider whether the accident caused or contributed to the diagnosed psychiatric condition: Briggs v IAG Limited t/a NRMA Insurance [2022] NSWSC 372 at [75]. The motor accident does not have to be the sole cause as long as it is a contributing cause, which is more than negligible: Owen v Motor Accidents Authority of NSW [2012] NSWSC 650 at [50]. Further, the provisions of the Civil Liability Act 2002 apply, in particular s 5D and s 5E.

The accident, admissions to hospital in Lebanon and events on return to Australia

Ms Ghoz confirmed that the date of the accident was 8 January 2021. At the time of the accident, she was in Lebanon and had only been there for 11 hours. She reported that her youngest sister was very sick with autoimmune diseases and that she had obtained permission from the government to travel to see her ill sister during the COVID-19 period.
When asked how Ms Ghoz found out about Adam’s death, she provided a rather complicated narrative of family members telling her various things, including her brother telling her she needed to go back to Australia and that Adam was driving and had an accident with his friends. She thought this was strange as Adam only had his learner’s permit and his friend had his P plates. She was then told that Adam had only broken his arm.
Ms Ghoz travelled to Beirut, asking for government permission to travel back to Australia and at that stage did not know that he was “fighting for his life”. She reported that her husband called her and told her that a driver had pushed Adam and his friend onto a footpath; however, he had only broken his arm. She was not given any extra information. She was being told by her brother to talk to her son and her husband about it.
Ms Ghoz remembered that she was praying for Adam’s wellbeing and had a “squeezing” sensation in her chest, which was painful. She said she had this overwhelming feeling that Adam had died. She reported that she kept wondering why she was having this feeling. Then, her nephew showed her news stories and a video of the accident. She believed maybe her family was trying to protect her as they were not letting her have access to her phone.
Ms Ghoz reported that she eventually found out about the time that Adam died, which was 2.00am (5.00pm Beirut time). She said that in her faith (Islam), there is a rapid burial of the dead and she was unable to farewell him and did not see him before he was buried. The burial occurred the day after his death.
Ms Ghoz ultimately came back to Australia on 20 February 2021, approximately a month after the accident. She commented that she had support in Beirut, including her mother, who had gone through Ms Ghoz’s younger brother passing away previously, and she did not want her mother to be worried.
Prior to coming back to Australia, Ms Ghoz reported that she had three admissions to hospital in Lebanon. She said that four days after the accident, her blood sugar level was very high; she referred to it being “twenty-eight.” She also had problems with feeling numb and having chest pains, and she was told by doctors that she had a 96% risk of stroke. She reported that ultimately, she did have “a stroke” when she came back to Australia.
When initially back in Australia, Ms Ghoz had to enter quarantine, during which she had high sugar levels, “a stroke,” and feelings of numbness. She had to go to hospital regarding these as well. She reported that she had a stroke on 4 January 2022, from which she collapsed and was unable to talk but could hear and see things. She was in hospital for 48 hours and then started talking again. She believed ultimately, she had a transient ischemic attack. She was told by nurses that it was probably due to psychological problems. She had a follow-up assessment with a neurologist who told her she had to accept what had happened and there was nothing that could be done. She reported that she still had problems opening her left eye properly, and she believed that her mouth was crooked. She still had numbness in her face at times. She reported that she was seeing a new neurologist, Dr Robinson, who was “still worried about [her].” She believed that all her medical difficulties were because she kept her problems “inside.” She reported that she never let people see her true emotions.
Ms Ghoz went on to say that she had had no intracranial bleeds and in fact was put on blood-thinning medication. She reported that she had another “stroke” in March 2024 because of high blood pressure, and this time it affected the right side of her body, not her left side. It also affected her jaw.

Bundles of documents

The parties have each presented their respective bundles of documents upon which they rely. The Panel have 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, in much the same manner as parties not referring to or not specifically relying on a document in their own bundle and submissions.
The fact that evidence is not referred to in these reasons does not mean it has been overlooked and nor is it required that each piece of evidence be mentioned (WAEE v Minister for Immigration and Citizenship (2003) 75 ALO 630 at [46]).The Panel is not required to “analyse every piece of information from every opinion contained in a document with which he [it] was provided” – see Farr v Insurance Australia Limited t/as NRMA Insurance Ltd [2014] NSWSC 1435 at [46]. The Panel is to come to its own conclusion and to take its own history.

SUBMISSIONS
Insurer’s submissions of 9 May 2023

I provide a summary of the insurer’s submissions dated 9 May 2023 by way of reference to paragraph numbers:
The accident
[1] The insurer acknowledges the tragic nature of the accident, which it avers occurred on 7 January 2021, not 8 January 2021 as referred to in the claimant’s application. The insurer relies on the NSW Police Report dated 16 June 2021 in support.
The dispute
[2] The insurer does not dispute that the claimant suffered psychological injuries as a result of the accident and accepts that the claimant’s injuries have resulted in some ongoing impairment but submits that any such impairment does not exceed the 10% WPI threshold.
Issues in dispute
[3.1] – [3.3] The insurer refers to [21] of the claimant’s submissions, Ms Ghoz states there was no prior history of psychiatric illness and relies on Dr Rikard-Bell’s diagnosis of Persistent Complex Bereavement Disorder. The insurer does not dispute that diagnosis but submits that it is a non-threshold injury.
[3.4] – [3.6] The insurer refers to [22] of the claimant’s submissions, the claimant claims the injury has had a significant psychological impact and would, if assessed, exceed 10% WPI. The insurer notes that Dr Rikard-Bell did assess the claimant’s WPI and determined it to be 2%. The insurer submits that the claimant cannot selectively rely only on favourable aspects of Dr Rikard-Bell’s report and that there is no evidence that her injury exceeds the threshold.
Medical evidence and supporting material
[3.7] – [3.8] In support of its position, the insurer highlights the following:
(a) – (b)Dr Rikard-Bell assessed the claimant’s WPI at 2% on 25 August 2022 following a review of extensive materials.
The insurer refers to “records from Dr Bassel Hassan as at
5 December 2022 (Claimant’s A10) and clinical records from the Claimant’s GP, Dr Abouzeid at the ForHealth Campsie Medical and Dental Centre as at 17 January 2023 (Claimant’s A11).
In reference to the above records, the insurer submits:
(i)While Dr Abouzeid’s records document grief counselling and psychological symptoms, these were not as frequent or severe as suggested by the claimant.
(ii)Contrary to [18] of the claimant’s submissions, the first recorded prescription of antidepressants (Dothep) was on 24 June 2022, and ceased on 30 September 2022 due to side effects. No further medication was prescribed.
(iii)The claimant attended Liverpool Hospital ED on 23 January 2022 with functional symptoms secondary to psychosocial stress, but this episode resolved.
The insurer submits these records do not support a WPI in excess of 10% and would not materially affect Dr Rikard-Bell’s 2% assessment.
Psychiatric impairment rating scale (PIRS) assessment
(c) With reference to the PIRS, the insurer submits:
(i)Self-care and personal hygiene:
Mr Aboumelhem recorded the claimant as neat and casually dressed. Although she reported forgetting to cook and losing motivation to eat, GP records show minimal weight change (from 90kg in March 2021 to 89kg in October 2022). Dr Rikard-Bell observed mild impairment.
The insurer submits a class 2 impairment is appropriate.
(ii)Social and recreational activities:
The claimant maintained social contact with friends and family.
The insurer submits a class 1 impairment is appropriate.
(iii)Travel:
Although the claimant reported emotional difficulty with travelling, there was no evidence of physical incapacity. She was described as a safe but cautious driver.
The insurer submits a class 2 impairment is appropriate.
(iv)Social functioning:
Both treating psychologist and psychiatrist noted strained family relationships.
The insurer submits a class 2 impairment is appropriate.
(v)Concentration, persistence and pace:
Forgetfulness and distraction were noted in multiple reports, but these resulted only in mild impairment.
The insurer submits a class 2 impairment is appropriate.
(vi)Adaptation:
The claimant resumed teaching Arabic post-accident and later undertook paid part-time work. Despite discrepancies in her employment history, Dr Rikard-Bell recorded class 2 impairment. The insurer submits that continuing work at or above pre-accident levels indicates no impairment.
The insurer submits a class 1 impairment is appropriate.

Insurer’s submissions of 5 April 2024

I provide a summary of the insurer’s submissions dated 5 April 2024 by way of reference to paragraph numbers:

Error 1 - Failure to provide adequate or sufficient reasoning

[2.1] – [2.3] At [8.a] of the claimant’s submissions, she alleges that the Medical Assessor failed to provide adequate reasoning. The insurer submits that the Medical Assessor clearly stated his diagnosis, causation findings, and reasons at [18] – [19] of the Certificate and there was no failure to provide extensive reasoning.
[2.4] At [17]–[35] of the claimant’s submissions, the claimant outlines factual disagreements and alternative explanations, many of which, the insurer submits, are not based on the material before the Medical Assessor.

[2.5] – [2.6] The insurer submits the claimant particularly disagrees with the Medical Assessor’s finding that her deterioration in functioning was substantially affected by the prescription of THC in medicinal marijuana. The insurer submits the claimant’s alternative theories (e.g., cultural and familial stressors) were not put before the Medical Assessor at the time and are raised for the first time on review.
[2.7] – [2.9] The insurer submits that disagreement with the Medical Assessor’s clinical reasoning does not make those reasons inadequate and contends that the Medical Assessor exercised sound clinical judgment and the claimant’s alternate theories or facts should have been disclosed during the assessment process.
[2.10] The insurer submits there is no error on this ground.

Error 2 - Failure to take a detailed history from the claimant

[2.11] – [2.12] The claimant alleges at [8.b] of her submissions that the Medical Assessor failed to take a detailed history. The insurer submits that pages 3–6 of the Certificate are dedicated to the claimant’s detailed history.
[2.13] The insurer submits the claimant had the opportunity to raise relevant factors, including any familial psychological effects or cultural stressors on her statement or at the examination, but did not do so.
[2.14] The Medical Assessor noted at page 5, section 10 of the Certificate that the claimant’s account “did not permit clarity regarding the evolution of her symptoms” and that “her mental state has remained consistent since the motor accident.”
[2.15] – [2.16] The insurer submits it is not the role of the Medical Assessor to cross-examine the claimant or hypothesise unmentioned causes, particularly where a clear medical explanation (THC use) was available and the failure to report cultural or familial issues during the assessment is not attributable to any failing on the part of the Medical Assessor.
[2.17] – [2.18] The insurer contends that criticisms based on hindsight are improper and that the claimant had full opportunity to raise all relevant matters at the time of assessment. The insurer submits there is no error on this ground.

Error 3 - Failure to consider the claimant as an individual, and the facts and circumstances of the case

[2.19] – [2.20] At [8.c], the claimant alleges the Medical Assessor failed to consider her as an individual and account for the facts and circumstances of her case. At [26]–[30] of her submissions, the claimant references cultural expectations and her family’s psychological conditions.
[2.21] – [2.22] The insurer submits that none of this information was provided during the examination or in the materials accompanying the assessment, and the Medical Assessor or therefore cannot be faulted for failing to consider it. The insurer submits there is no error on this ground.

Error 4 - The finding of a discrepancy by the Medical Assessor where the claimant says none exists

[2.23] At [9] – [13] of her submissions, the claimant submits that the Medical Assessor incorrectly found a discrepancy between the severity of her condition and her reported impairment level.
[2.24] – [2.25] The insurer submits the list of similarities at [11] of the claimant’s submissions provides the histories given to Dr Rikard-Bell and Medical Assessor Roberts were similar. The insurer submits the claimant’s quotation from paragraph 16 of the certificate is incomplete and misrepresents the Medical Assessor’s findings.
[2.26] The insurer highlights that the Medical Assessor began that paragraph by stating: “No overt inconsistencies were apparent with respect to her account,” before noting a discrepancy in functioning compared to earlier assessments.
[2.27] – [2.29] The insurer submits that there were genuine changes in functioning, particularly regarding employment and social activity, between the time of
Dr Rikard-Bell’s report and the Medical Assessor’s own assessment 17 months later. The insurer submits such differences over time are not the kind of inconsistency that requires being put to the claimant for clarification and there is no error on this ground.

Error 5 - The failure of the Medical Assessor to put any alleged inconsistency or discrepancy to the claimant

[2.30] At [14]–[16] of her submissions, the claimant alleges that the Medical Assessor failed to raise inconsistencies with her during the assessment.
[2.31] The insurer reiterates that the Medical Assessor expressly noted there were no “overt inconsistencies,” which is why he did not raise any.
[2.32] The insurer refers to the certificate (page 5, section 10) where the Medical Assessor stated that the claimant’s account “did not permit clarity regarding the evolution of her symptoms” and that he ultimately formed the impression that her mental state had remained consistent.
[2.33] The insurer submits that to the extent possible, the Medical Assessor explored symptom evolution and reached a reasonable conclusion that functioning had changed while mental state remained stable.
[2.34] The insurer submits there is no error on this ground.
Claimant’s submissions of 14 March 2024

I provide a summary of the claimant’s submissions dated 14 March 2024 by way of reference to paragraph numbers:
Introduction
[1] The claimant seeks review of Medical Assessor Samson Roberts’ Certificate dated 13 February 2024, provided on 16 February 2024.
[2] The claimant submits that on 8 January 2018, her son was walking on a footpath when the insured driver swerved off the road, crossed three lanes of traffic and struck him.
[3] The claimant's son passed away from his injuries two days later in hospital.
[4] The claimant brings a claim for nervous shock.
Basis for review
[8] The claimant submits that Medical Assessor Roberts made material errors, namely:
(a) failure to provide adequate or sufficient reasoning;
(b) failure to take a detailed history, and
(c) failure to consider the claimant individually, in light of the case’s facts and circumstances.
Substantive submissions
[9] At paragraph 16 of the certificate, the Medical Assessor stated there was a “discrepancy between the apparent severity of her condition and her reported level of impairment,” compared to the report of Dr Christopher Rikard-Bell.
[10] The claimant submits there is no such discrepancy, and that her symptoms have remained consistent and ongoing.
[11] A table is included in the submissions comparing symptoms reported to Dr Bell in August 2022 and those reported to Medical Assessor Roberts in January 2024, demonstrating substantial consistency.

[12] – [13] The claimant submits that her presentation and the nature of her symptoms have remained consistent and the Medical Assessor’s reliance on a perceived discrepancy is a material error warranting review.

Failure to address alleged inconsistencies

[14] – [18] The claimant submits that if the Medical Assessor believed a discrepancy existed, he was required to raise it with her during the assessment. The claimant submits that the Medical Assessor relied on generalisations and assumptions, such as paragraph 18 of the certificate, particularly attributing the discrepancy to her use of medicinal cannabis oil.
[19] The claimant references Dr Rikard-Bell who assessed the claimant before she started using THC and, as no other adverse events were reported, it was appropriate to attribute her deterioration to THC use.

[20] – [23]The claimant submits that the Medical Assessor made a conclusive finding solely based on her use of cannabis oil and that this conclusion was made without giving her an opportunity to respond to or explain any inconsistencies. The claimant submits the Medical Assessor did not obtain any relevant history regarding her use of cannabis oil and it was insufficient for the Medical Assessor to draw a major conclusion without properly investigating the circumstances and providing adequate reasoning.

Failure to consider individual circumstances

[24] – [25]The claimant quotes paragraph 19 of the certificate, where the Medical Assessor stated that the usual natural course of a psychiatric condition following trauma is one of improvement, not deterioration. The claimant submits that the Medical Assessor failed to consider the claimant’s individual experience and reaction to the trauma.
[26] – [27] The claimant submits the Medical Assessor failed to take into account the claimant’s background and cultural expectations as a wife and mother. The claimant submits that this was not an isolated trauma, but one shared by her husband and two other children, who also suffered psychological harm.
[28] – [30] The claimant submits that she comes from a cultural background where, despite personal grief, she is expected to prioritise her family's needs. The claimant states the Medical Assessor did not consider the pressure to support and care for her family.
[31] – [32] The claimant submits that her capacity to deal with the trauma has diminished over time, and the “natural course” theory relied on by the Medical Assessor is inapplicable in her case and should not have been used to discount her presentation.
[33] – [34] The claimant submits that the Medical Assessor failed to consider the full context of the accident and assessed her in generic terms rather than as an individual. The claimant submits that, had the Medical Assessor done so, he may have identified alternative explanations for her deterioration rather than making assumptions based on cannabis oil use.

The claimant submits that the Medical Assessor’s conclusions were not supported by adequate reasoning and were based on assumptions and generalisations, not her actual clinical presentation and history.

Claimant’s submissions of 11 April 2024

I provide a summary of the claimant’s submissions dated 14 March 2024 by way of reference to paragraph numbers. The submissions regarding introduction, procedural history, jurisdiction and issues in dispute have been omitted to avoid repetition to the submissions of 14 March 2024.
Psychological injuries
[14] The claimant refers to the Certificate of Capacity dated 5 May 2021, which identifies “adjustment disorder, depression (traumatic loss of family member)” as resulting from the subject accident.
[15] The claimant cites an email dated 17 November 2021 from Mr Dany Aboumelhem to NRMA, which states that the claimant meets the diagnostic criteria for Major Depressive Disorder (MDD), although not enough time had passed to confirm Prolonged Grief Disorder (PGD). The email records that the claimant’s symptoms are constant, worsen during the day, and are always present.
[16] The claimant seeks to rely on clinical notes from Southwest Wellness Centre, which document her fear of further tragedy, difficulty concentrating, social withdrawal, and forgetfulness. In a consultation on 9 December 2021, she was noted to suffer from severe emotional distress related to her son’s graduation.
[17] In a consultation on 28 February 2022, it was recorded that the claimant felt things were “getting harder and harder” and she became emotional simply hearing her son’s name.
[18] Notes from several consultations at MyHealth Medical & Dental Centres refer repeatedly to the claimant’s severe grief and reliance on antidepressants.
[19] In her statement dated 19 July 2022, the claimant describes feelings of isolation, difficulty concentrating, emotional withdrawal from family members, and being easily triggered by trauma-related reminders. School events such as HSC and graduation had a particularly severe psychological impact, preventing her from engaging in recreational activities.
[20] The claimant relies on a psychiatric report by Dr Christopher Rikard-Bell dated
25 August 2022, which records her emotional difficulty managing the loss of her son, disturbed sleep due to recurrent dreams, and a strong sense of pain and disconnection. He writes that she “feels like she has been stabbed in the chest” and suffers from “a constant longing and sorrow.”
[21] Dr Rikard-Bell confirmed that the claimant had no history of anxiety or depression requiring psychiatric intervention prior to the accident. He stated that her psychiatric condition had stabilised and diagnosed her with Persistent Complex Bereavement Disorder, based on the traumatic death of her son and her ongoing symptoms of sorrow, numbness, and emotional disinhibition.
[22] The claimant submits that the psychological injuries and resulting psychiatric condition caused by the accident have had a significant impact on her life, and that her condition would, if assessed, result in a WPI of over 10%.
[25] The claimant seeks to recover the maximum regulated costs applicable to this application.

ASSESSMENT UNDER REVIEW
Background

Medical Assessor Roberts took a psycho-social and pre-accident history [8].
Ms Ghoz was previously a high school teacher, resuming teaching for one year after the accident as a primary school teacher for 20 hours a week, teaching English and Arabic to non-Arabs.
Ms Ghoz grew up in Lebanon, the eldest of five siblings.
Ms Ghoz completed high school and obtained two bachelors degrees, studying journalism and becoming an English language teacher and a teacher of Arabic.
She left Lebanon in 1997, after marriage. Her children being born in Australia.
Her mother and siblings remain in Lebanon and call her around two or three times a week.
Ms Ghoz told the Medical Assessor that she had been chased by dogs before the accident and for four years she did not go to the shops.

History of symptoms and treatment following the accident

Medical Assessor Roberts provided a history symptoms and treatment of Ms Ghoz at [10]:
“Ms Ghoz’s account did not permit clarity regarding the evolution of her symptoms and ultimately the impression was derived that her mental state has remained consistent since the motor accident notwithstanding the impression derived from the documents. Her account of her experience is presented below.”

Current symptoms

Medical Assessor Roberts outlined the current symptoms of Ms Ghoz at [12]:
“As stated above, Ms Ghoz presented a disorganised account of the course of her psychiatric symptoms. She stated that she used to be very sociable, she used to manage the home and her children and was always in control. Since her son’s death, she had become forgetful and withdrawn such that she avoids engaging with people. She stated that her children worry about her.
Ms Ghoz stated that she would be unable to pursue any further study because of her impaired concentration. She also stated fear of failure. She added incongruently that when her daughter finished her degree, she did not inform Ms Ghoz of her results. She received this information from her husband. Ms Ghoz recalled her concern that her daughter was not happier than she appeared to be.
Ms Ghoz’s account reflected anhedonia. She described diminished energy and stated that she does not feel strong. When she feels severely depressed, she may sleep for 18 hours but typically sleeps for only three to four hours. She did not report an adverse temper. She did not report irritability or impatience. She reiterated however that she is forgetful such that she even forgets to eat. She wants the days to pass and she looks forward to the end of each day.
Ms Ghoz spoke of episodes of numbness and weakness on her left side. She has been hospitalised in this context but no pathology has been identified. She stated that her symptoms have been attributed to her psychological state. She acknowledged that she worries more than she should. She stated, ‘When I hug Tarik (her surviving son), I say, ‘I hope it’s not the last one’’. She experiences a sense of relief when she hears her children returning home. She is scared to visit her mother in Lebanon again fearing that something similar could happen to her children while she is away.
Ms Ghoz recalled attending Court proceedings relating to her son’s death. Although she did not know the driver, he was familiar to her from the local area. She recalled that the side of her face drooped after attending the Court case.”

Current and proposed treatment

Medical Assessor Roberts outlined the current and proposed treatment of Ms Ghoz at [13]:
“Ms Ghoz is prescribed Ozempic, Trajenta, Apixaban and Tramadol. She is also prescribed cannabis oil products namely NovT80/800 and Cirrus T800.
Ms Ghoz did not report a history of alcohol use or cigarette smoking. She did not report a history of illicit substance use. When asked regarding her past psychiatric history, she replied that she has been scared of animals since a young age. Her father’s sister owned cats. The family sought to address Ms Ghoz’s fear of animals. She spoke of one of the cats however jumping on her and scratching her face and neck such that she required stitches.
Ms Ghoz was referred to a psychologist by her general practitioner but has not remained under the care of a psychologist. She stated that she was on the antidepressant Dothep (dothiepin) approximately one year ago.”

Clinical examination

Medical Assessor Roberts outlined the clinical examination of Ms Ghoz at [14]:
“Ms Ghoz was teary during the course of the interview and described a pervasively depressed mood. She acknowledged a tendency to reflect on Adam and the way he died. She expressed anxiety regarding the safety of her children. She presented her account in a mildly disorganised manner and at times appeared to have difficulty articulating the nature of her emotional experience. Clinical examination – start with Ms Ghoz was teary & described a pervasively depressed mood. She acknowledged the tendency to reflect on Adam & include next sentence.”

Current functioning

Medical Assessor Roberts outlined the current functioning of Ms Ghoz at [15]:
“As stated above, Ms Ghoz resumed teaching primary school following the motor accident while prior to the motor accident she taught high school. She continued teaching for one year stating that she could not persist due to neck symptoms.
When asked how she currently spends her time, Ms Ghoz replied that she empties the dishwasher. Otherwise, she makes plans to do things but does not follow it through. She spoke of going to Coles to purchase items and by way of example of her forgetfulness, spoke of an instance when she went to Coles three times to buy rice and ultimately came home with none. Her concentration is compromised. She does not reliably attend to household tasks. She might write a list of tasks but then she fails to look at it.
With respect to her relationship with her two surviving children, Ms Ghoz stated, ‘I’m everything for them.’ She stated that they worry about her and she reiterated that she is anxious about them. She stated that her relationship with her husband is poor but she did not provide further details and could not explain why their relationship is such. She recalled that her friends were initially supportive of her but now only two of her friends remain supportive.
Ms Ghoz acknowledged that she is not looking after her personal care. She has become indifferent in this regard. She showers less frequently. She will however attend her general practitioner if necessary.
Ms Ghoz stated that she is an anxious driver. Because she is on cannabis oil, she will only drive early in the morning when there is no one on the road. She prefers to be driven.
When asked further how she passes her days, Ms Ghoz replied that typically the television is on but she is not watching it properly. She expressed concern about the extent to which her concentration is compromised. She spoke of having lost interest in her garden.”

Review of documentation

The Medical Assessor summarised the relevant documentation at [17].
He referred to material from a psychologist Danny Aboumelhem who on
17 November 2021, stated his patient did meet the diagnostic criteria for major depressive disorder.
He refers to the report of Dr Christopher Rikard-Bell dated 25 August 2022, who documented an absence of a past history of anxiety or depression, although he noted some depression following the death of her father. He referred to the history of a minor stroke in early 2022.
Dr Rickard-Bell diagnosed a persistent complex bereavement disorder and calculated whole person impairment (WPI) of 2%.
The Medical Assessor referred to correspondence from Dr Bassel Hassan of
7 March 2022. He diagnosed “functional/psychogenic” condition.
The clinical nots of Campsie Medical and Dental Centre were reviewed by the Medical Assessor. A mental state examination was documented in a GP Mental Health Care Plan on 4 May 2021 referring to a “mixed anxiety and depression.”
An activities of daily living (ADLs) assessment report of 7 September 2021 identifies “adjustment disorder and depression/traumatic loss of family member”. This trauma has impacted her “ability to complete self-care and domestic tasks, manage responsibility of her role as a mother and engage in the community”. It refers to a lack of motivation and a tendency to become overwhelmed.

Diagnosis and reasons

The Medical Assessor provided his diagnosis and reasons at [18].
The Medical Assessor considered a diagnoses of persistent complex bereavement disorder (DSM-5) and Prolonged Grief Disorder (DSM-5-TR), but it was apparent he said, based on her account, that her symptoms were more fully characterised “by a diagnosis of Persistent Depressive Disorder. Namely, she is suffering prominent depressive symptoms including a pervasively low mood, anhedonia, loss of energy and motivation, indifference, impaired concentration and variable sleep.”
The Medical Assessor considered that Ms Ghoz’s current presentation was affected by the prescription of medicinal marijuana.
The Medical Assessor was of the opinion that the accident represented a greater than negligible contributor to her current psychiatric impairment, and noted that Dr Rikard-Bell’s assessment was made based on the presence of psychiatric symptoms prior to the introduction of THC.

Degree of permanent impairment psychiatric impairment rating scale

The Medical Assessor undertook a PIRS at [21]:

Psychiatric diagnoses	1. Persistent Depressive Disorder
Psychiatric treatment description	Nil ongoing

Category	Class	Reason for Decision
1. Self Care and Personal Hygiene	2	Ms Ghoz described a tendency to neglect her personal care about which she has become indifferent. She is unable to consistently participate in household tasks. Overall, Ms Ghoz is moderately impaired in this area of functioning is of moderate severity in which she could not live independently. It is apparent however that this impairment is influenced by pre-existing physical symptoms and likely to be influenced by the effects of THC. Also, by her account, her functioning in this area is in part an effect of memory deficits and disorganisation which will be addressed under concentration, persistence and pace. When seen by Dr Rikard-Bell, she was participating in household tasks albeit “a little unfocussed”. He found that she was not attending to her personal care in the way she had been prior to the motor accident. It expected that the diagnosed psychiatric condition would contribute mild impairment irrespective of other factors.
2. Social and Recreational Activities	2	Ms Ghoz reported sometimes going out for coffee with a friend but otherwise she is socially reclusive. Overall, her account reflected rare social participation and only when coerced. When she was seen by Dr Rikard-Bell, he considered her unimpaired in this area. However, the nature of the symptoms documented at that time and the compromise in other areas of functioning create the impression that she was functioning as well as her account at the time of his assessment suggests. It is expected that THC would undermine motivation to engage in such outlets. It is appropriate to ascribe part of the impairment to psychiatric factors and part to non-accident-related factors. Whilst her current impairment is moderate overall, it is appropriate to ascribe mild impairment to the psychiatric injury.
3. Travel	2	Ms Ghoz confirmed that she drives in the local area. When seen by Dr Rikard-Bell she was driving to work with increased caution. She stated that since being prescribed medicinal marijuana she has restricted her driving
4. Social Functioning	2	Ms Ghoz reported a compromised marital relationship. She could not describe the basis upon which this has arisen and it is probable that it has in part been influenced by the psychiatric diagnosis. Dr Rikard-Bell obtained a positive account of the support provided by Ms Ghoz’s family members. He nevertheless identified stress affecting family relationships. On this basis, it is appropriate to consider that irrespective of other factors, a degree of strain and mild impairment would be present arising from her psychiatric condition.
5. Concentration, Persistence and Pace	2	Ms Ghoz described poor concentration and compromised memory. She stated her expectation that she would be unable to study. Having regard for her account at interview, forgetfulness and disorganisation undermines her ability to participate in household tasks. She engages in no activities of a nature that demand persistence and pace and, having regard for her account, she would be unable to pursue activities that require persistence and pace. At interview, a degree of disorganisation was apparent. When assessed by Dr Rikard-Bell, she was found to demonstrate normal cognition. His conclusion was that her forgetfulness and distractibility reflected mild impairment. THC is expected to exert a significant effect on concentration, persistence and pace. Overall, it is apparent that Ms Ghoz is currently severely impaired in this area of functioning. Marijuana is inevitably contributing, it remains psychiatrically probable that the motor accident-related condition is contributing to a mild degree. Clinically, the diagnosed psychiatric condition is not, in itself, one which would produce impairment of the degree described.
6. Adaptation	2	Having regard for Ms Ghoz’s overall presentation, she is currently unemployable. She stated that she ceased work due to physical symptoms having undertaken a year of primary school teaching on a part-time basis following the motor accident. It is noted that she was teaching part time in high school prior to the motor accident and reduced her hours by four hours per week and was teaching in primary school. Given that she has been on a disability support pension, the nature of her work role remains uncertain. Dr Rikard-Bell identified a reduction in functioning in this area reflective of mild impairment. It is inevitable that the consistent use of THC would undermine functioning with respect to adaptation. Having regard for Ms Ghoz’s ability to resume work albeit in a diminished capacity for one year and accepting that contrary to her impression her psychiatric condition may have contributed to her ultimate decision to cease work, it is appropriate to conclude that she is mildly impaired in this area by virtue of the psychiatric injury.
List classes in ascending order:			2, 2, 2, 2, 2, 2
Median Class Value:			2
Aggregate Score:			12
% Whole Person Impairment:			6%

*%WPI = Percentage Whole Person Impairment

The median value class of the PIRS rating was 2 and the percentage WPI was 6%.

The claimant’s statement

Ms Ghoz made a statement on 19 July 2022. This statement was available to the Medical Assessor and the Panel.
Ms Ghoz relevant said at [11] that her routine has changed and she now visits Adam’s grave and is no longer able to walk for leisure due to a lack of motivation and because she does not enjoy leisure activities (including walking).
She continues at [12] that before the accident she enjoyed making sweets for her family and friends. This was something she had been “extremely passionate about” and that it gave her joy seeing her family wat the sweets that she made. After the accident she no longer makes sweets as she doesn’t have the motivation.
She states at [13] that she no longer shops with her husband, something she used to enjoy.
She states at [14] that before the accident she used to have coffee with the ladies from school. She no longer does this as she does not get together with them, and she does not feel it necessary to see other people.
She states at [15] that she no longer has the motivation to keep her house clean.
She states at [16] that she would visit her family friends in Lebanon every two years. This has stopped, she would find it difficult to return to travelling without her son.
She refers at [17] to the change in social activities.
In the balance of the statement, she refers to other changes for example, at [22], her concentration levels have decreased.
She refers at [24] to her treatment since the accident.

RE-EXAMINATION BY THE PANEL

Ms Ghoz was assessed by audio-visual link on 23 April 2025 by Medical Assessor Christopher Canaris and Medical Assessor Matthew Jones.

Medical treatment and history

Ms Ghoz reported that she received Ozempic injections for obesity. She said she was previously 100kg and after the accident lost 13kg and is now approximately 88kg. She said however she is not certain of her exact weight as she no longer goes near scales. She reported she is 164cm tall.
Ms Ghoz also reported she has medications for diabetes as well as medications for high blood pressure. She is taking an antidepressant, Mirtazapine 30mg, which she has taken since March 2024.
Ms Ghoz reported that she has had a number of procedures between May 2024 and March 2025. She has been in hospital four times for a blocked colon. She was told that they were unable to operate on her. She was experiencing lower back pain, especially when trying to open her bowels. She had four attempts at colonoscopies; however she had blockages from faeces. Ultimately, she saw a colorectal surgeon who, on
3 March 2025, performed a colonoscopy and removed the faeces.
Ms Ghoz reported that in 2001 she had haemorrhoid surgery and had been worried about her bowel since that time but had not experienced any constipation until more recently. She said, “Everything they say is psychological.”
The Medical Assessors asked Ms Ghoz about her chronic neck pain. She commented that she had loved gardening and in 2002 she pulled out a chilli tree whilst gardening and “damaged the spine inside.” She has had neck problems since then. She reported that she needed surgery for this, however she ultimately never had surgery on her neck. She reported she was also diagnosed with a protein S deficiency in her blood which was a contraindication to surgery. She had inherited this from her father and the result of the disease is that it makes her blood very thick. Her father died at the age of 40 from heart troubles, as did her brother at the age of 30. She believes that they had also had protein S deficiency.
Ms Ghoz reported that in 2010 she thought she had had a heart attack, but it was a reaction to medications at the time. She said she takes a blood component medication to assist her with her protein S deficiency.
The Medical Assessors asked about medicinal marijuana mentioned in the documents. She said she has a THC preparation and she vapes at night and sometimes during the day. Ms Ghoz started medicinal cannabis in September 2023 and therefore has been taking it for about 18 months. She said that she has problems moving her neck properly and the cannabis helps, providing quick pain relief. She uses this when she is upset or when she is in too much pain. She also uses it when she has stomach problems from her hernia. She said it saves her stomach from tablets. She said “it helps a lot”.
The Medical Assessors asked Ms Ghoz what her plan for treatment was, and she said that she likes her neurologist, who says that he wants to fix her. She still experiences numbness. She said she had an MRI, which found that she had small vessels that were blocked. She believes that these are “related to psychological issues.” She has an upcoming appointment in May 2025. She said the last “stroke” had affected her legs. She feels that she is “dying, part by part.” She wants to see a heart specialist. She said that seeing a psychologist was too expensive for her.

Psychiatric history

Ms Ghoz reported she had never seen a psychologist, taken psychiatric medications, or suffered from anxiety or depression. She referred to herself as previously being a very calm person who was very relaxed. She said she was someone who loved routine. She commented that she was someone who “can’t scream.”

Personal background

Ms Ghoz reported that she is from the generation of the civil war in Lebanon. She said it was “very bad.” At the time, her area was controlled by Syria. There were problems between political parties, there was fighting, and the Syrian army were present. She lived next-door to a mufti who was assassinated in the mosque. She said this was very scary. She remembers after the attack she “could see the meat on the walls.” She said that there was one point where Lebanon came to a complete standstill for three months. She said she had a cousin killed in 2008/2009 by Hezbollah, but no one closer than this.

Treatment and symptoms following the accident

Ms Ghoz reported that after she had the stroke, she was very scared and worried and was unable to talk. She went to see a psychologist. She said she was unable to cry for the first three or four sessions, but after this she was able to. She did however have very heavy sensations in her chest. The psychologist’s name was Dany Aboumelhem, whom she saw at Parramatta, and another location, in a suburb near Adam’s grave. She saw this psychologist weekly for a few months in 2021. She has not seen a psychologist for two or three years. She reported however she has a female friend who specialises in relationship counselling and coaching, and she has assisted her informally many times. Her son, Adam, was the only friend of this woman’s son. They became very close after the accident, and she would often come and see her.
Ms Ghoz denied any history of recreational drug or alcohol ingestion. She denied any criminal history. She denied any involvement in any major motor vehicle accidents or any other compensation or litigation processes.
Ms Ghoz reported that her new general practitioner (Dr Abouzeid) prescribed her medicinal cannabis. She said it took her a year to have an appointment with the neurologist. She underwent an MRI for her lower back pain, and she was told that she had fluid in her spine which was causing pain. She said this needs yearly monitoring and that her lower back pain has decreased with taking the medical cannabis at night.
Ms Ghoz reported that after her “stroke” she had pins and needles in her legs. She said it feels like someone is pulling her legs out from her body. Which was why she was referred to see a neurologist and have the MRI.

Current functioning

Ms Ghoz reported she has no other family in Australia. She has made friends in Australia, especially through the school. She sees one friend, who is a relationship counsellor and coach as well as her daughter’s friend’s mother. She used to have several friends coming to see her, and her husband’s family was always around. She said that people no longer come to see her, and she described herself as “a sad lady.” She remembers that she used to have barbeques, or cook for people, every week or two, but this no longer occurs.
Ms Ghoz reported she maintains a New South Wales driver’s licence and has a car. She has problems with driving long distances and cannot drive for more than 30 minutes because of her neck. She has driven to the cemetery to visit Adam’s grave every day, except when she has been in hospital.
The Medical Assessors asked Ms Ghoz what her average day entailed, and she described herself as having “no plans.” She said “wherever the day goes, it goes.” She commented that she is not cooking, apart from once every 10 days to two weeks. She sees her children bringing food into the house and she feels guilty. She commented that she has no “eating routine.” She said she does not feel hungry and does not enjoy eating.
Ms Ghoz reported she will wake-up, she will read the Koran, and she will pray. She reported she will drive her motor vehicle to the cemetery to visit Adam’s grave and spend three hours there. When at home she will sometimes clean or cook and she no longer has the daily routine she used to. She reported that sometimes she just sits and does nothing and turns her phone off.
Ms Ghoz reported she will put the television on, and she will watch it, but she will not pay attention. She said sometimes her brothers calls her.
Ms Ghoz reported she does not attend mosque but will pray at home. She fasted through Ramadan.
Ms Ghoz reported she is getting along very well with her daughter, and well with her son. She said her children are blaming their father for how he is treating her. The Medical Assessors asked if there was anything that brought Ms Ghoz any joy or enjoyment and she said that she was very happy when her daughter graduated and found a good job. She is also very pleased with her son’s achievements. She said she is always praying that nothing bad happens to them.
Ms Ghoz reported she has no problems performing duties of self-care and personal hygiene. She went on to say however that she “usually forget[s] to have a shower.” She said this was especially in 2025. She said she wears the same clothes, does not care and does not change them. She went on to say that nothing interests her anymore.
She reported her neck stops her from hanging up her washing and if she is driving, she cannot park on the right side.
Ms Ghoz reported she can do physical tasks for about 30 minutes and then her neck pain flares up. She then has to stop and have a break every half hour or so. She said nothing however gets finished and said that she is therefore just doing one thing at a time. She said her husband and daughter do the washing for the house.
The Medical Assessors asked Ms Ghoz about her memory and concentration. She said she will write everything down on her phone and cannot remember things, for example what to pick-up from the chemist, so she sets alarms for herself. She said her daughter has downloaded memory games for her and she is playing these. Ms Ghoz will read things but has to re-read them. She can remember things from early on in her life but has trouble remembering things more recently. She can read the news, but finds it hard to remember details. She commented that she has three bachelor’s degrees and is a very educated person and that she is “trying.” She said her new GP is very good and is encouraging her to relax and try and be healthy. She has been reassured that she will not stay like this all her life.
Ms Ghoz reads the Koran every day for up to an hour in the mornings, and sometimes in the evenings. She will read the news on her phone. She reported she started watching a television series with an actress who she likes, however the actress played a teacher who lost her 9-year-old son and went back to teaching. She said she watched it, and it was if someone was telling her story. She said she tries not to watch television news, especially after the recent troubles in Lebanon. She said that family members in Lebanon had received messages to leave their house.
Ms Ghoz concentrated well for the assessment which had a duration of approximately 100 minutes.

Current symptoms

Ms Ghoz reported that she is “so good in controlling [her] feelings” and said that this was the case even before the accident. She said the accident has affected her body and her health badly and that every time she talks about Adam, she gets a distressing feeling in her chest and abdomen. She reported that during one of her investigations it was found that she had a hernia in her diaphragm. She said the Mirtazapine has helped a lot with respect to this. She said she takes the Mirtazapine when she feels scared. She said she was “so angry inside” and that she has “nothing to care about.” She said the only thing that now makes her scared or angry is the thought of something happening to her surviving children. She said when she is driving and she sees children walking, she slows down or stops, especially when children are walking on the road or riding a bike.

Ms Ghoz reported that the last blood test she had indicated she still had a 96% risk of stroke. She said that she does not want to be in a wheelchair.
Ms Ghoz reported that there was a lady who lost her son three years ago and who came to visit a friend, the principal at the school. Ms Ghoz reported that these two women were talking about her. Then the woman who lost her son came to visit
Ms Ghoz, they started talking and she told her that she will be okay when she has grandchildren. She told Ms Ghoz that she was keeping things inside and that it was because she did not see her son after his death. Ms Ghoz reported that interacting with this woman “woke-up everything.”
She reported there was another teacher at the school who had lost her son on a motorcycle, on the same road, when he was 26 and he died instantly. This teacher started talking about the burial and how she hugged her son. Ms Ghoz reported that she felt jealous of her. This woman did not know that she had not seen Adam after his death. Ms Ghoz also reported that there was a road trauma support group who called her, but she asked them not to keep calling her, and she would call them if she wanted to.
With respect to sleep, Ms Ghoz reported she previously would sleep to escape things, however since the accident she can have no sleep for two days and then sometimes sleep up to 18 hours, after something has happened. She gave an example that she slept for 16 hours after the lady visited to talk about the death of her child. She said she gets in a state where she does not “want to think about it.” She said her body is often not relaxed and she will wake-up very tired and her face will be tense.

Mental state examination

Ms Ghoz was a female of Middle Eastern appearance who had dark hair which was tied back. She had spectacles and wore a black t-shirt. She was seen by audio-visual link. Her speech was normal, with a strong accent, and there was no evidence of formal thought disorder or delusional thought processes. There was no evidence of current thoughts of self-harm or thoughts of harm to others. When asked about her mood, she said that since two days before it was “not good.” She went on to say that she was “keeping everything inside.” Her affect (expressed emotion) was calm, reactive, congruent and appropriate. She came across as a genuine historian. She was teary at times. She was responsive to humour. She came across as somewhat stoic. There was no evidence of perceptual abnormalities consistent with psychosis. Her cognition, insight and judgement appeared intact in the context of the assessment. Rapport was very good, and Ms Ghoz spoke openly and freely. The assessment had a duration of approximately one hour and forty minutes.

Consistency

The Medical Assessors cross-checked a few details of the documents with Ms Ghoz. We referred to a GP entry from Dr Abouzeid in a note on 21 November 2020, which records that Ms Ghoz wanted her daughter to be her carer, and that she claimed that she was having problems finishing her daily tasks cleaning, cooking, driving for long periods “and so on.” The need for a carer seemed to be questioned by the GP.
Ms Ghoz reported that she had forgotten about this and then said that she “didn’t do it.” She does remember that she asked her GP to make her daughter her next of kin. She then went on to say that the people she was seeing at the pain clinic were asking her to get a carer, as they were wanting to decrease her pain medication.

Diagnosis

Ms Ghoz’s reported narrative and presentation at assessment was consistent with having a DSM-5TR diagnosis of prolonged grief disorder. She satisfies diagnostic criteria under DSM-5TR. Her son died more than twelve months ago (criterion A). She has had clinically significant yearning and longing for her son and preoccupation with thoughts or memories of him, visiting his grave on a daily basis for up to three hours (criterion B). She has experienced intense emotional pain, problems with reintegrating into life after his death, with loss of friends, loss of interest and loss of purpose. There is a high degree of emotional numbness and feelings that life is meaningless (criterion C). Her experience has caused clinically significant distress or impairment in important areas of functioning including socially and occupationally (criterion D). The duration and severity of her bereavement has exceeded expected cultural and religious norms (criterion E). Her symptoms are not better explained by physiological effects of a substance, a medical condition or other psychiatric disorder (criterion F).
Ms Ghoz’s clinical state appears to have stabilised and there does not appear to be any prospects for significant change in symptoms or level of impairment in the upcoming 12 months. The Medical Assessors considered that she has a permanent psychiatric impairment within the relevant definitions. Although Ms Ghoz is currently taking an antidepressant medication, which she reported has assisted her, and taking medical cannabis, which has provided some assistance with respect to some of her physical problems, she has not seen a psychologist for approximately two or three years. The Medical Assessors’ opinion is that ongoing treatment is providing only a mild treatment effect.
With respect to apportionment, there have been significant medical problems subsequent to her son’s death, however these do not appear to be having significant impact on her experience of prolonged grief. They are also not sufficiently distinct to enable the Medical Assessors to delineate any adjustment for subsequent impairment. From a psychiatric perspective, it does not appear that there was any pre-existing impairment.
Current WPI:

Psychiatric diagnoses	1. Prolonged Grief Disorder
Psychiatric treatment description	Antidepressant medication

Category	Class	Reason for Decision
1. Self-Care and Personal Hygiene	2	Mild impairment Ms Ghoz appeared with no marked signs of neglect at assessment. She is able to manage her own self-care and personal hygiene activities such as showering, dressing, cooking and domestic tasks, however she reported a reduced level of motivation and attention to these tasks. In the Medical Assessors’ opinion, she would be able to live independently with little or no assistance. Utilising clinical judgement, there is a class 2, mild impairment.
2. Social and Recreational Activities	3	Moderate impairment Ms Ghoz reported little, if any, in the way of social and recreational activities. She does have contact with a couple of close friends who may visit. Although she leaves her residence, there is no evidence of going out socially to any social events or outings. She has reduced her level of social interaction considerably. There is also little in the way of solo activity with respect to hobbies or interests. Utilising clinical judgement, there is a class 3 moderate impairment.
3. Travel	1	Minor deficit attributable to the normal variation in the general population. Ms Ghoz reported she is able to drive independently and drives on a daily basis to visit her son’s grave. She also drives locally. She reported she is not able to drive longer than thirty minutes because of problems with her neck, and these problems are not psychological in nature. Utilising clinical judgement, there is a class 1, minor deficit in this category.
4. Social Functioning	2	Mild impairment Ms Ghoz reported close ongoing relationships with her children and family of origin. She has maintained a couple of close friendships and social contacts but has withdrawn from most of her pre-accident friendships. Her situation with her husband is unusual and appears to be one of separation under the same roof, however this appears to be instigated by her husband, and the reasons for this separation are not clear to Ms Ghoz. The Medical Assessors deliberated on this issue and considered that these marital issues are related to the accident with respect to their effect on Ms Ghoz’s husband, but not related to Ms Ghoz’s mental health problems from the accident. Utilising clinical judgement, there is a class 2, mild impairment.
5. Concentration, Persistence and Pace	2	Mild impairment Ms Ghoz concentrated well for the assessment, which had a duration of approximately one-hundred minutes. She reported she is able to read the Koran for up to an hour each morning and sometimes in the afternoons. She reads news on her phone, however reported some problems with remembering details. She was able to watch a television series, however found the content emotionally disturbing. She is able to perform physical tasks for up to 30 minutes, before she has issues with pain. She also has medical symptoms which would interfere with her concentration, persistence and pace at times (not taken into account in this assessment). Taking into account all factors, including her mental state at assessment, the Medical Assessors (utilising clinical judgement) considered that Ms Ghoz had a class 2, mild impairment, in this category.
6. Adaptation	3	Moderate impairment Although Ms Ghoz was receiving the Disability Support Pension prior to the accident it appears that she was also teaching part-time for a two-year period not long before the accident. She reported she was performing home duties at the time of the accident. Since the accident, she has been able to work up to two days per week teaching Arabic part-time to primary school students. The Medical Assessors’ assessment was that Ms Ghoz has capacity for working, in a reduced demand or complexity role, up to half time, which is consistent with a class 3, moderate impairment.
List classes in ascending order: 1 2 2 2 3 3
Median Class Value: 2
Aggregate Score: 13
Pre-existing % Whole Person Impairment: 7%

*%WPI ^{= Percentage Whole Person Impairment}

REVIEW PANELS CONSIDERATION OF SUBMISSIONS

The claimant’s submissions:
(a)    With respect to submissions [22], the Panel carefully considered the relevance of the claimant being prescribed and taking cannabis oil. The Panel was of the view that the treatment received by Ms Ghoz was providing only a mild treatment effect. The Medical Assessors commented at [111] that she had reported that taking medical cannabis had provided her with some assistance with respect to some of her physical problems. She had not seen a psychologist for approximately two or three years, and the opinion of the Medical Assessors was that the ongoing treatment was providing only a mild treatment effect.
(b)    With respect to [25] and [26], the Panel gave careful consideration to these submissions.
(c)    With respect to [28] and [29] the Panel expressly considered the cultural responses.
(d)    The Panel did consider the matters referred to in [30] either expressly or by implication.
Insurer’s submissions:
(a)    In relation to [2.5], the Panel has dealt with the issue of prescription of THC.
(b)    As to history taken from the claimant, the Panel believes that the Medical Assessor took a reasonable history, but in any event, the Panel has taken a detailed history.
(c)    As to [2.19]-[2.22] the Panel has noted these submissions and that in any event it has considered Ms Ghoz as an individual and has taken into account all relevant considerations such as cultural expectations, her role as a wife and mother, the psychological condition of her husband, and all other relevant matters.
(d)    With respect to the insurer’s submission of 9 May 2023, it is noted that NRMA does not dispute the diagnosis of Dr Rikard-Bell of a persistent bereavement disorder, or that it gave rise to a non-threshold injury.
(e)    The Panel has considered the submissions by NRMA in respect of the PIRS classification made by the Medical Assessor, in each of the categories and has arrived at its own clinical judgment as to the class on the basis of its clinical examination of the claimant and all other documents and information which were available to it.

DETERMINATION

The Medical Review Panel revokes the determination of Medical Assessor Roberts that the injuries i.e. persistent depressive disorder, gave rise to a WPI of 6%, and substitutes its primary diagnosis that the claimant sustained a prolonged grief disorder giving rise to WPI of 8%.

[2025] NSWPICMP 443

23 June 2025