Hilyander v Insurance Australia Limited t/as NRMA Insurance
[2022] NSWPICMP 465
•10 November 2022
| DETERMINATION OF REVIEW PANEL | |
| CITATION: | Hilyander v Insurance Australia Limited t/as NRMA Insurance [2022] NSWPICMP 465 |
| CLAIMANT: | David Hilyander |
INSURER: | Insurance Australia Limited trading as NRMA Insurance |
| REVIEW Panel | |
| MEMBER: | Susan McTegg |
| MEDICAL ASSESSOR: | Margaret Gibson |
| MEDICAL ASSESSOR: | Clive Kenna |
| DATE OF DECISION: | 10 November 2022 |
CATCHWORDS: | MOTOR ACCIDENTS – The claimant sustained injury in a rear end collision on 26 March 2017; injuries referred for assessment were the left shoulder, right shoulder, cervical spine and thoracic spine; at time of assessment by Panel both cervical and thoracic spine asymptomatic; dispute as to causation of shoulders; Held – Panel satisfied as to causation of right shoulder injury; Panel found the accident did not cause injury to the left shoulder, no contemporaneous complaint; no complaint re the left shoulder when assessed by medico-legal practitioners on 9 October, 2017, 13 April 2018 and 24 April 2018; not satisfied left shoulder condition due to favouring the right shoulder; degenerative change and normal wear and tear resulted in labral tear, glenohumeral osteoarthritis and adhesive capsulitis; Panel assessed 3% whole person impairment for injury to right shoulder. |
| DETERMINATIONS MADE: | CERTIFICATE OF DETERMINATION Medical Assessment –Permanent Impairment Review Panel Certificate The Panel revokes the Combined Certificate of Medical Assessor Woo dated 27 May 2021 and issues a new certificate determining that the following injuries were caused by the motor accident and give rise to a whole person impairment (WPI) which is not greater than 10% and is 3%: · Injury to the cervical spine; · Injury to the thoracic spine, and · Injury to the right shoulder. The Panel finds the following injury was not caused by the accident: injury to the left shoulder.· |
REVIEW PANEL REASONS FOR DECISION
BACKGROUND
On 26 March 2017 Mr David Hilyander (the claimant) was the driver of his stationary vehicle with his family on board when the at fault vehicle collided with the rear of his vehicle (the accident). Mr Hilyander asserts he sustained injury to his neck, shoulders and back.
Insurance Australia Limited trading as NRMA Insurance (the insurer) is the relevant insurer with liability to pay any damages to the claimant under the Motor Accident Compensation Act, 1999 (the MAC Act).
This dispute is in relation to whether the degree of permanent impairment sustained by the claimant as a result of the injury caused by the accident is greater than 10%. This constitutes a medical dispute within the meaning of the MAC Act.[1]
[1] Sections 57 and 58 of the MAC Act.
Certificate of Medical Assessor Berry
Medical Assessor Neil Berry assessed the claimant on 24 April 2018 and issued a certificate dated 30 April 2018.[2] He reported the claimant had pain in the neck which extended down the right arm to affect the right thumb, index and middle fingers. He reported the claimant no longer had pain in the thoracic or lumbar spine.
[2] AD7 (claimant’s bundle of documents uploaded to the portal) p 815.
Medical Assessor Berry found that soft tissue injury to the thoracic spine had resolved. He assessed a 5% whole person impairment (WPI) for soft tissue injury to the cervical spine and a 5% WPI for soft tissue injury to the right upper extremity.
Medical Assessor Berry reported the following left shoulder range of movement:
Shoulder Movements
Active
ROM Right
Active
ROM Left
Flexion
120°
180º
Extension
40°
50º
Adduction
40°
50º
Abduction
120°
180º
Internal Rotation
70°
90º
External Rotation
70°
90º
The matter was thereafter referred for further assessment on the basis of a deterioration of the injuries previously assessed and on the basis of additional relevant information. The claimant asserts he had suffered a further deterioration of his right shoulder and that he now has a labral tear, osteoarthritic changes and a restricted range of movement of his left shoulder. It was this application which resulted in the assessment by Medical Assessor Woo the subject of this dispute.
MEDICAL ASSESSMENT UNDER REVIEW
Certificate of Medical Assessor Woo
In his Certificate dated 27 May 2021 Medical Assessor Alexander Woo issued a certificate dated 27 May 2021. The following injuries were referred for assessment:
· left shoulder;
· right shoulder;
· cervical spine, and
· thoracic spine.
He found there was no tenderness in the cervical spine and range of motion was normal. He also found the neurological examination was normal. Similarly in respect of the thoracic spine Medical Assessor Woo found no tenderness, normal range of motion and a normal neurological examination.
Medical Assessor Woo found tenderness in both shoulders and discomfort throughout the range of motion in both shoulders.
Shoulder Movements
Active
ROM Right
Active
ROM Left
Flexion
110°
90º
Extension
30°
30º
Adduction
30°
30º
Abduction
100°
90º
Internal Rotation
40°
40º
External Rotation
50°
50°
Medical Assessor Woo concluded the findings were consistent with bilateral frozen shoulder. He also noted that the operation reports of Dr Kadir showed osteoarthritic changes in both shoulders which likely existed prior to the accident.
Medical Assessor Woo assessed a 10% WPI in respect of injury to the left shoulder and a 9% WPI in respect of injury to the right shoulder. However, he apportioned half of the claimant’s current impairment to his pre-existing degenerative changes resulting in a final WPI of 9%.
REVIEW PROCEDURE
The present application is a review of a medical assessment pursuant to s 63 of the
MAC Act.An application for review of the medical assessment of Medical Assessor Woo was lodged on 25 June 2021 within the 30-day timeframe.
On 2 August 2021, the delegate of the President being satisfied there was reasonable cause to suspect that the medical assessment was incorrect in a material respect having regard to the particulars set out in the application referred the medical assessment to the Review Panel (the Panel).[3]
[3] Section 63(2B) of the MAC Act.
The Personal Injury Commission (Commission) commenced operation on 1 March 2021 and the Claims Assessment and Resolution Service was abolished by cl 3 of Part 2, Division 2, Schedule 1 to the Personal Injury Commission Act 2020 (the PIC Act).
Under cl 14A(1)(a)(vii) Schedule 1 of the PIC Act pre-establishment proceedings include proceedings that before the establishment of the Commission were required or permitted to be dealt with by a review panel for a medical assessment constituted under the MAC Act.
Clause 14F(2) of Schedule 1 of the PIC Act states that the new review provisions apply in relation to a decision of a new decision-maker in completed pre-establishment proceedings, including the medical assessment the subject of this review which was completed before 1 March 2021.
The new review provisions provide that a review panel consists of two medical assessors and a member assigned to the Motor Accidents Division of the Commission. The President’s delegate referred this application for review to the Panel.
The Motor Accident Permanent Impairment Guidelines (the Guidelines) were issued pursuant to s 44(1)(c) for the assessment of permanent impairment. The Guidelines are based on the American Medical Association’s Guides to the Evaluation of Permanent Impairment Fourth Edition (AMA 4 Guides). The Guidelines are definitive with regard to the matters they address but where they are silent on an issue, the AMA 4 Guides should be followed.[4]
[4] Clause 1.2 of the Guidelines.
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.[5]
[5] Section 41(2) of the PIC Act.
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.[6]
[6] Rule 128 of the PIC Rules.
The review is by way of a new assessment of all matters with which the medical assessment is concerned.[7]
[7] Section 63(3A) of the MAC Act.
Clearly in matters involving assessment of permanent impairment there are strong arguments for a review panel conducting a re-examination. The Panel considered it appropriate for the assessment to review all matters with which the assessment of Medical Assessor Woo was concerned.
On 7 October 2022 the claimant was examined by Medical Assessor Gibson on behalf of the panel.
MATERIAL BEFORE THE PANEL
The Panel issued a Direction to the parties on 12 May 2021 (the first Direction) which required each party to file an indexed, paginated bundle of documents.
In response to this direction the solicitor for the claimant uploaded to the portal a bundle of documents paginated from pages 1 to 837 and marked AD7.The solicitor for the insurer uploaded to the portal a bundle of documents paginated from pages 1 to 793 and marked AD9. The index to the insurer’s bundle is AD8.
THE EVIDENCE
The claimant was 44 years of age at the date of accident and is currently 49 years of age.
Summary of relevant radiological investigations and medical imaging
MRI left shoulder – 15 April 2013
The report concluded:[8]
1. “1. Rotator cuff normal.
2. 2. Degenerative change postero-inferior labrum.
3. 3. Subchondral sclerosis posterior glenoid with subchondral cyst formation noted.
4. 4. Axillary pouch synovitis noted.”
[8] AD9 p 99.
CT cervical spine – 29 March 2017
The report noted there was “mild cervical disc osteophyte complexes causing no significant narrowing of the central spinal canal, cord compression or evidence of neural exit foraminal narrowing to account for the symptoms…”.[9]
[9] AD7 p 350.
MRI cervical and lumbar spine – 7 April 2017
The report of the MRI of the cervical spine concluded:[10]
5.”Loss of the normal cervical lordosis most likely due to muscle spasm. No cord contusions haemorrhage noted. No ligamentous disruption detected.”
[10] AD7 p 338.
The report of the MRI scan of the lumbar spine concluded:
6.“No significant disc bulging, herniation or exit foraminal stenosis. No pathological marrow oedema detected. There is facet joint arthropathy. No traumatic disc bulging or herniation identified.”
MRI cervical spine and brachial plexus – 14 March 2018
The report of the cervical spine concluded:
7.“There is disc degenerative disease within the cervical spine as described above. There has not been any significant progression when compared to the prior imaging.”
The report pertaining to the brachial plexus concluded:
8.“There is no definite evidence of a brachial plexopathy. No mass lesions in the supraclavicular region or around the brachial plexus demonstrated.”
Nerve conduction studies and EMG studies – 11 May 2018
The report concluded:[11]
9.“There is neurophysiologic evidence of bilateral median nerve neuropathy at the wrist, suggestive of carpal tunnel syndrome. They are of mild degree in severity with marginally worse findings on the right side”.
[11] AD9 p 56.
Ultrasound left shoulder – 10 July 2018
The report concluded:[12]
10.“…Supraspinatus tendon defines normally. Due to limited external rotation, subscapularis tendon is poorly seen, but appears intact. The infraspinatus tendon is intact. Long head of the biceps is intact. There is a small joint effusion in the biceps tendon sheath. There is thickening of the subacromial bursa. There is bursal bunching with abduction. There is limited external rotation suggesting adhesive capsulitis. The acromioclavicular joint shows mild soft tissue swelling.”
[12] AD7 p 457.
An ultrasound of the left elbow of the same date found no cause of the pain detected in the upper forearm.
EMG studies – 3 August 2018
EMG studies on 3 August 2018, showed no evidence of a right C5/6, C6/7 or C8/T1 muscle myopathy or denervation or radiculopathy.[13]
[13] AD 31 p 52.
MRI left shoulder – 12 November 2018
The report concluded:[14]
“1. advanced glenohumeral osteoarthritis;
2. extensive labral tear;
3. posterior capsular laxity without a definite posterior dislocation;
4. glenohumeral joint effusion with synovitis which may relate to adhesive capsulitis;
5. bicipital tenosynovitis; and
6. mild adhesive capsulitis.”
MRI right shoulder – 14 November 2018
[14] AD7 p 509.
The report concluded:
“1. inferior glenoid fracture essentially undisplaced with bone oedema;
2. inferior labral contusion;
3. small SLAP tear;
4. focal high-grade partial-thickness tear of the anterior supraspinatus;
5. subscapularis and biceps tendinosis;
6. subacromial-subdeltoid bursal inflammation; and
7. AC (acromioclavicular) joint arthropathy.”
Pre-accident treating medical records
The claimant consulted Dr Peter Giblin, orthopaedic surgeon on 7 September 2004 with a history of falling down some stairs on 6 August 2004 and suffering a hyperextension, abduction type injury to his right shoulder.[15] Dr Giblin reported most of the tenderness was at the fracture site of the undisplaced greater tuberosity. He thought the rotator cuff seemed reasonably intact.
[15] AD 9 p 602.
On 1 October 2008 the claimant attended Liverpool Hospital with a one week history of shoulder pain.[16] He reported he was doing push ups when he heard a ‘cracking’ sound and immediate pain in the vicinity of the right shoulder area. He was unable to move his right arm without pain. On examination he had some tenderness to palpation on his acromioclavicular joint and reduced range of motion in shoulder abduction and external rotation. He underwent medical imaging.[17] The diagnosis was ‘soft tissue injury? rotator cuff strain’.
[16] AD9 pp 650 and 689.
[17] AD9 p 658.
On 11 August 2010 Dr Nabavi, orthopaedic surgeon performed a right knee arthroscopy and partial medical meniscectomy following complaints of right knee pain.[18]
[18] AD9 p 70, p 104.
On 17 October 2010 the claimant attended Campbelltown Hospital with a reported strain of the hip flexor muscle.[19]
[19] AD9 p 100.
The claimant saw Dr Nabavi again on 19 April 2013. He reported the claimant was lifting a 25kg box when he felt some pain in the left shoulder and since then he had experienced anterior shoulder pain radiating through the posterior aspect of the shoulder. He concluded there was no evidence of rotator cuff tear but some damage to the labrum in the glenohumeral joint.[20] On 31 March 2013 and again on 31 May 2013 Dr Nabavi reported the claimant had an excellent response to the subacromial injection, with a full range of motion and no pain.[21]
[20] AD9 p 73.
[21] AD9 pp 74 and 772.
In relation to the injury to his left shoulder of 11 April 2013 the claimant completed an eight week ExPhys intervention. As of 23 August 2013 Tim Reus, exercise physiologist reported Mr Hilyander opined his left shoulder had returned to the state it was prior to the accident, he had no discomfort or pain, and he was certified fit for pre-injury duties.[22]
[22] AD9 p 80.
On 19 May 2016 the claimant underwent laparoscopic re-do sleeve gastrectomy and division of adhesions under the care of Dr Ali Zarrouk, consultant surgeon.[23]
[23] AD9 p 394.
Post-accident treating medical records
On 27 March 2017 the claimant consulted Dr Mina Iskarous. He reported his involvement in the accident and reported complaints of pain in the neck and lower back, pins and needles down the right leg, tenderness of the cervical spine and the right paracervical, weakness in the left hand, tenderness of the lower back and down the right buttock area.[24]
[24] AD7 p 24.
On 31 March 2017 Dr Iskarous reported “aching pains in the arms”.
On 5 August 2017 Dr Mina Iskarous reported the claimant had continued to frequent the practice suffering from cervical, thoracic and lumbar whiplash injury.[25] She stated he was gradually introduced back to work and was working four hours a day five days a week. She thought the prognosis was good.
[25] AD7 p 24.
On 24 November 2017 Dr Fady Shenouda reported complaints of sore hands, elbows, shoulders, ankles for a couple of days[26] and on 28 November 2017 Dr Iskarous reported back pain, right shoulder pain, bilateral wrist pain and bilateral elbow pain.[27]
[26] AD7 p 438.
[27] AD7 p 439.
The claimant commenced physiotherapy with Lifestyle & Sports Physiotherapy. An Allied health recovery request dated 22 June 2017 provided a diagnosis of WAD (whiplash associated disorder) with right shoulder girdle pain.[28] As of 16 November 2017, Mr Hyde reported the claimant was reporting inconsistent symptoms of acute neurological pain in the scapular and mid thoracic region.[29] Notably no complaint was made in respect of the left shoulder.
[28] AD7 p 216.
[29] AD7 p 264.
Dr Patel neurologist reviewed the claimant on 16 March 2018.[30] Nerve conduction and EMG studies were organised. He stated he was concerned about the following issues:
“1. right C6 radiculopathy;
2. right shoulder tendinopathy or bursitis;
3. right extensor origin tendinopathy; and
4. right carpal tunnel syndrome.”
[30] AD7 p 525.
On 11 May 2018 the claimant underwent nerve conduction studies which were suggestive of carpal tunnel syndrome.[31]
[31] AD7 p 524.
In May 2018 the claimant presented to Campbelltown Hospital Emergency Department complaining of left sided arm weakness. He did not report any shoulder complaints.
On 27 May 2018 Dr Iskarous reported inter alia cramps of the left arm and leg, reducing the ability to use the arm and leg and pins and needs on the tips of the fingers of the left hand.[32] An ultrasound of the left elbow the same day found no cause for the claimant’s pain in the upper forearm.
[32] AD7 p 443.
On 28 June 2018 Dr Patel noted ongoing symptoms including neck pain radiating to the left upper limb in the C7 distribution. He reported “he woke up with the problem”.[33] He recommended an ultrasound of the left shoulder and elbow and conservative treatment including physiotherapy and possibly an injection.
[33] AD7 p 522.
On 10 July 2018 Dr Tosson diagnosed “left shoulder adhesive capsulitis”.[34]
[34] AD7 p 444.
On 3 August 2018 Dr Patel reported worsening left shoulder pain. He referred the claimant to Dr Thakkar and noted the claimant had changes of adhesive capsulitis and bursitis on ultrasound.[35]
[35] AD31 p 44.
On 26 September 2018 the claimant saw Associate Professor Vivek Thakkar, consultant rheumatologist. He reported the claimant developed bilateral shoulder pain and right-sided neck pain after being rear-ended on the M5.[36] On examination he found features of adhesive capsulitis with restriction in range of movement particularly on the right. He also noted some mild restriction in range of movement of the neck, more to the left than the right. The claimant underwent an injection of both shoulders subacromially with a view to undergoing a glenohumeral joint injection in 10 days’ time.
[36] AD7 p 499.
The claimant was reviewed by Associate Professor Thakkar on 21 November 2018.[37] In respect of causation, he commented:
“This constellation of findings are quite advanced and significant. David is quite clear that he didn’t have significant shoulder symptoms prior to his MVA. One would have to postulate that certainly the left shoulder findings have been developing over quite some time but the right shoulder findings particulars with respect to the inferior glenoid fracture and oedema needs follow up with a surgeon and that some of these changes may in fact have had a component of trauma to exacerbate them whether that be his rehabilitation as it would seem a bit too far long past the initial insult.”
[37] AD9 p 467.
The claimant saw Dr Nabavi on 4 December 2018 in respect of both shoulders.[38] He reported the left side was more painful than the right and had been painful since the accident. He reported the pain was over the anterolateral aspect and associated with stiffness and crepitus. On examination he noted a particularly stiff left shoulder, and whilst the right shoulder had a better range of movement, he noted significant irritability with elevation past 90º. Dr Nabavi reported the right shoulder had a combination of rotator cuff tendinitis, labral pathology which he considered degenerate in nature and mild glenohumeral joint arthritis. He did not consider surgery was appropriate.
[38] AD9 p 75.
On 13 December 2018 the claimant came under the care of Dr Agus Kadir, orthopaedic specialist for his bilateral shoulder pain.[39] He reported the claimant sustained a whiplash injury to his cervical spine and an impaction injury to both shoulders in the accident. The claimant had cortisone injections into both shoulders without significant improvement. He concluded the claimant had right shoulder impingement and AC joint arthritis. He thought the glenoid fracture should have healed. He concluded the left shoulder pain was from arthritis.
[39] AD7 p 511.
On 18 January 2019 the claimant had right shoulder arthroscopy, debridement, AC joint resection, biceps tenotomy and subacromial decompression under the care of Dr Kadir.[40]
[40] AD7 p 512.
On 1 June 2019 the claimant had left shoulder arthroscopy, debridement, capsular release and subacromial decompression under the care of Dr Kadir.[41]
[41] AD7 p 702, AD7 p 762.
On 16 July 2019 Dr Kadir reported the left shoulder continued to be painful. He stated the claimant will eventually require a shoulder arthroplasty. He recommended the claimant see a pain specialist.[42]
[42] AD7 p 705.
The claimant saw Dr Laurent Wallace, pain specialist on 20 November 2019. On 9 December 2019 the claimant underwent left suprascapular nerve block and pulsed radiofrequency.[43]
[43] AD7 p 737.
On 26 February 2020 Dr Wallace reported the claimant had bilateral shoulder osteoarthritis and persistent post operative pain with bilateral frozen shoulder, left worse than right.[44]
[44] AD9 p 513.
Medico-legal reports
Dr Yuk Kai Lee
The claimant was assessed by Dr Lee, orthopaedic surgeon on 9 October 2017[45] and again on 28 November 2019.[46]
[45] AD7 p 59.
[46] AD7 p 65.
On 12 October 2017 Dr Lee reported the claimant injured his neck, back (thoracic spine) and right shoulder as a result of the accident. On 28 November 2019 Dr Lee the claimant had pain in both shoulders about equal intensity. He reported the neck and back had improved.
There was a significant deterioration in the claimant’s range of movement of each shoulder between the date of his initial assessment on 9 October 2017 and his further assessment on 28 November 2019, despite surgery to both shoulders. See the table below:
Active ROM Measured
RIGHT
Active ROM Measured
LEFT
9.199
28.11.19
9.10.17
28.11.19
Flexion
130°
110º
180°
90º
Extension
50°
30º
60°
20º
Adduction
30°
30º
50°
30º
Abduction
100°
70º
170°
60º
Internal Rotation
60°
30º
80°
30º
External Rotation
70°
60º
90°
50º
In terms of causation Dr Lee reported the claimant had his hands on the steering wheel and the impact could have caused the humeral heads to move upwards and backwards. However, he also noted the claimant had full movement in his left shoulder at the time of his first assessment and it was not too painful. He felt the left shoulder deteriorated because the claimant favoured the right shoulder. He concluded the impact of the operation caused the posterior labral tear in the left shoulder rendering the shoulder unstable leading to rapid degeneration. He found the left shoulder deteriorated because of favouring the right.
On 28 November 2019 Dr Lee Dr Lee assessed 10% WPI for the right upper limb, 12% WPI for the left upper limb resulting in a total WPI of 19%. He assessed a 0% WPI for both the cervicothoracic spine and the lumbosacral spine, noting those body parts had recovered well.
Gerard Glancey
The claimant was assessed by Gerard Glancey, psychologist. On 22 February 2018 he reported the claimant told him that “pins and needles in his leg and arm resolved however pain remained evident to the right side of neck, right shoulder and back”.
Dr Andrew Porteous
Dr Porteous, occupational physician assessed the claimant and provided a report dated 22 November 2019.[47] He reported following the accident the claimant had the onset of neck pain, back pain and right shoulder pain although at the time of the assessment he also had left shoulder pain. The claimant asserts he has pain at high levels at the end of the day.
[47] AD7 p 73.
He reported two distinct shoulder and thoracic areas of pain. Firstly, he reported posterior shoulder pain in the area of the scapula and upper thoracic spine, more prominent on the right than the left. Secondly, he reported lateral upper arm and superior lateral shoulder pain.
Dr Porteous reported the claimant developed significant left shoulder pain and restriction in 2018 due to favouring the right shoulder. Dr Porteous stated there were signs on the subsequent MRI scan to suggest an adhesive capsulitis, which he felt plausibly occurs after an overuse injury, which was most likely the case.
On examination Dr Porteous reported the claimant had full cervical range of motion without restriction.
He noted the following range of movement of both shoulders.
Shoulder Movements
Active
ROM Right
Active
ROM Left
Flexion
90°
70º
Extension
50°
30º
Adduction
30°
20º
Abduction
100°
90º
Internal Rotation
90°
90º
External Rotation
40º
20º
He also noted normal power, sensation and reflexes in the upper limbs and found no clinical evidence to suggest active carpal tunnel syndrome.
In the thoracic spine Dr Porteous found restricted range of motion to the right with guarding, but no spasm. He noted asymmetrical movement. He reported the claimant was on the wait list for the Pain Clinic at Liverpool Hospital. He had recently paid for a review with Dr Lawrence Wallace, pain physician who had recommended injections into the left shoulder which the claimant proposed to undergo on 9 December 2019.
Dr Porteous assessed an 18% WPI, as a result of 5% WPI in the thoracolumbar spine, 7% WPI due to injury to the right shoulder and 8% WPI due to injury to the left shoulder.
Dr Graham Hall
Dr Hall assessed the claimant and provided a report dated 13 April 2018.[48] Dr Hall initially diagnosed the claimant with a reduced range of neck and right shoulder movement of undetermined cause and pain and paraesthesia in the right upper limb of undetermined cause. Dr Hall observed a "very full range of (left) shoulder movement" during the examination.
[48] AD31 p 16.
Dr Hall noted there were no complaints of back pain and he found the claimant demonstrated a full range of back movement. Dr Hall stated the claimant presented as a credible historian with rather unusual symptoms.
Dr Hall re-assessed the claimant and provided a report dated 23 April 2020.[49] He found there had been “no great changes” regarding movement of the claimant’s right shoulder since his examination in 2018. He found there were no longer any neck symptoms. However, he found the left shoulder was “now grossly restricted to a greater extent than the right”. He observed wasting which he considered consistent with the history and the observed ranges of movement.
[49] AD31 p 24.
Dr Hall stated:
“Both Dr Yuk Kai Lee and I recorded a normal range of left shoulder movement at our previous assessments. It is therefore surprising that between April and November 2018 the left shoulder could become so bad that the MRI disclosed advanced glenohumeral osteoarthritis and led Dr Kadir to surgery in June 2019. Mr Hilyander weighed approximately 150 kg at the time of the accident and this mass exerted through his outstretched arms to the steering wheel could have produced soft tissue injury in the shoulders. If this were the case however one would expect shoulder symptoms, particularly left shoulder symptoms, to have become apparent much earlier. In the absence of an event of which we are unaware, given the history and the demonstrated pathology, it is difficult to avoid the conclusion that the shoulder damage is related to the subject vehicle accident”.
Dr Hall provided a supplementary report dated 25 October 2021.[50] After reviewing additional medical records, he concluded the left shoulder condition was unrelated to the accident and the right shoulder condition was perhaps aggravated by the accident although he described the aggravation as transient. His diagnosis of bilateral shoulder pathology, now mainly osteoarthritis remained unchanged.
[50] AD9 p 758.
Dr Murray Hyde Page
Dr Hyde Page provided a report dated 27 August 2020.[51] He examined the claimant and concluded his neck and back conditions had fully recovered, whilst his bilateral shoulder problems were not directly caused by the accident.
[51] AD31 p 33.
Dr Hyde Page found the following ranges of movements of the shoulders:
Shoulder Movements
Active
ROM Right
Active
ROM Left
Flexion
160°
100º
Extension
40°
20º
Adduction
40°
40º
Abduction
120°
90º
Internal Rotation
80°
40º
External Rotation
70°
50°
Dr Hyde Page concluded the claimant developed symptoms in his right shoulder after the accident and appeared to have aggravated underlying degenerative changes. However, he concluded the pain and stiffness in the left shoulder developed well after the accident and was as a result of severe osteoarthritis in the glenohumeral or left shoulder joint. He also concluded that the claimant made a full recovery from the shoulder injury sustained in 2013.
Dr Hyde Page also concluded the claimant had not sustained a consequential injury to the left shoulder where his right shoulder had settled down quite well and he was not significantly favouring the right shoulder by the time he developed pain and stiffness in the left shoulder towards the end of 2018.
He was also of the view the accident was only a mild rear end collision which would not have done major injury to either shoulder.
SUBMISSIONS
Claimant’s submissions
The claimant provided amended submissions dated 25 June 2021 addressing the test to be applied by the Delegate of the President, that is whether the assessment of Medical Assessor Woo was incorrect in a material respect.[52]
[52] AD7 p 831.
The claimant submits that Medical Assessor Woo’s findings on causation, assessment of impairment, and the application of a 50% deduction for alleged pre-existing impairments are inconsistent with the claimant’s treating medical evidence, particularly with regard to his pre-accident recorded medical history, and have been calculated and applied in breach of the requirements of both the AMA4 Guides and the Guidelines.
The claimant also submits the findings of Medical Assessor Woo regarding the mechanism of the claimant’s shoulder injuries having regard to what he alleged was a minor impact cannot be maintained in the absence of an opinion prepared by a biomechanical engineer expert with appropriate qualifications.
Insurer’s submissions
The insurer provided submissions dated 2 April 2020, 22 December 2020 and 15 July 2021. The insurer disputes causation of the claimant’s shoulders injuries and says they were not caused by the accident.
The insurer highlights the following in the claimant’s evidence:
(a) the clinical records of Dr Nabavi are integral to the issue of causation of the left shoulder. The claimant damaged his left shoulder labrum in the glenohumeral joint in April 2013 suffering severe left shoulder pain. He was diagnosed with ongoing rotator cuff impingement syndrome with secondary capsular cuff tightening;
(b) an MRI of the left shoulder in April 2013 revealed early degenerative changes in the acromioclavicular joint, deformity and blunting posterior-inferior labrum, subchondral sclerosis posterior glenoid with subchondral cyst formation and axillary pouch synovitis;
(c) the claimant told Dr Lee on 12 October 2017 that he "continued to have neck pain, back pain and pain in the right arm region". Any left shoulder pain or discomfort was not disclosed;
(d) there is no clinical evidence documenting left shoulder complaints immediately following the accident and for 16 months thereafter, until 24 November 2017 when Dr Fady Shenouda, recorded the claimant's complaints of "sore hands, wrists, elbows, shoulders, ankles";
(e) the claimant alleges in the Personal Injury Claim Form and Medical Certificate injury to his right shoulder only;
(f) the claimant told Mr Glancey on 22 February 2018 that "pins and needles in his leg and arm resolved however pain remained evident to the right side of neck, right shoulder and right arm and back";
(g) in March 2018, Dr Patel noted there was "normal tone and power in upper limbs except mild give way weakness at right shoulder abduction due to pain";
(h) in May 2018, the claimant presented to Campbelltown Hospital Emergency Department complaining of left sided arm weakness;
(i) the claimant denied any "left upper limb, head or leg tremor" during an examination with Dr Patel in April 2018;
(j) on 28 June 2018, the claimant attended Dr Iskarous, to receive a B12 injection due to low vitamin deficiency. The B12 injection was given intra-muscular into the claimant's left deltoid;
(k) the claimant told Dr Patel on 28 June 2018 that he "now experiences neck pain radiating to left upper limb, in C7 distribution. He woke up with the problem ... He reported mild tremor on his left upper limb". In August 2018, the claimant reported "worsening of left shoulder pain";
(m) one week later on 6 July 2018, the claimant presented for a further B12 injection into the left deltoid;
(n) on 10 July 2018, Dr George Tosson, general practitioner diagnosed the claimant with "left shoulder adhesive capsulitis" or frozen shoulder;
(o) the claimant presented for a further B12 injection on 16 July 2018. Dr Iskarous directed Ms Bungey to perform the injection in the left deltoid. The insurer notes that the claimant was diagnosed with left shoulder adhesive capsulitis less than a week before;
(p) on 3 August 2018, Dr Patel referred the claimant to Dr Vivek Thakkar, Rheumatologist for "severe neck pain, and left shoulder pain. He has changes of adhesive capsulitis and bursitis [sic] on ultrasound";
(q) in September 2018, the claimant told Dr Thakkar that he experienced bilateral shoulder pain since the accident. In November 2019, the claimant told Dr Wallace that the pain in his left shoulder started when he had the accident. The insurer submits this history is incorrect and for the first 16 months post-accident the only complaint related to the right shoulder;
(r) Dr Thakkar observed that the claimant's adhesive capsulitis was more marked on the right than left shoulder. Dr Thakkar observed that the claimant appeared to have a picture of adhesive capsulitis on a background of morbid obesity. Dr Thakkar then performed a glenohumeral joint injection in both shoulders. The insurer notes that Dr Thakkar was clearly not aware of the claimant’s pre-existing shoulder injury;
(s) coincidentally, the claimant was diagnosed with possible adhesive capsulitis in the right shoulder in December 2016, three months prior to the accident. The Insurer submits that this condition is likely a recurring condition that is unrelated to the accident, having regard to the fact that it had onset in the other shoulder immediately prior to the accident, and
(t) therefore, the insurer submits the claimant's left shoulder condition and subsequent deterioration was not caused by the accident. Rather, it is likely to have been caused by an organic source related to his obesity or by virtue of his pre-existing 2013 workers compensation injury.
The insurer highlights the following inconsistencies in the claimant’s evidence:
(a) on 22 January 2019, the claimant told Dr Betaken, psychiatrist that he took four months off work after the accident because he was in "such severe pain in the neck and shoulders";
(b) on 23 April 2020, the claimant told Dr Hall that "mild left shoulder symptoms had been present from the outset but had increased" which allegedly led to surgery at the hands of Dr Kadir;
(c) the insurer submits that the claimant did not report any accident-related left shoulder symptoms from the outset;
(d) the claimant did not disclose these symptoms in his initial examination with Dr Hall or Dr Hyde Page nor did he disclose the symptoms to his own expert, Dr Lee, during his examination in October 2017;
(e) both Dr Lee (2017) and Dr Hall (2018) recorded normal findings of left shoulder movement with no complaints by the claimant, and
(f) the insurer submits that the claimant's assertion cannot be true in the absence of evidence from the date of the accident to July 2018 – a 16-month timeframe.
Further, the insurer submits the claimant failed to disclose to Medical Assessor Berry and all medico-legal experts, the following:
(a) in August 2004 (13 years prior to the accident), the claimant suffered a fall which "jarred" his right shoulder which resulted in a "fractured humeral heath". Dr Giblin, orthopaedic surgeon reviewed the claimant in respect of this injury and referred to his "fractured right shoulder";
(b) in 2008 (nine years prior to the accident), Liverpool Hospital diagnosed the claimant with right rotator cuff shoulder syndrome as a result of an injury whilst performing push ups, and
(c) in April 2013 (one year to the accident), the claimant suffered a soft tissue injury to his left shoulder arising out of a workplace injury, the subject of an undisclosed workers compensation claim.
The insurer relies upon the opinion of Dr Hall and Dr Hyde Page and provides the following comparison of the left shoulder examination findings of Dr Lee, Dr Hall and Dr Hyde Page as follows:
11. Body Part
12. Dr Lee
13. 9.10.2017
14. Dr Hall
15. 13.4.2018
16. Dr Lee
17. 28.11.2019
18. Dr Hall
19. 23.4.2020
20. Dr Hyde-Page
21. 27.8.20
22. Abduction
23. 170º
24. Full range of movement
25. 60º
26. 80º
27. 90º
28. Adduction
29. 50º
30. Full range of movement
31. 30º
32. N/A
33. 40º
34. Flexion
35. 180º
36. Full range of movement
37. 90º
38. 70º
39. 100 º
40. Extension
41. 60º
42. Full range of movement
43. 20º
44. 10º
45. 20º
46. External rotation
47. 90º
48. Full range of movement
49. 50º
50. Unable to approach hand to neck
51. 40º
52. Internal rotation
53. 90 º
54. Full range of movement
55. 30º
56. Minimal
57. 70º
The insurer submits the left shoulder deterioration is unusual and unexplained.
RELEVANT LEGAL AUTHORITY
Causation of injury is addressed in the Guidelines:
“1.5 An assessment of the degree of permanent impairment is a medical assessment matter under Section 58 (1)(d) 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 claims assessor) in considering such issues.
1.6 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.
1.7 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.”
EXAMINATION
Mr Hilyander attended as arranged. He is 49 years of age. He was unaccompanied during the examination but advised his wife had driven him from their home in Campbelltown.
Relevant personal details
Mr Hilyander lives with his wife and two daughters aged 6 and 7 years in Campbelltown.
He was born in Australia.
After leaving school, he worked as a printer/graphic designer with the Commonwealth Bank from age 18 to 27 years. He said that early in his career, he had done a lot of hands-on physical printing. He was retrenched from this position, and he then worked as a self-employed graphic designer until commencing full time employment with Apple in June 2016. He is employed as a computer graphic designer and works remotely.
Pre-Accident medical history
Mr Hilyander had injured a shoulder in 2013. He initially said that this had been his right shoulder, but when I raised the MRI scan performed on 15 April 2013, he agreed that it was likely his left shoulder. However, he said he had only “pulled some muscles” when he was moving some heavy paper. He said he was off work for a few weeks. He had some physiotherapy and subsequently his shoulder symptoms totally resolved.
He had injured his right knee in 2010. At that time, he was a contestant in “The Biggest Loser.” He had required arthroscopy and trimming of the meniscus of his right knee.
He had gastric sleeve surgery in 2016.
There are no other history of accidents or injuries and no relevant medical problems.
History of the accident
Mr Hilyander had been driving, his seatbelt fastened, his wife in the front seat and two children in the back seat. They were heading to the airport to pick up his mother who had returned from an overseas trip.
He said that the traffic had come to a stop as he approached the M5 tunnel. It was then that he was hit from behind by another car and apparently the vehicle behind that car was also unable to stop, so effectively, it was a three-car collision. Fortunately, Mr Hilyander had allowed sufficient space in front such that there were no further impacts and so no airbag deployment.
Immediately after the accident, he checked on his children. Details were exchanged with the other driver. Mr Hilyander recalled there had been immediate right-sided pain and tingling to the fingertips of the right hand and the toes of his right foot. Nevertheless, he continued his journey to the airport in the same car, as they were close by, and his mother was waiting.
Later that day, his wife drove him to Campbelltown Hospital. There was a substantial wait to be seen, so they were told to attend the after-hours clinic next door. They did so and he was examined by a doctor. Painkillers were prescribed and he was referred to his general practitioner.
He visited his general practitioner Dr Mina Iskarous on 22 March 2017. He said by then, his whole right side, neck and upper back was uncomfortable as well as painful. Dr Iskarous referred him for imaging and then for physiotherapy and exercise physiology.
As he was not improving, he was later referred to rheumatologist, Associate Professor Vivek Thakkar and then sent for an MRI scan of his right shoulder which was performed on 14 November 2018. He had cortisone injections to both shoulders.
He was referred to Dr Agus Kadir who he had visited on 13 December 2018. Dr Kadir performed right shoulder subacromial decompression, AC joint excision on 18 January 2019 and then left shoulder arthroscopy, debridement, capsular release, and subacromial decompression on 1 June 2019.
Unfortunately, despite the surgical intervention, Mr Hilyander continued to experience quite significant symptoms in both shoulders. He was then referred to Dr Laurent Wallace, a pain physician who he saw on 20 November 2019.
Dr Wallace had organised a left suprascapular nerve block and pulsed radiofrequency treatment on 9 December 2019. Mr Hilyander said there was slight improvement for a few weeks, but following this, no significant change.
Dr Wallace prescribed Targin 10/5 one a day commencing in November 2019 and at last review 8 September 2022, he added Gabapentin 600mg and Endep 100mg. Mr Hilyander stated there had been mild improvement with these new medications.
He added that at the last visit seven to eight weeks ago, Dr Kadir had discussed the prospect of arthroplasty to the right shoulder although noting that Mr Hilyander is currently thought to be too young for that procedure.
There had been no other treatment since then.
Current Symptoms
Mr Hilyander indicated that he had limited mobility, mainly in relation to moving his arms due to the shoulder symptoms.
He sleeps poorly.
He said he is restricted in the activities he can participate in. He said he used to be a Level 2 strapper for rugby league and a sports photographer but had been forced to cease these activities six months after the accident. He also can no longer play golf. He feels his shoulders are becoming progressively worse and added that even after the surgical procedure he had only had a few months relief.
There were no current symptoms in his neck, although there is discomfort over the trapezius muscles bilaterally.
His upper back is also asymptomatic.
Clinical examination
Mr Hilyander indicated he was 172cm tall and weighed 189kg.
On examination of the cervical spine, there was full pain-free movement in all planes. There was no asymmetry, muscle spasm or guarding.
On examination of the upper limbs, power, sensation, and reflexes were symmetrical. Reflexes were bilaterally of low amplitude and difficult to elicit, but nevertheless present and equal.
Circumferential measurements of the upper limbs were consistent with right-hand dominance, 44cm arms bilaterally, and 35cm right forearm, 34.5cm left forearm.
On examination of the thoracic spine, there was full pain-free movement in all planes There was no asymmetry, muscle spasm or guarding. Lower limb neurology was normal.
Shoulder movements were recorded as follows:
Shoulder Movements Active ROM Measured
RIGHT
Active ROM Measured
LEFTForward Flexion
100° 80° 90°
90° 80° 90°
Extension 50° 35° 40° 30° Internal Rotation 10° 10° External Rotation 60° 50° Abduction 100° 70° 60° 50° Adduction 45° 60° 25° 30°
I note that the measurements were variable in relation to shoulder movements today. I asked him about this, and he indicated that his shoulders fatigue on repeated movement and that his shoulders have been worsening over time, thus accounting for the deterioration in his measurements between the two medical assessments of Medical Assessors Berry and Woo.
PANEL FINDINGS
Causation
Mr Hilyander is a 49-year-old man who was injured in the accident of 26 March 2017. There had been initial neck and upper back pain. There is no dispute as to causation of injury to the cervical and thoracic spine.
Mr Hilyander also alleges progressive shoulder pain and dysfunction and despite cortisone injections and two surgical procedures, progressive impairment of both shoulders.
The test for causation set out in the Guidelines requires the Panel to determine whether the injury was caused by materially contributed to by the accident and whilst the accident does not have to be the sole cause it must be a contributing cause which is more than negligible.
Causation of the right shoulder injury
One day after the accident on 26 March 2017 the claimant consulted Dr Iskarous when he complained of weakness in the left hand and on 31 March 2017 Dr Iskarous reported “aching pain in the arms”. Whilst neither party included the Personal Injury Claim Form in their documents the Panel notes the insurer concedes that both the claim form and the attached Medical Certificate referred to injury to the right shoulder. By June 2017 the claimant had commenced treatment with Lifestyle & Sports Physiotherapy in respect of whiplash and right shoulder girdle pain.
The Panel is satisfied the claimant suffered an injury to his right shoulder in the accident.
Causation of the left shoulder injury
Causation of injury to the left shoulder is more problematic. It is clear from the MRI of the left shoulder of 15 April 2013 including “degenerative change postero-inferior labrum” and from the evidence of Dr Nabavi that Mr Hilyander injured his left shoulder in 2013. Dr Nabavi diagnosed ongoing rotator cuff impingement syndrome with secondary capsular cuff tightening.
Following the accident on 26 March 2017 there is no record of complaint pertaining to the left shoulder until 24 November 2017 when Dr Shenouda recorded the complaints of “sore hands, wrists, elbows, shoulders, ankles”. 16 March 2018 Dr Patel reported he was concerned about “right shoulder tendinopathy or bursitis” and on 28 June 2018 Dr Patel reported:
58.“He now experiences neck pain radiating to left upper limb in C7 distribution. He woke up with the problem. He reports lots of cramps. He reports mild tremor on his left upper limb.”
On 10 July 2018 Dr Tosson, general practitioner diagnosed the claimant with “left shoulder adhesive capsulitis” or frozen shoulder and on 3 August 2018 Dr Patel referred the claimant to Dr Thakkar for “severe neck pain, and left shoulder pain” and reported changes of adhesive capsulitis and bursitis on ultrasound.
Thereafter the clinical notes report consistent complaints pertaining to the left shoulder.
In Norrington v QBE Insurance (Australia)Ltd[53] Brereton J addressed the presence or absence of a contemporaneous record of complaint in the determination of causation stating at [31]:
59.“In the context of medical assessment under MACA, there is now a substantial body of authority that a panel which decides the question of causation solely on the basis of the existence or otherwise of contemporaneous evidence of complaint of injury fails properly to address the questions posed by s 58(1), and that this is jurisdictional error.”
[53] [2021] NSWSC 548, Norrington.
Brereton J referred to the decision of Campbell J in Owen v Motor Accidents Authority(NSW)[54] where it was noted that the failure of a treatment provider to make a record of complaint should not be treated as decisive where “busy doctors sometimes misunderstand or misrecord histories of accidents, particularly in circumstances where their concern is with the treatment or impact of an indisputable, frank injury: Davis v Council of the City of Wagga Wagga[2004] NSWCA 34 at [35]).”
[54] [2012] NSWSC 650.
In Kinchela v Insurance Australia Group Ltd t/as NRMA Insurance[55] Justice Walton set aside the decision of a Medical Review Panel. In considering the question of causation in relation to an amputated toe Justice Walton stated by focusing on whether there was a contemporaneous record of complaint in the clinical notes the actual question the Review Panel was required to consider was overlooked, in that case, did the motor vehicle accident materially contribute to the right second toe amputation.
[55] [2021] NSWSC 804, Kinchela.
In addressing causation, the Panel notes not only did the claimant not make any contemporaneous complaint to his treating practitioners, but he did not disclose any complaint when assessed by medico-legal practitioners. Dr Lee assessed the claimant at the request of his lawyers on 9 October 2017 and did not record any complaint pertaining to the left shoulder. He reported the claimant continued to have neck pain, back pain and pain in the right arm region.
On 22 February 2018 Gerard Glancey, psychologist reported “pain remained evident to the right side of neck, right shoulder and back”.
On 13 April 2018 Dr Hall observed a "very full range of (left) shoulder movement" during the examination. His diagnosis was limited to the neck, right shoulder and right upper limb.
The Panel also notes when the claimant was assessed by Medical Assessor Berry on 24 April 2018, he made no complaint about the left shoulder and no restriction in range of movement was identified on examination.
The Panel also refers to the comparison of range of movement of the left shoulder set out in the table at paragraph 101 above which suggests there is no temporal connection between the accident and the onset of symptoms relating to the left shoulder.
The claimant relies upon the opinion of Dr Lee and Dr Porteous who both conclude the claimant developed significant left shoulder pain and restriction in 2018 due to favouring the right shoulder. Dr Lee suggested the impact of the operation caused the posterior labral tear in the left shoulder rendering the shoulder unstable leading to rapid degeneration.
However, it is apparent from the 15 April 2013 MRI scan that there was already degenerative change in the labrum and the Panel considers that normal wear and tear over the following five years on the background of morbid obesity as suggested by Dr Thakkar resulted in the labral tear, glenohumeral osteoarthritis and adhesive capsulitis. As Dr Thakkar stated, “one would have to postulate that certainly the left shoulder findings have been developing over quite some time”.
The Panel is not satisfied the claimant sustained an injury to the left shoulder in the accident.
ASSESSMENT OF PERMANENT IMPAIRMENT
Cervical [Cervicothoracic] spine
There were complaints of pain or symptoms, but without vertebral body compression or vertebral fracture. There were no clinical findings and in accordance with Table 7 of the Guidelines the cervical spine injury would be assessed at DRE Impairment Category I, resulting in a 0% WPI.
Thoracic [Thoracolumbar] spine
There were complaints of pain or symptoms, but without vertebral body compression or vertebral fracture. There were no clinical findings and in accordance with Table 7 of the Guidelines the thoracic spine injury would be assessed at DRE Impairment Category I, resulting in a 0% WPI.
Right shoulder
Shoulder movements were variably restricted when measured at assessment by the Panel, and by comparison to earlier examinations. Clause 6.50(d) of the Guidelines states “If there is inconsistency in range of motion then it should not be used as a valid parameter of impairment evaluation.” Clause 6.50(e) of the Guidelines states “If range of motion measurements at examination cannot be used as a valid parameter of impairment evaluation, the assessor should then use discretion in considering what weight to give other available evidence to determine if an impairment is present.”
The Guidelines advise that the assessor can use their clinical judgement in determining an appropriate impairment rating. The Panel considered all the available clinical and radiological evidence, and notes cl 6.67 of the Guidelines permits an assessment to be completed by analogy. The Panel was of the opinion that the accident related shoulder impairment may be considered analogous to moderate intermittent acromioclavicular joint crepitation. Referring to Table 19 of the AMA 4 Guides at page 3/59 the Panel found there was a 20% impairment from joint crepitation which equates to a 3% WPI in accordance with Table 18 of the AMA 4 Guides.
CONCLUSION
The Panel finds the accident caused the following injuries and give rise to a total WPI of 3%:
· injury to the cervical spine;
· injury to the thoracic spine, and
· injury to the right shoulder.
The Panel finds the following injury was not caused by the accident:
· injury to the left shoulder.
Pre-existing/subsequent impairment
There is no pre-existing or subsequent impairment.
Apportionment
Apportionment is not applicable.
4
0