Insurance Australia Limited t/as NRMA Insurance v Cooper
[2025] NSWPICMP 257
•14 April 2025
| DETERMINATION OF REVIEW PANEL | |
| CITATION: | Insurance Australia Limited t/as NRMA Insurance v Cooper [2025] NSWPICMP 257 |
| CLAIMANT: | Christine Cooper |
| INSURER: | Insurance Australia Limited t/as NRMA |
| REVIEW PANEL | |
| MEMBER: | Jeremy Lum |
| MEDICAL ASSESSOR: | Wayne Mason |
| MEDICAL ASSESSOR: | Christopher Rikard-Bell |
| DATE OF DECISION: | 14 April 2025 |
| CATCHWORDS: | MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; review of Medical Assessment Certificate (MAC); threshold injury; Review Panel found claimant’s pre-existing social anxiety disorder was aggravated by the motor accident and was therefore not a threshold injury; Todev v AAI Limited t/as GIO applied; claimant did not meet DSM-5-TR Criterion A for diagnosis of PTSD; Held – motor accident caused an aggravation of social anxiety disorder which is not a threshold injury; MAC revoked; new certificate issued. |
| DETERMINATIONS MADE: | CERTIFICATE OF DETERMINATION Certificate issued under Division 7.5 of the Motor Accident Injuries Act 2017 1. The Review Panel revokes the certificate of Medical Assessor Samson Roberts dated (a) The Review Panel certifies the following injury was caused by the motor accident: (i) aggravation of pre-existing social anxiety disorder. (b) The Review Panel finds that the above injury is NOT a threshold injury for the purposes of the Motor Accident Injuries Act 2017. |
STATEMENT OF REASONS
BACKGROUND
Christine Cooper (the claimant) was involved in a motor accident on 5 August 2020.
The claimant says she was driving her car through a roundabout when another vehicle entered the roundabout and struck the passenger side of her car. She suffered injuries to the left side of her body including her wrist/hand, shoulder and hip. She also says she suffered anxiety from the motor accident.
She made a claim for statutory benefits with Insurance Australia Limited t/as NRMA (the insurer), the third-party insurer of the vehicle that she says caused the accident.
A medical dispute arose about whether the claimant’s psychological injury is a threshold injury or not a threshold injury and the matter was referred to the Personal Injury Commission (Commission) for medical assessment.
On 18 September 2023, Medical Assessor Samson Roberts found the motor accident caused the claimant to suffer from post-traumatic stress disorder which is not a threshold injury.
The insurer lodged an application with the Commission seeking review of the Medical Assessor’s decision. This was allowed by the President’s delegate and this Panel was convened to conduct the review.
RELEVANT LEGISLATION
Threshold injury
Under the Motor Accidents Injuries Act 2017 (the MAI Act), there is a scheme for statutory benefits (under Part 3) for persons injured in motor accidents in New South Wales. Such benefits can include treatment and care and weekly payments.
For injured persons who have “threshold injuries”, they cannot receive statutory benefits beyond 52 weeks after the accident and cannot recover damages.[1]
[1] The terminology for accidents that occurred before 1 April 2023 (such as the present) was “minor” injury and statutory benefits were only paid for up to 26 weeks.
Version 9.3 of the Motor Accident Guidelines (Guidelines), effective from 6 December 2024, applies to the review. Part 5 deals with the assessment of threshold injury for psychiatric injuries.
The general provisions for medical assessment are contained in cl 5.6 of the Guidelines and are in the following terms:
“5.6 The assessment of whether an injury caused by the accident is a threshold injury for the purposes of the Act should be based on the evidence available and include all relevant findings derived from:
(a)a comprehensive accurate history, including pre-accident history and pre-existing conditions
(b)a review of all relevant records available at the assessment
(c)a comprehensive description of the injured person’s current symptoms
(d)a careful and thorough physical and/or psychological examination
(e)diagnostic tests available at the assessment. Imaging findings that are used to support the assessment should correspond with symptoms and findings on examination.”
Specifically, in relation to threshold psychological or psychiatric injury assessments, cls 5.10-5.12 provide as follows:
“5.10 In assessing whether an injury is a threshold psychological or psychiatric injury, an assessment of whether a psychiatric illness is present is essential.
5.11 The assessment of whether a psychiatric illness is present must be made using the Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), published by the American Psychiatric Association.
5.12 Where the symptoms associated with the injured person’s psychological or psychiatric injury do not meet the assessment criteria for a recognised psychiatric illness, with the exception of acute stress disorder and adjustment disorder, the injury will be considered a threshold injury.”
Causation of injury
It is necessary for the Panel to consider whether the accident caused or contributed to the diagnosed psychological or psychiatric condition. The provisions regarding causation of injury are contained in cls 6.5 to 6.7 of the Guidelines and apply to both permanent impairment and threshold injury disputes. [2]
[2] Briggs v IAG Limited Trading as NRMA Insurance [2022] NSWSC 372 per Wright J at [35].
The provisions state:
“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 biological factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following”
1.The alleged factor could have caused or contributed to the 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.”
Further, the provisions of the Civil Liability Act 2002 apply, in particular s 5D and s 5E.
MEDICAL ASSESSMENT UNDER REVIEW
As mentioned above, Medical Assessor Roberts diagnosed the claimant as suffering from post-traumatic stress disorder. The claimant gave an account of intrusion symptoms, namely nightmares and vigilance when travelling in addition to the degree of avoidance behaviour or at least the preference to avoid travel. Her account of the motor accident indicates that it was of sufficient impact to render both vehicles undrivable and to cause enduring symptoms. As such, this was enough for the Medical Assessor to conclude that Criterion A trauma was satisfied. The Medical Assessor went on to find that the history from the claimant reflected a diagnosis of post-traumatic stress disorder albeit at the mild end of the spectrum of severity.
The Medical Assessor found that post-traumatic stress disorder is not a threshold injury.
ISSUES FOR DETERMINATION
The insurer submits that Medical Assessor Roberts did not give sufficient reasoning on how his clinical findings satisfied the DSM-5 criteria for a diagnosis of post-traumatic stress disorder.
According to the DSM-5, the insurer says a diagnosis of post-traumatic stress disorder requires the satisfaction of 8 criterion – A to H. The insurer contends that the Medical Assessor failed to show how the claimant meets Criterion B, C, D, E, F and G.
Specifically, and in respect of each criterion, the insurer says:
· Criterion B – The claimant reports she has nightmares but she does not recall the content of the dreams. There is no indication that these dreams are associated with the traumatic events/motor vehicle accident as per criterion B requirement. The claimant does not report flashback.
· Criterion C – The claimant did not report avoidance of stimuli associated with the subject accident. Whilst the claimant reports feeling anxious when driving, she continues to drive and remain confident in her own driving.
· Criterion D – The claimant did not report depressed mood. She is able to enjoy things and continue with activities that she enjoys eg. reading. The claimant also maintains a good relationship with her family and socialises with her family. There is no evidence that the claimant has signs noted in point 4 to 7 of criterion D.
· Criterion E – The claimant reports being hypervigilance and extremely alert in traffic only. The claimant reports she sleeps through the night and it is the pain from the physical injuries that affects her sleep. The Medical Assessor also notes the claimant did not report deficits of concentration and memory. She watches TV and reads a book collection when at home. It is submitted the claimant only has one of the two or more signs needed for criterion E.
· Criterion F – The insurer notes that criterion F requires the disturbance in criteria B, C, D and E to be more than 1 month. Since the claimant fails to meet criteria B, C, D and E, she therefore does not meet criterion F.
· Criterion G – There is no evidence of significant impairment in the claimant’s daily living, social, occupational or other important areas of functioning arising from her psychological injuries.
The insurer submits that according to DSM-V, the claimant must meet all eight criterion, that is criterion A to H for a diagnosis of post-traumatic stress disorder. It is submitted that the claimant does not meet all eight criteria and that the Medical Assessor failed to explain how the claimant meets the diagnosis of post-traumatic stress disorder in accordance with DSM-5.
The claimant did not lodge a reply to the insurer’s application for review.
REVIEW OF THE EVIDENCE
On 15 November 2024, the Panel issued a direction to the parties requiring indexed and paginated bundles of the information they relied upon. The Panel stated that unless documents are uploaded to the review file, the Panel would not be able to read and consider those documents. The parties responded with the lodgement of bundles – the claimant’s bundle comprising of pages 1-17 and the insurer’s bundle comprising of pages
1-37.At the Panel’s preliminary conference, a further direction was issued to the parties requiring the following:
· all general practitioner’s (GP) notes of the claimant including from Weston Medical Centre from 2019 to present day;
· any treating psychologist/psychiatrist records from 2019 to present day;
· all clinical records (if any) from Dr Saric, psychiatrist, and
· photographs (if available) of the damage to the vehicles involved in the subject accident including identification of the claimant’s vehicle.
On 14 March 2025, the claimant provided the clinical notes of Procare which attached reports from the claimant’s treating psychiatrist, Dr Domagoj Saric, dated 9 February 2022, 27 April 2023 and 29 August 2023.
On 7 April 2025, the claimant provided the clinical notes from Weston Medical Centre.
Both parties advised that they did not hold photographs of the damage to the vehicles involved in the subject accident.
The relevant material is summarised in the Panel re-examination report below.
RE-EXAMINATION FINDINGS
The Panel determined that the claimant be re-examined by Medical Assessors Mason and Rikard-Bell on 17 March 2025. The re-examination report is as follows:
“Brief Personal Details
Ms Cooper is a 40-year-old woman who is not working and is in receipt of Jobseeker payments through Centrelink. She lives in her own home in Hunter Valley near Cessnock with her 2 daughters aged 18 and 19 years.
Personal history
Ms Cooper was born in Liverpool Hospital with a normal birth and development. Her 59-year-old father was a sheet-metal worker who had a stroke 7 years ago and is currently not working because of what she described as a Functional Neurological Disorder. Her 56-year-old mother continues to work running a small accounting business. Ms Cooper is the oldest of 4 children with brothers aged 38 and 36 and a sister age 35 years. She described a happy childhood in which she suffered no form of abuse. She said her parents moved to Maitland in the Hunter Valley when she was 2 years of age.
Ms Cooper described being involved in a serious motor vehicle accident when she was less than 2 years of age. The details she gave were provided to her by her mother. She said it happened at a crossroads near Casula when another vehicle came through a red light. She said her mother was driving the vehicle and was pregnant at the time. Her paternal grandmother and her younger brother (who was a baby) were also in the car. She said her paternal grandmother's arm was ripped off at the shoulder. This was surgically reattached but was essentially neurologically non-functional. Her mother said before the accident she was a friendly child who would run up to people, but afterwards her personality changed and she became shy, less bubbly and avoided people. Ms Cooper did not lose consciousness in that accident and has no memory of it. However, she did report having images of a car spinning and a yellow car hitting a wall until she was about 10 years of age. She also described nightmares at that time.
She attended Gillieston primary school; she said it was a very small school and she had one friend throughout. She then attended Rutherford Technology High School but left in year 11 because of bullying and having trouble keeping up with her studies. She said she was isolated in high school but after year 10 got along well with some new students. She did well in mathematics and English and enjoyed Japanese but did not do well at art. She said she was an anxious child and was socially fearful.
After leaving school she worked at Best&Less for 2 years. She became involved in a relationship at 18 years of age and lived with her partner. Her daughter was born when she was 20 and she left work at that time. She said they were together for a total of 18 years but married in 2010. She said her partner went downhill after his mother died and began to use drugs and get into trouble with police. He became violent towards her older daughter and she asked him to leave. She said it was a difficult time because he threatened suicide but she was better off after he left and was well supported by her family; they separated in 2021.
Ms Cooper then commenced an online degree in primary school teaching with Curtin University in Western Australia. She obtained her bachelor's degree in 2015. She commenced teaching with the Department of Education in the Hunter Valley. She was initially in the casual pool which resulted in between 3 and 4 days of work per week. In 2020 and 2021 she was employed full-time as a casual teacher at Singleton Heights primary school. She said at that time she was being considered for a permanent appointment with the department.
Leisure activities consisted of going to trivia nights at local hotels if she was accompanied by a family member. She said she could never go alone because of social anxiety and she would not stand up to answer the question because of social anxiety. However, she did enjoy attending and coming up with the answers. She also enjoyed going for drives with her daughters in the local area and to the beach.
Ms Cooper denied any past insurance claims and said she had not been in trouble with the law.
Medical history consisted of the onset of migraines at 15 years of age which she said were so severe at times she passed out in the classroom. She developed hyperthyroidism in 2016 which was treated with radioactive iodine. She also suffers from hypertension. In 2023 she had gained 20 kg and developed sleep apnoea which has been successfully treated with CPAP for the past year. In 2024 she developed type 2 diabetes which is treated with oral medication. Surgery consisted of the Caesarean delivery of her second child in 2006.
Past psychiatric history has consisted of a long history of social anxiety dating back to her early childhood. She said she was always socially fearful. At age 16 she became really withdrawn and did not want to leave the house due to a combination of both anxiety and depression. This was caused by the death of a female cousin who died at 15 years of age after being hit by a car. She was in a depressed state in which she did not care about anything and simply wanted to sleep; she denied suicidal ideation. She received treatment from her GP who prescribed the antidepressant sertraline. Ms Cooper continued to use sertraline 150 mg for 3 years but stopped due to emotional numbing. She saw psychologists on a few occasions which was not particularly helpful. In more recent years the anxiety precluded her from going where she did not know people and she could not go to crowded venues. She said she was okay in some shopping centres but always tried to go shopping with her daughters. If absolutely necessary she could go shopping alone but she would experience episodes of blanking out (dissociating) and would find herself walking up and down the aisles not knowing what she was looking for. She denied agoraphobia but confirmed she was subject to panic attacks. As a teacher prior to the motor accident, she was able to manage the basic tasks required of her in the classroom and the broader school environment. As noted above, she could not attend trivia nights alone and was extremely uncomfortable in drawing attention to herself.
Family history of psychiatric illness consists of her father’s depressive illness prior to having a stroke which required antidepressant medication but not hospitalisation. Her sister has been diagnosed with bipolar affective disorder which also requires medication but not hospitalisation. She noted four paternal cousins have attempted suicide. One maternal cousin was hospitalised following a suicide attempt. An uncle died at 45 years of age in 2012; he suffered from schizophrenia.
Current medications consist of venlafaxine 225 mg at night and propranolol 25 mg twice daily prescribed by treating psychiatrist Dr Saric. She uses an antihypertensive agent but was unable to remember the name. Metformin 500 mg is taken in the morning for diabetes. Topiramate 100 mg at night is used for migraine. Amitriptyline 25 mg is used at night for both pain and depression.
Ms Cooper denied the use of cigarettes, alcohol and recreational drugs. She said she does not gamble. Caffeine consumption consists of 1 L of Coca-Cola per day.
Prior to the motor accident she said her self-care and personal hygiene was adequate. She had some friends but largely confined herself to family interactions. She was able to drive, travel as a passenger in a car and use public transport without anxiety. She was not in a relationship. She enjoyed reading and watching television. She was working full-time in a casual teaching role.
History of the Motor Accident
Ms Cooper said she was taking her daughter to a 7:30 AM appointment prior to school. The accident occurred in a roundabout close to her home. She was a seat belted driver of a 4-door Ford Territory SUV. Her daughter in the front seat was also wearing a seatbelt. She said another vehicle hit the passenger side of her vehicle towards the rear. Airbags did not deploy. Her vehicle was pushed towards the gutter. There was no head injury or loss of consciousness.
She said the other vehicle was small and was badly crumpled. She was able to self-extricate and was worried about the other driver. She did not describe being in fear for her life. She was worried about her daughter and how she would be affected. She checked on her and was relieved to see she was okay. Serendipitously, police arrived 1 minute later. She exchanged details with the other driver and took photographs. She called her father who came to the accident site and took them home.
History of Symptoms and Treatment Following the Motor Accident
Ms Cooper attended her GP on that same day. She described pain around her ribs and neck which she said settled fairly quickly. She was not prescribed analgesia and no x-rays or scans were immediately ordered. She returned to the GP 2 days later because of pain in her left shoulder, left hip and left hand in the area of the carpal bones. X-rays were ordered which revealed no fractures. She was provided with analgesics for control of pain. Nerve conduction studies were conducted with negative results. Ultrasounds resulted in a diagnosis of bursitis and tendinitis of her left shoulder and left hip. She was referred to hand specialist orthopaedic surgeon Dr Joshua Hunt who noted degenerative changes in the third carpometacarpal joint. This did not respond to cortisone injection and he recommended fusion of the metacarpal-capitate joint.
Psychological symptoms consisted of the immediate onset of anxiety associated with driving and being a passenger in a car. She said she developed nightmares in which she would wake up screaming. She said these were different to be old nightmares she experienced up until the age of 10 years. She referred to them as night terrors which consisted of being attacked, not being able to speak and fear of dying. She said they were not specifically connected to the subject motor accident. She said she was commenced on another antidepressant by her general practitioner but could not remember the name.
She avoided driving but could do it if absolutely necessary. She said she was much more uncomfortable as a passenger in a vehicle. If she had to drive for an extended period of time, she would develop nausea and faecal incontinence and was subsequently worn out and would have to sleep. She said she experienced intrusive thoughts regarding the motor accident if she was not otherwise occupied.
She said she did experience flashbacks in which she would see the motor accident as if she was there again. These initially occurred every couple of days but gradually reduced in frequency and stopped approximately 12 months ago.
Since the motor accident she has been a lot more fearful. She said she thinks she could die at any minute. She confirmed that she did not fear she would die in the actual motor accident. She said she is unable to watch a motor accident on television so avoids the news. She is unable to scroll on Facebook in case she encounters the news of someone dying. She described being much more fearful of many activities and said she now could not go on a rollercoaster, do white water rafting or watch horror movies. She finds it much harder to make telephone calls to people. She confirmed she did have an exaggerated startle response, particularly to car horns.
She confirmed she did continue to work from August to December 2020 but she became much more affected by anxiety. She said she needed special conditions at work. She was unable to do playground duty where she was exposed to a large number of children. She was unable to go to the staff common room because of social anxiety. She said she could not do dual teaching with another teacher because of fear of perceived judgement. She was unable to move far from her classroom which was near toilet facilities because of increasing faecal urgency.
Treatment consisted of talking to her GP and parents throughout the following year. She said she tried to see a psychologist and had 3 or 4 sessions in early 2022 but said she was not able to establish a good rapport. She was unable to find another psychologist because she could not afford to go.
She was referred to psychiatrist Dr Saric in 2022 which she thought was helpful. She believes she has had 3 or 4 sessions. He commenced her on venlafaxine 75 mg and this was eventually increased to 225 mg which she thinks has been helpful. Propranolol was increased to 20 mg twice daily. She noted topiramate 100 mg assisted with headaches, nightmares and sleep.
Injuries or Conditions since the Motor Accident
Ms Cooper said another cousin died of a brain seizure in November 2024 at 24 years of age. She said this did cause sadness and depression and she does not believe she has made a full recovery from that event.
Current Symptoms
Ms Cooper said she continues to be withdrawn and hide away socially. Sleep remains disrupted. She continues to have anxiety while driving but can drive wherever she wishes. Extended trips result in her being physically ill, suffering diarrhoea and being extremely tired. She said she continues to sleep excessively and yet feels like she has not had a good sleep. Vivid dreams do continue. She described going to bed at 10:30 PM and getting off to sleep quickly but then waking every 2 hours. She said she does get back to sleep easily and rises at 8:00 AM or 8:30 AM. She denied suicidal ideation, is not experiencing flashbacks but does continue to have nightmares which can wake her. She no longer attends trivia nights with her parents and is unable to work as a teacher because of anxiety. She said she can do some data entry tasks in her mother's accountancy business.
Current and Proposed Treatment
Ms Cooper will continue to consult with her GP and psychiatrist and use the prescribed medication. She said she will also make efforts to obtain a regular psychologist.
Current Functioning
Ms Cooper said she can take her dog for a 15-minute walk in the mornings. She also drives her daughters to university or to the bus stop. She said she spends her day doing genealogy or reading Jane Austen books. She has difficulty with housework because of pain but is assisted by her daughters. She said she does not do any socialising and does not attend trivia nights. She helps her mother in her business behind the scenes but does not engage with clients. She is not involved in a relationship. She said she can read a book for 1 hour. She is physically restricted from prolonged standing, walking for long distances or lifting heavy loads.
Consistency of presentation
Ms Cooper’s presentation was internally consistent, consistent with the documentation provided and consistent with the diagnosis I have made.
Mental State Examination
Ms Cooper is a 40-year-old right-hand-dominant woman whose appearance is consistent with her stated age. She was identified from the photograph on NSW driver's licence in the same name. She was located alone in a room in her home. She was interviewed using the Microsoft Teams application with a good Internet connection. The interview commenced at 2 PM and concluded at 3:15 PM.
Ms Cooper appeared to be very anxious at the beginning of the interview but this gradually settled as the interview proceeded. She was not depressed in appearance. She displayed a full range of appropriate affective expression. She did not describe symptoms consistent with a mood disorder and was not tearful throughout the interview. She denied suicidal ideation and anhedonia.
She described the presence of pre-accident anxiety symptoms and noted that these were significantly increased following the motor accident. She was not fearful of losing her life in the subject motor accident. She described the development of frequent nightmares following the motor accident and the development of flashbacks. However, she was most disabled by increased social anxiety which interfered with her ability to work and to socialise. She described the development of physiological concomitants of anxiety such as tremors, sweating, fear of faecal incontinence, occasional panic attacks and dissociative episodes.
Ms Cooper was fully oriented in time, person and place and displayed no evidence of organic or psychotic psychopathology.
Summary of Relevant Documentation
Clinical record of Weston Medical Centre (Dr Ann Fernando) is dated 3 September 2021. Ultrasound left hip on 2/9/2021 indicated the presence of trochanteric bursitis.
The full clinical records of Weston Medical Centre contained pre-accident entries dating back to October 2018. An entry dated 21 May 2020 noted anxiety and panic attacks with anxiety worsening after returning to work following COVID 19. There was social anxiety and a panic attack happening (today) at work. An entry on 17 July 2020 noted worsening of anxiety and experiencing panic attacks. Claimant worried about minor things and unable to leave house. Interference with ADL.
Post-accident entries from 5 August 2020 to October 2020 included left wrist, shoulder and hip pain from the motor accident. From 2 November 2020, there was a worsening of the claimant’s anxiety. The claimant was unable to work and ceased work in December 2021.[3] In 2022, she separated from her husband.[4] She was seeing psychiatrist Dr Saric for anxiety and depression which worsened. Further entries in 2024 and early 2025 detailing anxiety and stress with a lack of motivation, feeling withdrawn and staying at home.
[3] The history as given to the Panel was that the claimant ceased work in December 2020.
[4] The history as given to the Panel was that the claimant separated from her husband in 2021.
Orthopaedic hand surgeon Dr Joshua Hunt sought approval for fusion of the metacarpal capitate joint on 17 June 2021 as a consequence of pain arising from a motor accident. He noted 6 weeks in a cast and a 3-month recovery. On the same date he noted cortisone injection had not been of any help.
Psychiatrist Dr Domagoj Saric provided a report to the treating doctor dated 9 February 2022, 18 months after the MVA. The claimant was referred for diagnosis and medication review. He noted she grew up in Liverpool, school till year 11, initially worked in parents’ accounting business and then at Best&Less. No mental health admissions and no previous psychiatrists. Ceased casual work as a teacher in December 2020 due to anxiety. Does some part-time work in accounting with mother. Anxiety exacerbated by any form of confrontation and driving. Denies agoraphobia but admits to panic episodes. Intense vivid dreams all her life. Put on 20 kg in last 3 years. Denies anhedonia. Uses avoidance to manage anxiety. Has a family history of paternal depression, a sister with bipolar affective disorder and PTSD and an uncle with schizophrenia. 4 of her father's cousins have suicided. Involved in a massive car accident at age 2 when grandmother's arms ripped off. Developed PTSD symptoms. Witnessed domestic violence in aunt’s relationship. Parents were emotionally available but Christine was distant. No evidence of personality disorder. No alcohol or drug use. Medication sertraline 150 mg and propranolol 20 mg twice daily. Diagnoses were generalised anxiety disorder and PTSD. He recommended continuing current medication and referral to psychologist and physiotherapist; prazosin recommended for control of nightmares. Increase sertraline to 200 mg. Mood 4/10.
Dr Saric provided a further treatment report dated 27 April 2023. At that time she was using venlafaxine 150 mg in the morning. She noted being totally disabled by anxiety in school and all school related work and requested completion of TPD forms via superannuation. She had been using venlafaxine 75 mg which helped a little. She is also using topiramate 50 mg which helped with migraines and night terrors. He suggested increasing venlafaxine to 150 mg for 1 month and then to 225 mg if tolerated. She is not consulting a psychologist. He again recommended psychological consultation.
There was a further report from Dr Saric dated 29 August 2023. Dr Saric noted that he saw the claimant on 9 February 2022 and again on 27 April 2023 where he diagnosed the claimant with Generalised Anxiety Disorder and Post-traumatic Stress Disorder. He stated that the claimant’s symptoms had only mildly improved a year on and suspected any return to working as a primary school teacher was ‘a long way off’. He recommended ongoing psychological therapy with occupational rehabilitation support.
Certificate of PIC assessor Alan Home dated 28th February 2023 was received on 30 January 2025. He assessed the following conditions as minor injuries:
Left wrist/hand – underlying degenerative changes at the third carpometacarpal joint
Chest – bruising to the rib cage, now resolved
Left hip – soft tissue injury and trochanteric bursitis of the left hip
Left shoulder – aggravation of underlying rotator cuff tendinopathy with superimposed bursitis.”
DETERMINATIONS
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 and is to be by way of a new assessment of all the matters with which the medical assessment is concerned.[5]
[5] Section 7.26(6) of the MAI Act.
The Panel may confirm the certificate of assessment or revoke that certificate and issue a new certificate as to the matters concerned.[6]
[6] Section 7.26(7) of the MAI Act.
The Panel refers to the above re-examination report of Medical Assessors Mason and Rikard-Bell and adopts the findings in their entirety.
The Panel reconvened on 31 March 2025 and discussed the re-examination report findings before collectively making the below determinations.
Diagnosis and Reasons
The Panel diagnosed an aggravation of pre-existing social anxiety disorder.
The claimant meets DSM-5-TR criteria for social anxiety disorder as follows:
Criterion A. She has enhanced fear of social situations in which she is exposed to scrutiny and/or judgement by others.
Criterion B. She has enhanced fear she will be negatively evaluated by others.
Criterion C. Social situations almost always provoke fear and anxiety.
Criterion D. Social situations are always endured with intense fear or anxiety.
Criterion E. The fear is out of proportion to the actual threat.
Criterion F. The fear has lasted for more than 2 years.
Criterion G. The fear has caused social and occupational impairment.
Criterion H. It is not attributable to a substance or another medical condition.
Criterion I. It is not better explained by another mental disorder.
Criterion J. Another medical condition such as Parkinson's Disease which could give rise to a fear of social judgement is not present.The Panel did not diagnose post-traumatic stress disorder because the subject motor accident did not meet DSM-5-TR Criterion A for that condition.
Causation and Reasons
Ms Cooper was a vulnerable individual who had experienced social anxiety disorder in the past. She reported an aggravation of symptoms following the motor accident which impaired her ability to work as a teacher. She walked away from her job in December 2020.[7] The motor accident was capable of causing an aggravation of this nature given the apparent forceful nature of the impact and the claimant’s increased fear, anxiety and inability to function socially, such as no longer attending trivia nights or engaging with her mother’s work clients, as described in the Panel re-examination report above. In the opinion of the Panel, the motor accident materially contributed to the deterioration in her condition.
[7] Procare letter dated 9 February 2022 and history given by the claimant to the Panel.
While the Panel notes that “post-traumatic stress disorder” was the sole injury referred to Medical Assessor Roberts for medical assessment, the Panel considers the diagnosis of social anxiety disorder to be within the scope of the medical dispute referral.[8] This is because the claimant’s social anxiety is well documented in the Weston Medical Centre clinical notes and was a theme throughout the three reports of Dr Saric who was the claimant’s treating psychiatrist. Dr Saric also made an alternative diagnosis of generalised anxiety disorder which is reasonably consistent with the Panel’s diagnosis.
[8] Mandoukos v Allianz Australia Insurance Limited [2024] NSWCA 71 (4 April 2024).
Summary of injuries referred by the parties
The following injuries WERE caused by the motor accident:
· aggravation of pre-existing social anxiety disorder.
The following injuries WERE NOT caused by the motor accident:
· post-traumatic stress disorder.
Threshold injury
Section 1.6(1) of the Act states that:
“For the purposes of this Act, a threshold injury is, subject to this section, one or more of the following—
(a) a soft tissue injury,
(b) a psychological or psychiatric injury that is not a recognised psychiatric illness.”
Section 1.6(3) of the Act sates:
“A Threshold psychological or psychiatric injury is a psychological or psychiatric injury that is not a recognised psychiatric illness.”
Part 1, cl 4 (2) of the Regulation states:
“2) Each of the following injuries is included as a threshold psychological or psychiatric injury for the purposes of the Act
a) acute stress disorder
b) adjustment disorder
3) In this clause, acute stress disorder and adjustment disorder have the same meanings as in the document entitled Diagnostic and Statistical Manual of Mental Disorders (DSM-5)”
Aggravation of pre-existing social anxiety disorder is, by definition, a non-threshold injury for the purposes of the Act – see also Todev v AAI Limited T/as GIO.[9]
[9] [2023] NSWSC 836 (17 July 2023).
The assessment of whether the injury is a ‘threshold injury’ is not a direct measure of symptoms or disability. A finding that the injury is a ‘threshold injury’ indicates that there was an injury caused by the motor accident and that there may be continuing symptoms, however the injury satisfies the definition of a threshold injury under the Act and the Regulation.
CONCLUSION – THRESHOLD INJURY
The following injuries are not threshold injuries:
(a) aggravation of pre-existing social anxiety disorder.
The Panel agrees with Medical Assessor Roberts in that the claimant’s psychiatric injury caused by the motor accident is not a threshold injury. However, as the Panel has arrived at a different diagnosis, the Certificate of Medical Assessor Roberts is revoked. A new Certificate is issued at the front of the Panel’s determination.
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