Insurance Australia Limited t/as NRMA Insurance v Huynh
[2024] NSWPICMP 677
•24 September 2024
| DETERMINATION OF REVIEW PANEL | |
CITATION: | Insurance Australia Limited t/as NRMA Insurance v Huynh [2024] NSWPICMP 677 |
CLAIMANT: | Connie Huynh |
INSURER: | Insurance Australia Limited t/as NRMA Insurance |
REVIEW PANEL | |
MEMBER: | Terence Stern OAM |
MEDICAL ASSESSOR: | Anna Castle-Burton |
MEDICAL ASSESSOR: | Lauren Alach |
DATE OF DECISION: | 24 September 2024 |
CATCHWORDS: | MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; claimant suffered injury in a motor vehicle accident; Medical Assessor determined that the proposed treatment disputes were reasonable and necessary in the circumstances; the Medical Review Panel (the Panel) conducted its own examination and considered the Clinical Framework for the Delivery of Health Services per clause 4.80 of the Motor Accident Guidelines; Held – the Panel determined that 8 hours a week for home and nanny services for 3 months was reasonable and necessary in the circumstances; Medical Assessment Certificate revoked and a new certificate issued. |
DETERMINATIONS MADE: | CERTIFICATE OF DETERMINATION 1. The Review Panel revokes the determination of Medical Assessor Middleton and substitutes the determination to certify that the following treatment and care is reasonable and necessary in the circumstances: (a) eight hours a week home and nanny services for three months is reasonable and necessary in the circumstances. |
STATEMENT OF REASONS
INTRODUCTION
Connie Huynh (Ms Huynh), the claimant, was born in 1983.
She was injured in a motor vehicle accident (the accident) on 13 October 2022.
Insurance Australia Limited, ABN 11 000 016 722, trading as NRMA Insurance (NRMA) is liable to pay Ms Huynh the cost of medical treatment, under the Motor Accidents Injuries Act 2017 (MAI Act).
Medical Assessor Thomas Rosenthal determined in his certificate of 22 January 2024, that the following treatment and care:
(a) ongoing home and nanny services
relate to the injury caused by the accident.
The following treatment dispute was referred by the Personal Injury Commission (Commission) for assessment:
(a) whether ongoing home and nanny services were reasonable and necessary in the circumstances.
Medical Assessor Lisa Middleton certified that the following treatment:
(a) 16 hours a week for ongoing childcare and domestic support
was reasonable and necessary in the circumstances.
THE REVIEW
NRMA requested referral to a Review Panel (the Panel) on the basis that there was reasonable cause to suspect that the Medical Assessor was incorrect in a material respect.
The review of the medical assessment is by way of a new assessment of all the matters with which the medical assessment is concerned.
The Panel issued a direction to the parties requesting provision of respective bundles of documents for consideration. The parties filed bundles of documents.
DOCUMENTS CONSIDERED BY THE PANEL
On 5 July 2024, NRMA’s solicitor uploaded to Pathway an indexed bundle of documents (NRMA’s documents). On 9 July 2024, Ms Huynh’s solicitor uploaded to Pathway an indexed bundle of documents. (Ms Huynh’s documents).
LEGISLATIVE FRAMEWORK AND RELEVANT CASE LAW
General
Ms Huynh’s claim is governed by the provisions of the MAI Act. It provides a scheme for the compulsory third-party insurance of motor vehicles registered in New South Wales and a scheme of statutory benefits (under Part 3) and compensation by way of lump sum damages (under Part 4) for persons injured in motor accidents in New South Wales.
Statutory benefits payable by the “relevant insurer” in accordance with Part 3 of the MAI Act include:
(a) treatment and care benefits under division 3.4.
Unlike the previous scheme, damages for treatment and care cannot be recovered by Ms Huynh, against the insurer. The only mechanism for the recovery of the cost of treatment and care is through a statutory benefits claim.
Section 3.24 provides as follows:
“(1) An injured person is entitled to statutory benefits for the following expenses (treatment and care expenses) incurred in connection with providing treatment and care for the injured person - the reasonable cost of treatment and care.
…
(2) Statutory benefits are payable for the cost of treatment and care to the extent that the treatment and care concerned was reasonable and necessary in the circumstances or related to the injury resulting from the motor accident concerned.”
Reasonable and necessary
In order for the insurer to be liable to pay for the treatment, the claimant must establish that the treatment is “reasonable and necessary in the circumstances”. The “reasonable and necessary” test is different to, and arguably stricter than the test in the workers compensation scheme which requires a worker to establish that the treatment is “reasonably necessary”.
When discussing the meaning of “reasonably necessary” under s 60 of the Workers Compensation Act 1987 his Honour Justice Grove in Clampett v WorkCover Authority (NSW) (2003) 25 NSWCCR 99 (Meagher JA and Santow JJA agreeing), stated:
“[22] I return to the expression ‘reasonably necessary’ in s60. Dictionaries stipulate that ‘necessary’ has relevant definition as ‘indispensable, requisite, needful, that cannot be done without’ - (Shorter) Oxford English Dictionary, 3rd Edn and ‘that cannot be dispensed with’ - Macquarie.
[23] The essential issue is what effect flows from conditioning such qualities as ‘reasonably’. The consequence is to moderate any sense of the absolute which might otherwise be conveyed by the word ‘necessary’ if it stood alone. In order to contemplate such moderation, it is apt to consider surrounding circumstances, but the question to be addressed is whether modification of a worker's home, having regard to the nature of the worker's incapacity, is reasonably necessary. In contemplation of what might be ‘reasonably necessary’ there is this statutory obligation specifically to have regard to the nature of the worker's incapacity. It provides emphasis towards moderating the meaning of ‘necessary’ in this context.”
In Diab v NRMA Ltd [2014] NSWWCCPD 72 at [88] the following factors were found to be relevant to, but not determinative of the criteria of reasonableness in the workers compensation scheme:
(a) the appropriateness of the treatment in dispute;
(b) the availability of alternative treatment;
(c) the cost effectiveness of the treatment;
(d) the actual or potential effectiveness of the treatment, and
(e) the acceptance by medical experts of the appropriateness of the treatment.
While related to a different scheme and another test, the Panel considers these observations are relevant to our decision of whether Ms Huynh’s proposed treatment is “reasonable and necessary”.
In the circumstances
Of further note is that the test of “reasonable and necessary in the circumstances” does not direct attention to the relationship between the accident and the treatment. The question of the relationship between accident and treatment is dealt with in the consideration of whether the accident caused the injury and the disputed treatment’s relationship to that injury. Therefore, it may be reasonable and necessary for a claimant to have treatment to alleviate symptoms from an injury or a condition but if the injury or condition was not caused by the accident the claimant will not be entitled to statutory benefits.
The words “in the circumstances” in the context of whether a particular treatment is “reasonable and necessary” must therefore refer to the particular circumstances of the claim and the claimant in the proceedings before the Panel. As the members of another Review Panel said in the matter of Allianz Australia Insurance Limited v Vella (No 1) [2023] NSWPICMP 73:
“That may mean that a particular claimant has subjective requirements that may mean that some treatment for a specific injury is reasonable and necessary whereas the same treatment for the same condition of a different claimant may not satisfy the test.”
Dispute resolution
Pursuant to Schedule 2, cl 2 of the MAI Act, various matters are declared to be a medical assessment matters, including (b):
“whether any treatment and care provided or to be provided to the injured person is reasonable and necessary in the circumstances or relates to the injury caused by the motor accident for the purposes of section 3.24 (Entitlement to statutory benefits for treatment and care)”.
CERTIFICATE UNDER REVIEW
Medical Assessor Lisa Middleton (the Medical Assessor) issued a certificate on 21 February 2024.
The following treatment disputes were referred by the Commission for assessment:
(a) whether ongoing home and nanny services is reasonable and necessary in the circumstances.
Medical Assessor Middleton noted that Ms Huynh was previously well and did not suffer from any other ill health prior to her accident. The medical reports provided suggested that Ms Huynh had previously sustained a lumbar spine injury, but that this had resolved prior to her accident therefore the effects could not be related to her accident.
Medical Assessor Middleton took a history of the accident at [9]:
“Ms Huynh reported that she was involved in a motor vehicle accident on the 13th of October 2021. She was traveling in her car on Cowpasture Rd, NSW, at a reported reduced speed of approximately 40 kms per hour, when she was struck from behind by another motorist. She reported that she was not immediately aware of any specific injury, and she was able to drive her car to the intended event. She did not present to hospital for treatment. It was later that evening and over the next day that she presented with symptoms. She attended her general practitioner approximately 2 days after her accident.”
The Medical Assessor further took note of Ms Huynh’s symptoms at the time of the examination:
“Ms Huynh reported that she continues to experience unresolved symptoms following her motor vehicle accident and described these as follows:
Headaches.
Cervical spine / Neck pain.
Right shoulder pain.
Pins and needles / sensory changes in her right upper limb and right leg
In addition to her physical symptoms, she also reported that she experiences psychological symptoms including anxiety, panic attacks, PTSD and hyper-vigilance.”
The Medical Assessor conducted an examination which she reported at [17]:
“Posture
Ms Huynh is approximately 161cms tall and weighs approximately 64 kgs.
Range of Motion
No formal measurement of range of motion using a goniometer was undertaken, but observation of the claimant's ability to perform functional activities was completed. During the assessment Ms Huynh was asked to demonstrate her current range of movement. She demonstrated functional range of movement in her neck for daily activities, although she reported some decreased range at the extremes in all movement patterns. Her neck range of movement is adequate for most day-to-day activities, but it was noted that due to some reduction in range of movement to turn her head in both directions, checking of her blind spot while driving may be restricted.
Ms Huynh demonstrated full functional active range of movement in her both upper limbs, in all movement patterns.
Her range of movement in her lower limbs was functional for participation in mobility and performance of all transfers on and off her furniture.
Functional Mobility, Balance and Gait
Ms Huynh is independently mobile and walks without an aid or device for support. She is able to ascend and descend stairs and demonstrated safety and independence with dynamic balance. Functional Tolerance Ms Huynh reported that she has decreased tolerance for activities because of her pain, discomfort, and headaches. She stated that she has difficulty engaging in activity and being able to sustain her participation in tasks. She is able to perform her own personal care on a daily basis and also to participate in some meal preparation and light housekeeping tasks, such as wiping of surfaces and doing laundry. She reports that when she engages in day-to-day domestic tasks her symptoms increase, and she is then not often able to complete activities without some assistance.
Postural Tolerances
Sitting - She advised that her tolerance for sitting was approximately 30 minutes, however during the assessment Ms Huynh was observed to sit for approximately 1 hour, after which she modified her position to alternate between standing and sitting.
Standing and mobility - She stood and mobilised in and around her home for approximately 30 minutes.
Transfers - She was observed to transfer independently on and off the dining chair and her bed without restriction. She also reported independence with transfers on and off her toilet and in and out of her shower.
Upper Limb Function including Sensation, Power and Grip Strength
Ms Huynh reported weakness in her right upper limb, particularly at her shoulder, and in that regard advised that she has difficulty participating in some of her day- to-day activities. Manual muscle testing was not completed by the assessor, but observation of her functional skills used to determine her capacity for activity.
She demonstrated functional range of movement to be able to don and doff overhead upper limb clothing, manipulate doors and handles, pick up items located between knee and shoulder height, open and close her kitchen cabinetry, dishwasher washing machine and tumble dryer.
She reported that she is also able to drive, so it could be inferred that she has adequate strength and range of movement in both upper limbs to operate a motor vehicle.
She is right hand dominant.
Lifting / Carrying
Ms Huynh reported that lifting and carrying is difficult, she estimated her current capacity is limited to approximately 2 to 3 kilograms. She cannot perform lifting tasks on a repeated basis. She avoids lifting any heavy items, as this reportedly increases her pain and symptoms. She does however have to lift her youngest child, weighing approximately 12 kilograms, to assist with personal care including dressing and nappy changes. She tries to minimize the need to do this by sending her daughter to increased hours at daycare, maintaining the nanny service two days of the week, and utilising her husband’s assistance when required.”
Medical Assessor Middleton set out her determination and reasons at [25]:
“It is my determination that the following treatment and care, ongoing home and nanny services is reasonable and necessary in the circumstances.
Ms Huynh continues to experience symptoms, and she is subsequently restricted in her ability to complete her pre-injury childcare and domestic tasks. She is currently receiving 16 hours a week of self-funded childcare / mother’s help (8 hours per day on Monday and Friday). This assistance and support including provision of childcare to her 22-month-old baby, and also meal preparation, cleaning including changing beds, assistance with laundry and meal preparation.
The previous service provision was 12 hours per week for nanny / childcare, and then additional services for cleaning on a weekly basis. It is estimated that the 2 hours of cleaning a week would be appropriate, and an additional 2 hours for assistance with meal preparation would also be appropriate. In that regard it is deemed reasonable and necessary that 16 hours a week be provided for ongoing childcare and domestic support. A review may be required once her youngest child in at school as there will be a reduced requirement for childcare services, but cleaning and assistance with meal preparation should remain.”
SUBMISSIONS
NRMA’s submissions in support of an application for review of the medical assessment certificate of treatment and care of Medical Assessor Lisa Middleton, dated 21 February 2024
NRMA sought review of the certificate of Medical Assessor Lisa Middleton in accordance with the MAI Act.
NRMA submitted that Medical Assessor Middleton failed to have regard to or properly consider the material evidence available and to give proper reasons to support her findings. It considered that Medical Assessor Middleton had merely accepted Ms Huynh's complaints at face value and had failed to have regard to the contemporaneous records provided and to NRMA's submissions surrounding Ms Huynh's level of independence in domestic tasks and childminding.
NRMA submitted that Medical Assessor Middleton failed to give proper or adequate reasons for her findings of childminding and additional domestic duties. It considered that the Medical Assessor had gone beyond the scope of the dispute and factored in elements supporting her recommendations that did not fall within the range of Ms Huynh's physical injuries.
The Medical Assessor's reasonings did not make it possible to determine the impact of the physical injuries on Ms Huynh's functioning and the need for requested services.
NRMA argued that the Medical Assessor's recommendation of 16 hours per week, being 12 hours per week for nanny care and two hours per week each for meal preparation and cleaning, was arbitrary and based entirely on Ms Huynh's perceived current engagement level rather than actual need arising from the subject accident. It submitted that the Medical Assessor did not provide proper reasoning supporting the childcare and domestic assistance.
It also submitted that Medical Assessor Middleton's recommendations were inconsistent with the clinical framework for the delivery of health services required to be applied for treatment and care per Clause 4.80 of the Guidelines. Relevantly, for activities Ms Huynh can complete, ongoing services do not empower the injured person to manage their recovery and perpetuate the need and dependence on services. They also reinforce the perception of injury, incapacity and pain.
The Medical Assessor failed to consider task modifications for activities which Ms Huynh says she can do but which aggravate her pain. NRMA also submitted that once the Medical Assessor has determined that the need for nanny services would decrease at some point, she needed to determine until when those services would be reasonable and necessary in circumstances.
NRMA submitted that the Medical Assessor also failed to put issues of consistency of postural tolerances to Ms Huynh, therefore denying procedural fairness to the parties. Namely, the Medical Assessor recorded the reported postural tolerances, and that Ms Huynh was able to sit for longer.
NRMA also highlighted that Ms Huynh estimated her current capacity was limited to two to three kilograms yet was reported to have lifted her youngest child weighing about 12 kilograms, which she “tries to minimize”. NRMA submitted the Medical Assessor failed to put that issue of consistency to Ms Huynh and again denied her procedural fairness.
Overall, NRMA submitted that the Medical Assessor's reasons failed to provide evidence that 16 hours a week of domestic services was reasonable and necessary, within the meaning adopted in Johnston v QBE Insurance [2023] NSWPICMP 21.
NRMA submitted that the Medical Assessor said that Ms Huynh has the capacity to do the task, with or without modification, but prefers not to do the task. They submitted that a dependence or preference for services does not give rise to necessary treatment and care under the MAI Act in the absence of a lack of capacity to do those tasks.
Ms Hyunh's submissions in opposition to the insurer's application for review of the medical assessment of Lisa Middleton, dated 21 February 2024
Ms Huynh considered that Medical Assessor Middleton appropriately undertook a thorough clinical examination and provided commentary on her consistency. Ms Huynh considered that Medical Assessor Middleton had appropriately utilised her expert clinical judgment together with a comprehensive review of the material to frame her determination.
In summary, Ms Huynh considered that NRMA’s submissions did not demonstrate material errors or failure to give proper reasonings. Medical Assessor Middleton had adequately regarded the material medical evidence and demonstrated a path of reasoning in justifying her determination and view of the evidence. Therefore, she performed an assessment that was undertaken in accordance with the guidelines.
THE MEDICAL REVIEW PANEL
The Panel held its first meeting on 15 July 2024 at 3pm and determined that a medical examination would be necessary to address the parties’ submissions.
Medical Assessors Lauren Alach and Anna Castle-Burton attended the home of Ms Huynh on 14 August 2024 to complete the Occupational Therapy Medical Assessment. Only Ms Huynh and the Medical Assessors were present.
HISTORY
Psychosocial history and pre-accident history
Ms Huynh reported that after the birth of her first child about seven years ago, she took time to “adjust to motherhood”. She felt lonely and isolated and was putting pressure on herself regarding mothering. She saw her family doctor and then a psychologist for two to three sessions but was not prescribed medication. She did not feel a connection with the psychologist so did not continue.
She did not report experiencing similar symptoms after the birth of her second child, Camellia who was six months old at the time of the accident. She returned to Pilates and playing tennis about three months after Camellia was born because she wanted to look after herself physically and mentally.
Ms Huynh said that she was still performing those activities by the date of her accident and was not seeking psychological counselling or treatment for any physical conditions.
History of the motor accident
Ms Huynh was the driver of a vehicle involved in a collision on 13 October 2022. She said that she was on her way to her sister-in-law's home for dinner when the driver of another vehicle hit her car from behind.
Her car was driveable and because the accident occurred in peak hour and she was closer to her sister-in-law's home than her own, she continued to her sister-in-law's home. She thought she was experiencing symptoms of shock and did not initially focus on her physical symptoms.
History of symptoms and treatment following the motor accident
Ms Huynh reported that about two or three days after the accident, she felt “bruising” and “aching” in her neck and shoulders. She booked an appointment to see her general practitioner (GP), Dr Stephanus Hugo.
Dr Hugo referred her to physiotherapy at Wetherill Park. Ms Huynh was not sure how long she attended but thought it could have been up to 6 months. She attended weekly initially before asking to attend more often. She increased to twice weekly sessions, during which she was receiving hands-on treatment for her neck and shoulder symptoms.
When her symptoms remained, she reported being referred to a Neurologist, Dr Paul Teychenne. She said that Dr Teychenne struggled to diagnose her condition and did not advise her as to how she could improve.
Ms Huynh was not sure that her physiotherapy was helping her and a mother at her daughter's school recommended that she try another physiotherapist at FunctionFit Clinic, Smithfield. She started attending twice a week for pressure point and manual therapy, as well as doing stretches at home. The stretches were explained to her, and she did not follow a written exercise program. She noticed a “drastic change”, including her headache becoming less severe.
She sought another opinion from Dr Abhay Venkat, Neurologist, who diagnosed her with Functional Neurological Disorder (FND). Ms Huynh said that she researched that condition online and noticed that her symptoms fitted well with that diagnosis. She reported feeling “heard” and “validated” by that diagnosis. She is still waiting on a report from Dr Venkat and plans to see him again in about six months.
Ms Huynh said that she continued attending FunctionFit Clinic twice a week until the insurer stopped funding physiotherapy a couple of months before this review assessment. Since then, she has been paying herself for physiotherapy at FunctionFit Clinic.
She said that she understands that recovery from FND can take a long time, so she is slowly increasing her engagement in activities to aid her recovery. She started swimming at Parramatta Aquatic Centre once or twice a week. She also started walking in the pool and around her local area. Ms Huynh said that she does not go to the pool more often because it is too far for her to drive there herself, and she relies on her husband having time off work. They also use the opportunity of having the nanny at their home on Friday so that they can go swimming at the aquatic centre together.
Ms Huynh said that her mental health deteriorated alongside her physical symptoms, and she sought psychological counselling. She was seeing a psychologist, Alexander Chemuel in Wetherill Park every few weeks until about a month before this review assessment. She recalled that after her psychological Functional Capacity Assessment, the psychologist, Michelle Harvey suggested that Mr Chemuel might not be the most appropriate psychologist for her. Her GP then referred her to MindSea Psychology, in Liverpool. She has had two phone consultations with Deniz Dagli so far.
Details of any relevant injuries or conditions sustained since the motor accident
Ms Huynh did not disclose any relevant injuries or conditions sustained since the motor accident.
Pre-accident social situation
Ms Huynh was born in Vietnam and has lived in Australia since 1989. She was married to her husband, Aurelius, and they had two children, Emmerson and Camellia. They lived in their own home in Smithfield. They had been living there for about five years and renovated it after they moved in. Emmerson was five years old and in primary school. Camellia was six months old, and Ms Huynh was caring for her at home.
Ms Huynh reported that her retired parents lived close by. They were ageing. Her mother had glaucoma and did not drive, and her parents did not speak English. She needed to translate for them at appointments and helped them to complete paperwork.
Her husband ran his own marketing company. He was working from home during the COVID pandemic. Ms Huynh was employed full-time for his business as a digital marketer and was paid for 38-40 hours. She worked from home doing administration and the “brand side” of his business.
She continued working full-time, up to and beyond the birth of her youngest daughter. Ms Huynh said that she could manage that because her hours were flexible, and she worked from home.
Ms Huynh did not report any physical or psychological impairments in the period leading up to her accident which affected her ability to work or look after her home and family. Because she worked from home, she was the primary carer for their two children. She did about “90%” of the cooking and most of the cleaning and laundry. Her husband was responsible for rubbish removal, managing the council bins, mowing the lawn, and looking after the outside of their home.
She would drop Emmerson to school three days a week, pick her up from school on four days and took her to extracurricular activities. She looked after Camellia while Emmerson was at school.
Current social situation
Ms Huynh was still living in the same home in Smithfield with her husband and two children. Her husband still worked from home running his own business, but she reported having no capacity to do any work due to her self-reported physical symptoms.
Their children were seven years old and two years and three months old. Emerson was in year 1 at Our Lady of Mount Carmel primary school in Horsely Park, and Camellia was attending daycare on three days a week (Tuesday/Wednesday/Thursday) at Clever Cubs Early Learning Centre at Smithfield.
Ms Huynh reported that because of her symptoms, she kept paying a nanny privately when the insurer stopped funding that service. She is currently paying for in-home childcare two days a week (Monday and Friday) for five hours each day, from 9.15am to 2.15pm. She stopped using the service paid by the insurer because she found it too expensive. Instead, she found someone through a contact who was willing to perform a combined childcare and domestic role for $50 per hour.
Ms Huynh said “I can do everything” but reported that “it takes a toll the following day” which is difficult for her to manage, particularly if it is a day when the nanny is not working. She was wary of doing too much and being in pain after. She therefore limits the domestic and physical parenting tasks that she does. She was trying to be more involved, including with Camellia’s evening routine. She pushed herself to do things such as taking her daughters to school and childcare in the morning and doing some shopping at the local shops. She said that she feels “wanted” and “validated” when she is more involved, particularly with care tasks for her youngest child, even though she found some tasks hard. Recently, they put a mattress on the floor in her daughter’s room and Ms Huynh had begun reading with Camellia and changing her nappy and clothes on the mattress. She reported feeling positive about that, although she said it caused her extra pain.
She described fearing pain from activities she tries to do. Ms Huynh reported feeling stressed and anxious on the days her youngest daughter is at pre-school that they may call, and she will need to pick her and look after on her own.
Current symptoms
Pain
Headaches: Ms Huynh described “aching”, “pinching”, “throbbing”, and “burning” pain at the base of her head, behind her neck and across both shoulders. She said the pain is present even at rest and “that's why I can't work”.
She estimated that pain on a Verbal Analogue Pain Scale[1] as 8-9/10. She described when the headache is intense, she closes the curtains and lies down.
[1] Haefeli M, Elfering A. Pain assessment. Eur Spine J. 2006 Jan;15 Suppl 1(Suppl 1):S17-24.
Ms Huynh reported trying several types of medication prescribed to her by treating neurologist, Dr Venkat, including Duloxetine, and Ajovy injections. She had to cease the injections due to severe side effects, including dizziness, nausea and depression. Therefore, she was taking only Nurofen and Panadol. She identified pushing and pulling movements, carrying her daughter, and cooking as being activities that aggravate her headaches.
Neck: she reported experiencing constant neck pain with “aching” and “burning” across her shoulders and radiating to sensory changes, including pins and needles, in her right fingers. She described her neck pain as increasing to 10/10 at its worst, which limits her turning her head when driving. She described a driving tolerance of about 15 minutes.
Right arm: Ms Huynh describes pain and sensory changes in her right arm, specifically down to her three-middle fingers. She estimated that pain as 6-7/10 on a Verbal Analogue Pain Scale.[2]. She described difficulty holding items at times and can drop things. That pain and discomfort affects her driving.
[2] Haefeli M, Elfering A. Pain assessment. Eur Spine J. 2006 Jan;15 Suppl 1(Suppl 1):S17-24.
Lower back and leg: she described a “stabbing” pain across her lower back which she estimated at 6-7/10 on a Verbal Analogue Pain Scale.[3] The pain radiates down her right leg and she described sensory changes, including numbness at times. Ms Huynh described having spasms in her right leg which cause her to limp and limit her safety when driving.
[3] Haefeli M, Elfering A. Pain assessment. Eur Spine J. 2006 Jan;15 Suppl 1(Suppl 1):S17-24.
Range of motion
Ms Huynh described reduced range of movement, particularly in lumbar flexion and bilateral shoulder flexion due to pain. She said that she avoids lifting and carrying, pushing, pulling, and repetitive movements because she fears the pain that she believes those movements cause her.
Functional tolerances
She reported reduced tolerances for lifting, walking, sitting, standing, and sleeping due to pain. She reported feeling anxious about pain and worried that it will be aggravated by activities. That was one reason for her limiting her physical performance. She fears the onset of pain and the effect that will have on her.
Psychosocial
Ms Hung described feeling misunderstood. She said that the pain and limitations she has experienced have affected her mentally and caused reduced self-esteem and self-confidence. It has affected her relationship with her husband. She described feeling alone, lonely, and isolated. She does not believe she has been given any guidance on what to do to treat her condition.
She described experiencing a change in behaviour. She said she has a short fuse and does not feel wanted or validated in her relationship. But she expressed that when she pushes herself to do something that she finds challenging, she feels good about it.
Current and proposed treatment
Ms Huynh still saw her GP, Dr Stephanus Hugo, regularly. She was no longer seeing her neurologist, Dr Venkat regularly but planned to see him again. She was not under any other regular specialist care.
She planned to continue with her counselling sessions through MindSea Psychology. She was not yet sure how often she would see them.
Ms Huynh continued to pay for weekly physiotherapy sessions at FunctionFit Clinic. That was mostly for manual treatment. She denied having a written home exercise program.
She attended Parramatta Aquatic Centre once or twice a week to exercise in water and walked around her local area for exercise.
She denied being provided with any treatment or intervention from an occupational therapist for energy conservation, pacing or task modification to accommodate her self-reported pain and consequent activity restrictions and functional limitations.
Employment status
Ms Huynh said that she had not returned to work in her pre-injury role since the date of the accident. Her occupational therapist from OT Rehab Consulting, Kira Ferry, prescribed a sit-to-stand desk and adjustable ergonomic chair to support her posture while working. Ms Huynh reported that she had not used that equipment to perform any work tasks.
CLINICAL EXAMINATION
The Panel’s clinical examination involved observations of Ms Huynh throughout the assessment combined with the results of standardised and self-report objective measures to quantify subjective reporting of impairment.
Pain: Ms Huynh completed a Pain Drawing (see below), where she was asked to mark on an outline of a body image where she experiences pain – with a key describing the type of pain experienced and the level of pain.
Ms Huynh indicated on the drawing that she experienced stabbing pain in the occipital area of her head with burning / aching pain across the bottom of her neck and top of her shoulders, and pins and needles down her right shoulder, arm, and hand.
She indicated stabbing pain across her lower back and aching pain with pins and needles down into her leg.
[IMAGE UNABLE TO RENDER]
Ms Huynh estimated overall her pain level at assessment was 8/10 on a Visual Analogue Pain Scale,[4] which was interpreted as Intensely severe pain.
[4] Haefeli M, Elfering A. Pain assessment. Eur Spine J. 2006 Jan;15 Suppl 1(Suppl 1):S17-24.
Ms Huynh was administered the Oswestry Disability Questionnaire,[5] which is a self-reported questionnaire designed to provide information about the intensity of a person’s pain, their functional tolerances and how these impairments affect their ability to manage functional activities. These include personal care; walking; sleeping; and social activity.
[5] Fairbank J.C. and Pynsent P.B. The Oswestry Disability Index. Spine. 2000. (25) (22); 2940-2953.
Interpretations of scores identify a higher score is indicative of more disability. Scores are classified as follows:
0-20%
Minimal disability – Can cope with most ADLs. Usually no treatment is needed, apart from advice on lifting, sitting, posture, physical fitness, and diet. In this group, some patients have particular difficulty with sitting and this may be important if their occupation is sedentary (typist, driver, etc.)
20-40%
Moderate disability – This group experiences more pain and problems with sitting, lifting, and standing. Travel and social life are more difficult, and they may well be off work. Personal care, sexual activity, and sleeping are not grossly affected, and the back condition can usually be managed by conservative means.
40-60%
Severe disability – Pain remains the main problem in this group of patients, but travel, personal care, social life, sexual activity, and sleep are also affected. These patients require detailed investigation.
60-80%
Crippled – Pain impinges on all aspects of these patients’ lives both at home and at work. Positive intervention is required.
80-100%
These patients are either bed-bound or exaggerating their symptoms. This can be evaluated by careful observation of the patient during the medical examination.
Ms Huynh scored 30/50 or 60%, indicative of severe disability, when pain remains the main problem in this group of patients, but travel, personal care, social life, sexual activity, and sleep are also affected. These patients require detailed investigation.
Her strongest endorsements at level 4/5, meaning the statement applied most of the time, were as follows:
(a) the pain is very severe at the moment;
(b) I can only lift very light weights;
(c) I have less than two hours of sleep;
(d) my sex life is nearly absent because of pain, and
(e) pain restricts me to short necessary journeys under 30 minutes.
Ms Huynh completed the Pain Catastrophizing Scale (PCS)[6] which is a 13-item instrument, where participants reflect on past painful experiences and indicate the degree to which they experienced each of 13 thoughts or feelings when experiencing pain. The participant uses a five-point scale with (0) meaning “not at all”, and (4) meaning “all of the time”. The PCS yields a total score and three subscale scores in accessing rumination, magnification and helplessness.
[6] Sullivan, M. J. L., Bishop, S. R., & Pivik, J. (1995). The Pain Catastrophizing Scale: Development and validation. Psychological Assessment, 7(4), 524-532.
She scored 48/52 with higher scores indicating greater level of catastrophizing. On the subscale rumination, she scored 15/16. On the subscale magnification, she scored 11/12 and under hopelessness, she scored 22/24.
The items she scored a level 4, meaning the statement is true for her all the time, were as follows:
(a) I worry all the time about whether the pain will end;
(b) I feel I can't go on;
(c) it's awful and I feel it overwhelms me;
(d) I feel I can't stand it anymore;
(e) I become afraid that the pain will get worse;
(f) I can't seem to keep it out of my mind;
(g) I keep thinking about how much it hurts;
(h) I keep thinking about how badly I want the pain to stop, and
(i) I wonder whether something serious may happen.
Clinical observation: Ms Huynh did not show the pain behaviours which would have been expected with her self-reported pain levels of between 6 and 10 out of 10. The Medical Assessors bought to her attention that a self-reported score of 9/10 on any pain scale, which she said she was the lowest her headache reduced to, is close to the highest pain level imaginable. That was inconsistent with her presentation at assessment as she was seated at a table talking to us. She then revised her headache score to 8/10 and responded that her pain remains at that level even when she is sitting, which is “why I can’t work”.
Her score on the Oswestry Disability Questionnaire suggests severe disability, however that did not correlate with her presentation at assessment. It was more consistent with Ms Huynh’s reporting that she can “do everything”, with pain after.
Ms Huynh’s functional tolerances were observed to be within normal limits, and she did not display significant physical restrictions or signs of pain behaviour. However, she presented as pain focused and self-limited by pain in all tasks observed during the assessment. That was also bought to her attention, and she reiterated what she said in point 101.
Ms Huynh results on the Pain Catastrophizing Scale show the extent to which she ruminates about pain, magnifies her pain and feels helpless. This was consistent with her presentation during the assessment.
Range of movement: Ms Huynh ’s range of movement in her neck, back, shoulders, and lumbar spine were measured by approximation and observation of her performing various functional movements.
| Cervical Spine | Normal | Active Range of Movement on the Right | Active Range of Movement on the Left |
| Rotation | 80° | 45° | 45° |
| Extension | 60° | 30° | |
| Flexion | 50° | 10° | |
| Lumbar Spine | Normal | Active Range of Movement on the Right | Active Range of Movement on the Left |
| Lateral Flexion | 25° | 25° | 25° |
| Flexion | 90° | 50° | |
| Extension | 25° | 25° | |
| Shoulder | Normal | Active Range of Movement on the Right | Active Range of Movement on the Left |
| Flexion | 180° | 160° | 180° |
| Extension | 45° | 45° | |
| Abduction | 180° | 180° | |
Clinical observation: Ms Huynh displayed functional range of movements in her cervical and lumbar spine and shoulders. There was no tightness or muscle spasm to palpation in her neck, shoulders or lower back at assessment. We saw nothing to explain her slightly reduced right shoulder movement. She appeared to be self-limiting during the range of movement assessment which was bought to her attention, and she indicated that she was limited by pain.
Functional status
Self-Report
Clinical Observation
Sitting
Pain prevents me sitting more than one hour.
Ms Huynh sat on a dining room chair for the assessment and was observed to sit without any discomfort noted to reduce her tolerances. She stood up after 30 minutes but resumed sitting.
Standing
Pain prevents me from standing more than 30 minutes.
She was observed standing intermittently throughout the assessment without signs of discomfort or limitation. She stood without needing to lean on furniture or walls for support.
Mobility
Pain prevents me walking more than 2 kilometres. I can sometimes walk longer than 2 kms but starts to limp.
Ms Huynh’s mobility was noted to be normal without any limitations when she was walking in and around her home.
Balance
Concerned about falls if my right leg spasms and gives way.
She stood on each leg individually for more than 10 seconds.
Lifting and carrying
Can only lift very light weights.
Ms Huynh was observed lifting 2 litres of milk out of the fridge and reported that she can lift her 15-kilogram daughter on an everyday basis, but her pain increases with repetitive lifting.
Bending
Restricted in bending
She was observed being able to bend and squat to pick things off the floor.
Transfers
Mymovements can be affected by pain
Ms Huynh was observed performing all transitional movements, including sitting, standing, walking, and toilet transfers without difficulty.
Bed mobility
Able to get on and off her bed
She was observed getting into and out of her bed and rolling from side to side without discomfort or limitations noted.
She demonstrated getting down to the mattress on the floor where her youngest daughter sleeps and got back up from the floor without difficulty.
Reaching
Difficulty reaching above head height particularly on the right side.
She was observed to have functional reach above head height with both arms.
Stairs
Able to complete stairs
Ms Huynh was observed to climb the internal stairs without need for rails or other support.
General functional tolerances
Ms Huynh said that the amount she can do in a day depends on what else she has done. When she is well rested, she has more energy to “put out”.
Environmental factors
Housing
Ms Huynh lived in a single-story four-bedroom two-bathroom home on approximately 560 square metres of land.
The home was accessed by a concrete path from street level with two threshold steps to the front door. There was a small area of grass either side of the front entrance with large mature trees and little formal garden beds in the front yard.
The front door entered an open plan living room, kitchen, dining area with floating floors. The living area consisted of a rug and sectional seating around a television.
The modern kitchen had an island bench and the usual appliances including a stovetop, oven, and fridge. The family did not use the oven as it had not worked for many years therefore used an air fryer that sat on the kitchen bench. There was a coffee machine and other appliances located at bench height.
The assessment took place on the formal dining room table that was in the area outside the open plan kitchen. There was a corridor that leads to the bedrooms, bathroom and an office.
Her youngest daughter's bedroom had a mattress on the floor as she was no longer in a cot.
The bathroom had a freestanding deep tub, shower stall and toilet.
Ms Huynh demonstrated how she knelt to play with her daughter in the bath although reported finding it difficult to get her in and out of the bath. She and her husband share a room with a queen-size mattress, vanity and built-in wardrobes.
There were three bedrooms and an office on that level. That had a height adjustable desk and an ergonomic chair.
Outside of the main area, there was a sub-level downstairs that housed a playroom for the children with all sorts of children's toys and a rower exercise machine.
A further six tile steps lead to the lower level of the house that houses an office that had a mattress where Ms Huynh’s mother-in-law was staying and the laundry. The surfaces were tiled.
There was internal access to a garage that was being used as storage for supplies and other associated equipment. There were two points of access outdoors, one was from the toy room and the other outside the laundry. Those lead to a small yard, with grass and a large brick paved area that contains a trampoline and other types of children's toys.
There were few formal garden beds, rather large mature trees and shrubs. There was an outdoor clothesline attached to the house, however it did not appear to be used as it was in a state of disrepair.
Clinical observation
The internal areas of the home were observed to be neat and tidy including the kitchen, living room and dining room. Ms Huynh reported this was due to the nanny cleaning up the home. The bedrooms, bathrooms and laundry were also free of any clutter and very tidy. The children's toy room was as would be expected for a toy room. The outdoor areas of the home had limited areas of lawn to mow and appeared in reasonable order.
Objective assessment of Ms Huynh’s physical functioning, and observation of her demonstrating functional tasks during the assessment, did not reveal obvious limitations to her being able to maintain her home as she did previously. However, her self-report is of high levels of pain and disability preventing her from completing vigorous physical tasks involving push-pull actions, lifting carrying or bending. They could not be verified at assessment.
Community access and transport
Ms Huynh reported that her pain and reported physical limitations, particularly the spasms in her leg and her lower back pain, limit her from driving for more than 30 minutes. She described feeling comfortable doing the school and daycare drop-off, which is around 15 minutes away from her home. She reported taking her husband with her to lift Camillia in and out of her car seat at daycare. He then walks home, and she continues to drop Emmerson at school. The day of the assessment she was going to try picking up Camellia herself from daycare. That is part of her plan to gradually increase what she does to care for the children.
She does not drive places that are further than 15 minutes away due to fear, as she has experienced episodes where she has had to pull over when driving due to leg spasm. She described her reduced driving tolerance as impacting her involvement in some of the physical activities that she feels she benefits from. That includes swimming at Parramatta Aquatic Centre where she relies on her husband to take her.
Ms Huynh relies on her parents to pick up the children twice a week as she reported finding afternoon pick-ups difficult. Another parent takes her oldest daughter to hip-hop.
Activities of daily living status
ACTIVITY
REPORTED FUNCTIONAL STATUS – PRE-INJURY
REPORTED FUNCTIONAL STATUS – CURRENT
Eating / drinking toileting Grooming Showering
Dressing
Fully independent
She has needed reminders to shower and pays less attention to her personal hygiene. She is physically capable of performing personal care tasks.
Clinical Observation: Connie presented, as well-groomed for the assessment.
Cooking / meal preparation
Ms Huynh was responsible for 90% of cooking and meal preparation. She had no limitations. Her husband cooked breakfast on the weekends.
She reported difficulty resuming her pre-injury role in cooking and meal preparation as she is restricted in heavy lifting of pots, and experiences pain with repetitive tasks such as chopping. She reported the nanny makes bulk meals, at least twice a week.
She has a dishwasher and reported being able to unpack its top draw.
Clinical Observation: Ms Huynh was observed in her kitchen environment and demonstrated the ability to access all levels of her fridge. She could lift out pots and pans but did not attempt to lift the cast iron pot. The assessor determined that the pot was extremely heavy.
She was observed to access the oven and reach into cupboards above head height.
The family do not use the oven, rather use the air fryer which sits on the kitchen bench and was easily accessible. Ms Huynh was observed accessing the top draw of the dishwasher without difficulty. She did not show any functional limitations to cooking or meal preparation.
She reiterated that she could do everything, but it takes a toll the following day when the nanny is not there, and the aftermath of her engaging in activities affects her daily life.
Shopping
Ms Huynh performed the majority of the shopping in person without difficulty.
She reported that they now do a combination of online shopping and some in-person. She reported struggling to carry heavy or bulk shopping and relies on her husband to do so. She can drive to the shops and buy a limited number of items. She can only carry light bag into the house, a maximum of 3 litres of milk in one bag.
Clinical Observation: Ms Huynh’s objective physical assessment did not reveal significant physical limitations that would affect her ability to complete incidental shopping. It is a practical strategy to continue to do online shopping and have the goods delivered.
Light Cleaning and Tidying (wiping down benches, stove and dusting)
Ms Huynh was independent with managing the light cleaning. She prided herself on a clean and tidy home environment.
She remains capable of doing the light cleaning, such as wiping down benches, dusting and doing cleaning that does not involve bending. She reported no longer having the energy to operate the cordless stick vacuum and relies on her husband and nanny to vacuum regularly.
Clinical Observation: Based on observations of Ms Huynh functioning during assessment, she would be physically capable of light cleaning, including use of a cordless Dyson for daily vacuuming.
Heavy Household Cleaning (vacuuming, sweeping, cleaning bathrooms)
She reported sharing the heavy cleaning with her husband and was not limited. As noted above, she enjoyed having a clean and organised environment.
Ms Huynh reported being unable to participate in heavy household cleaning, including vacuuming, mopping floors and cleaning bathrooms and toilets. She reported struggling with heavy lifting, bending, and push-pull movements as they aggravate her pain. Therefore, she no longer completes these tasks. She relies on her husband and the nanny to do all heavy household cleaning tasks.
Clinical Observation: Ms Huynh’s objective physical assessment did not reveal significant physical limitations which would prevent her performing bending, lifting, and push/pull movements during heavy household tasks on a one-off basis. The impact of repetitive task performance couldn’t be verified during the assessment.
Laundry
(folding of laundry, ironing, bed-making)
Ms Huynh was responsible for completing the laundry, including folding, ironing and regularly changing bed sheets.
She now relies on the nanny to manage the sheet changes every two weeks, reporting that she cannot lift the mattress to change the sheets.
Ms Huynh reported struggling with the heavy laundry and therefore relies on the nanny and the laundry gets done only on Mondays and Fridays. She reported using the clothesline and airers to hang clothes and sheets to dry.
Clinical Observation: Ms Huynh’s laundry room was viewed and noted to have a front-loading washer and dryer side-by-side. She demonstrated the ability to squat to access both the washer and dryer and admitted that she could carry a light bucket of clothes to hang on the clothes airers. Her objective physical and functional assessment did not reveal limitations to suggest that she would be precluded from managing the light or heavy ironing, laundry, folding or bed changes.
Garden and lawn mowing
Ms Huynh was not responsible for lawn mowing or significant gardening outside of managing pots plants.
Her husband continues to manage the lawns and gardens, although she indicated that he has less time to spend maintaining the property due to his additional roles and responsibilities in the home.
Clinical Observation: There was observed to be a small amount of grass in the back and front of the property to maintain, and limited need for regular gardening
Garbage management
This was her husband's responsibility.
He continues to be responsible for garbage maintenance.
Home maintenance
This was the responsibility of her husband.
It remains her husband's responsibility.
Parenting
Ms Huynh reported being predominantly responsible for parenting her two children, aged 5 years old and 6 months.
She did all the pickup and drop-offs to school and activities, but they shared tasks such as bathing.
Ms Huynh reported struggling to perform parenting activities for her youngest child, who is now 2 years and 3 months old and weighs approximately 15 kgs.
She described struggling to lift her up and carry her multiple times a day and struggles to bath her.
She was in a cot, but recently they moved a mattress onto the floor in her daughter's room so Ms Huynh can lie down on the mattress on the floor and interact with her.
Her daughter is not yet toilet-trained and she finds it difficult to lift her up to change her. She can do that on the mattress.
Ms Huynh prefers to have the nanny with her on the days that her daughter is home from daycare so the nanny can assist her to push the pram and push Camellia on her trike to the park.
Ms Huynh described feeling anxious, when left to look after her daughter on her own, because of the pain she reported experiencing.
Clinical Observation: MsHuynh was not observed interacting with her child at the assessment. However, based on physical and functional assessment results, she did not appear to have physical restrictions that would impact upon her ability to perform individual parenting tasks for their daughter who is 2 years 3 months old, and therefore walking independently.
Comments on consistency
Ms Huynh was cooperative throughout the assessment but heavily pain and disability focused with little objective evidence of her subjective complaints of pain and physical limitations observed during the assessment.
The effect of Ms Huynh’s self-reported physical impairments could not be confirmed through objective assessment or observation during the assessment. Although she reported very high levels of pain, she could sit and participate for at least 30 minutes. When asked about that, she reduced her pain score slightly and said that she can “do everything” but suffers pain when she does too much or in the days after. That was also the case when she was asked to demonstrate functional movements and components of domestic and other tasks. She then acknowledged her ability, but said that when she has not done much, and is well rested, she has more energy to do things.
REVIEW OF DOCUMENTATION
Summary of relevant documentation
Letter from Dr Nadia Khan, Fairfield Central Medical Centre, dated 8 November 2018 (22)
Dr Khan referred Ms Huynh for psychological opinion and management in 2018. She was having suicidal thoughts and feeling overwhelmed. She was suffering low mood since the birth of her child, plus ongoing lower back pain. She was becoming increasingly socially isolated, avoided seeing people and was unable to drive as she was feeling anxious. Her husband was very supportive of her and had taken on most of the responsibilities at home. A psychologist for diagnostic clarification and to help with her suicidal thoughts was recommended under a mental health plan.
Initial Needs, activities of daily living and Return to Work Assessment Report by Kira Ferry, occupational therapist from OT Rehab Consulting, dated 16 November 2022
Before the accident, Ms Huynh advised Ms Ferry that she was fit, healthy and active. She participated in Reformer Pilates, went to the gym and played tennis. She worked full-time from home and was the full-time carer for her six-month-old baby and five-year-old daughter. Her older daughter attended school between Monday and Friday. She reported no pre-existing injuries or illnesses that limited her participation in daily activities.
Ms Ferry reported the MRI scan showing disc bulges at C3, C4, C5 and C6 and Ms Huynh was referred to a neurosurgeon, Dr Bazina. She was certified unfit for work at the time of this assessment. She had commenced physiotherapy on 31 October 2022 in Wetherill Park and had so far participated in two sessions. She was still reporting pain in her neck, travelling down to her mid-back and nerve pain from her neck, including pins and needles at 9 out of 10 on a Verbal Analogue Pain Scale.
Regarding her pre-injury social situation and home environment, Ms Huynh was living in a single-storey house with a husband who worked full-time. He usually worked in the office but had been working from home since the accident. Prior to the accident, she'd been working full-time from home while caring for her daughters. She advised that her parents were elderly and in poor health so were not able to assist with domestic tasks, but they had been picking up her five-year-old daughter from school in the afternoon.
In terms of her pre-injury performance of domestic and childcare tasks, Ms Huynh advised that she was responsible for all cooking and meal preparation prior to the accident. She cooked rice, vegetable and meat most days. She performed all cleaning and laundry given that she worked from home. Her husband usually mowed the lawn.
Ms Huynh reported having difficulty with more than light household tasks and she was advised by her physiotherapist only to lift minimally until she was assessed by the neurosurgeon on the 23rd of November 2022. That was to be no more than two kilograms.
Recommended strategies included Ms Huynh continuing with physiotherapy until her review with a neurosurgeon to confirm her prognosis and treatment needs. She should participate in daily independent exercises prescribed by her physiotherapist, including walking as tolerated. She should use pacing strategies to perform light cleaning and laundry and implement strategies such as sitting with her children to perform activities on or near the floor to avoid lifting and carrying. A curved ergonomic low-profile pillow was recommended to assist her sleep.
Ms Ferry recommended cleaning assistance for two hours per week, fortnightly lawn mowing for the next four weeks to reduce the burden on her husband, and childcare assistance while her husband was working from his office, four hours a day, three days a week for up to three weeks pending the outcome of the neurosurgeon review. That childcare was for nappy changing, feeding, and lifting and carrying Ms Huynh's six-month-old baby in the afternoons when she's most active.
Letter from NRMA Insurance dated 30 November 2022
This letter relates to NRMA’s review of their decision to decline Ms Huynh's request for lawn mowing and childcare assistance. They decided that the original decision should be varied. The request for lawn mowing remained declined, but the childcare assistance would be approved.
In relation to the lawn mowing, they noted that in the OT Rehab Consulting Initial Needs, Activities of Daily Living and Return to Work Assessment Report dated 16 November 2022, Ms Huynh said that her husband was previously responsible for the lawn mowing at home. As per the Motor Accidents Guidelines, domestic and home maintenance services could be approved as appropriate treatment or care for a person whose only injuries are minor injuries if the domestic service and/or home maintenance is needed because the injuries caused by the accident have reduced fitness for domestic tasks, it is reasonable in their circumstances, and is required for tasks the person used to do before the accident.
As lawn maintenance was not Ms Huynh's responsibility prior to the accident, it was not thought reasonable to support that request as per the Motor Accidents Guidelines.
For childcare assistance, Ms Huynh’s Allied Health Recovery Plan for physiotherapy indicated a lifting restriction of no more than two kilometres, sitting capacity of 15 minutes, and Ms Huynh shouldn’t drive. That meant that she was restricted in looking after her dependants who she was responsible for before the accident. NRMA were satisfied that claimant still needed childcare assistance because of the accident.
Review of Decision by NRMA Insurance dated 03 February 2023
This letter related to NRMA’s review of their decision dated 18 January 2023 that Ms Huynh had sustained a minor injury. After considering the information available on her claim and the MAI Act, it decided that the original decision should be substituted. A new decision should be made to replace the original decision.
It determined that Ms Huynh’s psychological diagnosis of post-traumatic stress disorder was not a minor injury as defined by the act. That meant that NRMA were in the position to accept liability for personal injury benefits after 26 weeks from the date of Ms Huynh's accident.
In that decision it referred to Ms Huynh's Psychological Treatment Plan dated 23 December 2022 which stated a provisional diagnosis of post-traumatic stress disorder involving a range of symptoms. That was supported by psychometric scores in the extremely severe range.
It still considered that Ms Huynh sustained soft tissue injuries to her neck, lower back and right shoulder which met the criteria of a minor injury.
Letter from NRMA Insurance dated 10 May 2023
This letter relates to NRMA's review of their decision dated 28 March 2023 to decline Ms Huynh’s request for further home/nanny assistance. After considering the available information on the claim, and rules around entitlement to treatment and care, it decided that the original decision should be affirmed. Therefore, it was unable to support the costs of further home and nanny assistance.
It is that decision which was the subject of the original dispute assessment and certificate prepared by Medical Assessor Middleton.
After review of the available evidence about your current capacity, NRMA noted that there was some improvement in your functional capacity for domestic and childcare tasks. They considered that further assessment was required with an occupational therapy therapist to appropriately determine your current capacity. The therapist should prepare a detailed report outlining recommendations on the specific tasks, hours, frequency of services and the period that those services are required to assist you while you're recovering from accident-related injuries.
Until that report was available, the insurer was unable to determine your need for ongoing home and nanny assistance or properly assess your current capacity for domestic and childcare tasks.
Dr Abhay Venkat, consultant neurologist, dated 29 November 2023
Dr Venkat was suspicious that Ms Huynh had a functional neurological disorder. She presented that day with improvement in her headache, but had gait ataxia, periods of disequilibrium, and pre-syncope, with right side of weakness that can come and go.
The main disabilities she has regarding that functional neurological disorder were right-sided intermittent weakness and intermittent pain, as well as disequilibrium and headache. He did not think that she was putting on her symptoms, or that there is a secondary gain, because she clearly wants to get better.
On neurological examination, she had some give-way weakness on the right side of her body. But her upper and lower limb tone, power and reflexes were normal. The MRI of her brain and whole spine did not show any cervical compression or myelopathy, and a brain scan did not show any evidence of demyelination or traumatic brain injury.
He explained to Ms Huynh that her likely neurological diagnosis was now a functional neurological disorder with significant post-traumatic stress for which she was getting psychotherapy.
Dr Venkat explained to Ms Huynh that the mainstay of her treatment would now be non-pharmacological including psychotherapy, physiotherapy and occupational therapy, as well as ongoing assistance for daily living, including a nanny to help her husband who's currently working.
He said that it must be made certain to Ms Huynh that this is a neurological diagnosis, despite it having psychiatric components, and she's subconsciously weak because of trauma in the past.
Certificate of Capacity/Fitness by Dr Stephanie Hugo for the State Insurance Regulatory Authority dated 07 December 2023
About nine months before this review assessment, Ms Huynh's diagnosis was functional neurological disorder, neck pain and right shoulder pain. She also had mild subacromial bursitis and a C5/6 minimal disc bulge, “lower back pain” secondary to the accident, and post-traumatic stress disorder.
Her capacity was 12 kilograms as tolerated for lifting her child, and the same for bending, twisting and squatting. She should drive as tolerated. She wasn't considered to have any capacity for work currently.
Certificate of Medical Assessment – 2017 Treatment or Care (Physical) by Medical Assessor Thomas Rosenthal, dated 17 January 2024
Dr Rosenthal found that Ms Huynh had developed neck and back symptoms, with neck symptoms affecting her right arm after the motor vehicle accident on 13 October 2022. Her injuries have persisted, and her disability has continued. Medical Assessor Rosenthal determined that, in terms of ongoing home and nanny services, those continue to relate to the injuries caused by the motor accident.
In relation to whether nanny and domestic services were reasonable and necessary, Dr Rosenthal found that Ms Huynh appears to have suffered more than a simple whiplash injury. She developed symptoms of occipital neuralgia and there appeared to be a neuralgia component to her symptoms. Although her children were a little older, her 18-month-old child still required care.
Based on the available evidence, he thought it would be reasonable that ongoing home and nanny services should continue to be provided. Those would be reasonable and necessary in the circumstances until there was significant improvement in her symptoms associated with her injury. Dr Rosenthal considered that the insurer's decision to stop funding those services was based on incomplete medical information and further information from a neurologist was required. He referred the treatment in dispute to an occupational therapist.
By the date of this review assessment, information had been received from Dr Venkat and Dr O’Neil.
Treatment note from Mr Alexander Chemuel, psychologist dated 18 January 2024
At that session, Ms Huynh told him that Christmas was good because her husband was home from work, and she had more support. She had regressed in recent days, her anxiety had been significant, and she was catastrophizing resulting in thoughts of harm and dying.
Medical Records, Dr Stephanus Hugo, GP, dated various
Recent medical records for six months prior to the review assessment are considered relevant to provide recent information about Ms Huynh's medical and functional status related to the accident.
The Panel noted that only two records from surgery consultations were recorded by Dr Hugo during 2024:
(a) 1 February 2024: Ms Huynh reported to Dr Hugo that she was still in pain and that physiotherapy was helping. Her diagnosis had been redefined as a functional neurological disorder and her headaches as migraines, for which she had ceased medication. Her treatment was now going to be psychotherapy, physiotherapy, and occupational therapy.
(b) Dr Hugo suggested ongoing assistance for activities of daily living, particularly a nanny, and she was not fit for work. Ongoing psychological treatment was accepted as part of her case, because her psychological condition was now considered non-minor with a formal diagnosis of post-traumatic stress disorder. Ms Huynh was said to have noticed significant improvement and had developed strategies to cope though counselling. Sessions were going to move to three-weekly, with a plan to reduce to monthly. No medication for her psychological symptoms was needed at that stage.
(c) The physiotherapist was treating her condition as high-grade whiplash, and she was still seeing them twice a week and considering swimming. She was also seeing an acupuncturist, which was paying for herself. She had volunteered to work at a school and was still waiting for the school to respond.
(d) 7 February 2024: this presentation to Dr Hugo was because Ms Huynh was feeling “tired all the time” and had an iron deficiency which is not related to the motor accident.
Dr John O'Neill, consultant neurologist, dated 16 February 2024
NRMA sought this report from a neurologist, consistent with Medical Assessor Rosenthal's opinion that a further opinion from a neurologist is required to support Ms Huynh's ongoing need for services related to her injuries in the accident.
Although this report was not available to Medical Assessor Middleton when she conducted her medical assessment, the initial Review Panel Report and Directions dated 15 July 2024 indicated that this report has been made available to both the insurer and Ms Huynh and the panel is entitled to take it into account.
Dr O'Neill reported Ms Huynh's current symptoms to include pains and pins and needles, from the centre of her neck radiating out over both shoulders, down her right arm, down the right side of her spine to her buttock and down the right leg. Her symptoms aren't constant, but they increase with activity such as carrying her young child. She always has a headache across the junction of her head and neck, but that worsens about once a week and radiates forward over the side of her head to her forehead. She’ll then be a bit nauseous and want to lie down in a dark room.
She told him about a change in her bladder function with a tendency to leak a bit of urine if she laughed or sneezed and she's taken to wearing a pad as a precaution. There are also non-physical symptoms such as stress, worry and anxiety about her situation and her future and she was “paranoid” when driving. She would only drive short distances, mostly to take her daughter to and from school.
She told Dr O'Neill that she was seeing a psychologist every three to four weeks, which helped with her anxiety. She had not seen a psychiatrist or tried medication for anxiety. She said she had not been working since the accident and her priority was her wellbeing.
On examination, Ms Huynh could stand fully on the balls of both her feet and heels and cranial nerve examination was normal. She tensed up when asked to perform neck movements but performed those slowly and symmetrically without spasm. She said the slowness was because of pain and she was scared. Her limb bulk and tone were normal. There was give-way weakness on testing of her right arm and leg but all deep tendon reflexes were symmetrical and normal with both plantar responses flexor. There was some subjective blunting to pinprick in her right arm when compared to her left arm.
Following his examination, Dr O'Neill considered that Ms Huynh had sustained a minor soft tissue injury to her head and neck region in the motor accident of 13 October 2022 when the back of her head hit her headrest in a low-speed accident. That would be regarded as a minor or threshold injury under the MAI Act. Radiological studies showed pre-existing spondylitic changes which were most prominent at C5 and C6 and there was a small disc prolapse at that level not causing cord compression. He considered that Ms Huynh has not had any physical disability because of the accident and has certainly never had an incomplete cervical cord injury.
Ms Huynh was shocked at the time of her first accident, and she has since had severe anxiety and depression with psychosomatic symptoms.
Regarding his findings, Dr O'Neill considered that Ms Huynh should be told that she has not sustained any physical injury. He thought there was no doubt that she has general anxiety and depression because of the accident and should be seen by a psychiatrist and commenced on appropriate medication. Continued psychological sessions may or may not be helpful and there is no need for other treatment.
In terms of her prognosis, he thought that “not too bad” if she has appropriate psychological treatment. He considered her a sensible lady who might understand that psychosomatic factors can arise in the aftermath of a minor frightening accident type she experienced.
He considered that her current physical symptoms are stable, and the impairment won't change by more than 3% in the next year with or without treatment. Her neck symptoms and signs present a 0% whole person impairment.
Records of Alexander Chemuel, psychologist from AMC Psychology, until 14 March 2024
On review of recent records, Mr Chemuel had seen Ms Huynh twice in 2024, on 18 January 2024 and 29 February 2024. That is one session about every six weeks.
In the most recent confidential report dated 21 December 2023, about eight months before the review assessment, Mr Chemuel said that Ms Huynh was still presenting with symptoms of post-traumatic stress disorder. That was having a significant impact on her daily function and ability to operate independently in the community. Her psychological condition was further exacerbated by physical injuries from the accident, and her physical injuries and pain are major factors which contribute to her experiencing anxious and depressive symptoms, particularly concerning persistent beliefs of uselessness and worthlessness.
Ms Huynh had told him that she previously benefited from in-home support and nanny help, not only for the day-to-day care of an infant child, but also with household responsibilities which she now finds difficult. Unfortunately, those are no longer funded by the insurer, and she cannot afford to pay the private cost of such support. Mr Chemuel strongly advocated for Ms Huynh to receive National Disability Insurance Scheme (NDIS) support and assistance for activities of daily living, as her main source of support is her husband who's now a sole income earner.
A treatment note from 29 February 2024 indicated that Ms Huynh was waiting for physiotherapy because she had double booked herself. Her husband had been hospitalized in recent days due to breathing issues and the hospital were uncertain of the cause. Ms Huynh found that as proof that he was struggling with increased responsibility since her injury. An occupational therapist had visited from the Commission and had recommended that her services be reinstated and funded by the insurer. She was feeling increasingly responsible for her husband's stress, and psychoeducation was provided regarding anxiety and stress.
Dr Richa Rastogi, consultant psychiatrist, dated 15 April 2024
Dr Rastogi assessed Ms Huynh for medico-legal purposes. He considered that Ms Huynh had become socially dormant, avoids talking to her friends and struggles to maintain relationships. She feels a burden on her family and husband and is emotionally disconnected from her children. She struggles to perform household tasks due to severe pain and deconditioning and needs help from her husband and her nanny two days a week to help with her daughter and meal preparation. She drives locally and struggles to be a passenger with high anxiety and arousal triggered by heavy traffic.
He diagnosed Ms Huynh with post-traumatic stress disorder with secondary major depressive disorder from the subject motor vehicle accident. He considered that her prognosis is guarded in the setting of chronic pain, deconditioning, persistent avoidance and fear-based response. He considered her debilitated by pain and entrenched anxiety and fear. She remained incapacitated for work. He assessed her with a whole person impairment of 17% related to her Permanent Psychological Impairment.
Dr Rastogi recommended that Ms Huynh continue with psychological counselling with exposure and trauma focused therapy to address her anxieties and fears, adaptations to challenges and to decrease her risk of relapses in the future.
She would also need further pain management support and should see a psychiatrist for medication management.
Determination of an Application for a Review of a Medical Assessment, Personal Injury Commission Decision, dated 29 April 2024
This decision referred to the Medical Assessment Certificate of Medical Assessor Middleton dated 21 February 2024. It referred to one of the grounds in the applicant's submission that “the Assessor has failed to consider” or “have adequate regard” to the medical material available. Furthermore, the applicant submitted that there were inconsistencies between the Medical Assessor Rosenthal's certificates, with Professor Rosenthal stating that Ms Huynh had been engaging a nanny for one day per week for six hours, in contrast to the Medical Assessor recording that Ms Huynh had been engaging a nanny for two days per week for 16 hours per week.
It was determined that there was confusion regarding the Medical Assessor's assessment in the matter and the Medical Assessor had not provided a clear path of reasoning concerning the assessment made and how they arrived at the ultimate determination in respect of any inconsistencies which may have presented.
Therefore, it was determined that there was reasonable cause to suspect that the medical assessment is incorrect in a material aspect and the application would be accepted and referred to a review panel.
Functional Assessment Report, Kira Ferry from OT Rehab Consulting, dated 23 May 2024
NRMA referred Ms Huynh for a physical work performance evaluation for the purpose of determining her safe physical work abilities and limitations. Ms Huynh's level of participation was monitored throughout the standardized assessment by comparing her willingness to exert maximal effort to observations made by the Assessor when testing her capabilities for dynamic strength, position tolerance, mobility and endurance.
Ms Huynh participated fully in 12 out of the 19 tasks and demonstrated self-limiting behaviour by ceasing to participate in 9 out of 21 tasks. Therefore, her maximal capacity for lifting and carrying and other physical tasks couldn’t be properly determined.
Self-limiting behaviour during the evaluation means that Ms Huynh elected to cease participation before clinical signs of maximal effort were observed. Reasons for self-limiting were pain in her head, neck, shoulders and back and headache. If the client self-limits on more than 8 tasks, further evaluation of the psychological and motivational aspects of participation is strongly recommended as those factors are likely to be influencing physical performance.
Based on that evaluation, the factors underlying Ms Huynh's limitation appeared to be pain in her head, neck, shoulders and back and self-limiting behaviour. Therefore, it was recommended that Ms Huynh participate in a psychological functional evaluation to confirm her capacity to perform work based on her psychological injury.
Individual Prescribing History as of 29 May 2024
Provided by NRMA, this document indicated that Ms Huynh had been prescribed Oxycodone in April 2022. Other medications were prescribed after her injury.
Functional Assessment Report, Michelle Harvey, senior psychologist from OT Rehab Consulting, dated 5 June 2024
A psychological functional capacity evaluation was conducted to confirm Ms Huynh’s current medical and treatment status, determine rehabilitation needs, assess psychological functional capacity and recommend and plan appropriate services to help Ms Huynh meet rehabilitation goals.
Ms Huynh reported that she had been seeing a psychologist, Mr Alexander Chemuel, fortnightly and now every two to three weeks as needed. Those sessions started due to symptoms including panic attacks, anxiety when driving and fear of being a passenger. She would also had difficulty bonding with her youngest daughter who was only six months old at the time of the accident. Her daughter is now two years old and prefers to have her husband comfort her as he was her main physical contact over the last one and a half years.
She reported seeing a psychologist after the birth of her now seven-year-old daughter as she was shocked at being a new mother and wanted to prevent potential issues. She sought a different perspective to see if her symptoms were normal. But she did not connect with the psychologist and only went for two to three sessions. Besides that, she said she'd never had mental health issues before and the accident was her first traumatic event.
By the time of this report, Ms Huynh reported symptoms including poor sleep hygiene, rumination, feeling of worthlessness and helplessness, irritability, emotional dysregulation, low mood and social withdrawal. She also had reduced her engagement in household tasks and self-care and had reduced cognitive functioning with her brain feeling like “mush”.
In the detailed assessment, Ms Huynh was found to experience a range of symptoms consistent with major depressive disorder. Given the age of her baby at the time of the accident, and her expressed difficulty bonding due to physical constraints, it was thought likely that she could possess a postnatal depression diagnosis. Ms Huynh had a history of postnatal depression after the birth of her first child, although was reluctant to label it as such. Her result on the PAI indicate that Ms Huynh is defensive and reluctant to admit to shortcomings, which aligns with her reluctance to gain insight into her mental health and tendency to attribute her symptoms to somatic pain issues.
Despite those findings, she did not think that Ms Huynh was feigning illness. Rather, she has limited insight into her mental health condition and appears to require a physical explanation, as that could increase her sense of control. Her poor mental health could also be exacerbated by her experience of pain. She presented as extremely labile and tearful and therefore appeared generally distressed.
The recommendation was that Ms Huynh doesn't have the capacity to work currently and is at medium risk of self-harm. Due to her plateaued progress with psychological treatment, it could be necessary to consider inpatient care if she doesn't stabilize within four weeks. Psychopharmacological treatment could be considered, and she should consult with a treating psychiatrist to address her mental health needs effectively.
Barriers to her return to work included a history of reluctance to engage in necessary treatment and difficulty building rapport, lack of insight into her current symptoms and a primary focus on her physiological symptoms, and reluctance to engage in psychopharmacological treatment.
Referral from Dr Stephanus Hugo, GP, to MindSea Psychology dated 26 June 2024
Dr Hugo diagnosis of Ms Huynh in this referral was prolapsed disc and functional neurological disorder. Her current medications included Endep, Melatonin, Mobic and Panadeine Forte.
She summarised Ms Huynh's presenting complaint as a neck injury in the motor vehicle accident on 13 October 2022, which has resulted in post-traumatic stress disorder with a component of postnatal depression. She had been seeing a psychologist at AMC Psychology, but they had plateaued. Due to the complex nature of her mental health, it was recommended that she attend MindSea Psychology instead.
Dr Abhay Venkat, consultant neurologist, dated 23 July 2024
Dr Venkat described Ms Huynh having “recalcitrant right arm and leg pain, numbness and muscle spasm from the motor vehicle accident”. She also has a generalized anxiety disorder, post-traumatic stress disorder and generalized anxiety. As a result of a neurological condition, she was left with “crippling pain” as well as muscle fatigability and urinary incontinence requiring pads. She was finding it very difficult to look after a two-year-old and seven-year-old and can only drive short distances because of pain.
As neuroimaging had not revealed a causative lesion to explain her syndrome, he had diagnosed her with a Functional Neurological Disorder. He considered it important that functional neurological disorders are treated as a neurological diagnosis given the significant morbidity that ensues after the initial insult. That's often triggered by an event and in her case was a motor vehicle accident. He described that as an irreversible condition that's unlikely to resolve and will only show improvements with appropriate allied health interventions.
Focus should be on physiotherapy, exercise physiology, helping her with her care needs at home, including occupational therapy assessment for continence and daycare services to look after her children. He also recommended ongoing psychiatric and psychological support. Dr Venkat was advocating for allied health services given that the pharmacological measures had failed for treating her headache and pain.
According to that, he shared the client's perspective of her illness and how that affected her day-to-day life. That included her severe symptoms and that her injuries are valid despite not showing on MRI scans. She felt misunderstood, frustrated about everyone not understanding about a functional neurological disorder and not taking her physical symptoms seriously. Even after a functional assessment with the Occupational Therapist (OT), Ms Huynh told him that she could complete most of the task but required ongoing painkillers and the pain kicked in, pinching in her neck and radiating down to her right side, buttocks, legs and feet and then she was bedridden, needed to rest. She said her pain could be triggered by pushing, lifting something light, stress, trauma and anxiety from driving and the pain also comes on out of nowhere.
Support letter from Dr Abhay Venkat, dated 23 July 2024:
Dr Venkat wrote a support letter for Ms Huynh's NDIS application dated 23 July 2024, summarising similar information as he had in his report of the same date. This indicated that she was applying to become a participant in the National Disability Insurance Scheme based on her diagnosis of a functional neurological disorder since October 2022.
DETERMINATIONS – TREATMENT
Treatment and care – reasonable and necessary
Ms Huynh is required to establish that the treatment is both “reasonable and necessary”.
The Panel referes to the Diab criteria (at [21]) for what might be reasonable and necessary treatment are as follows:
(a) the appropriateness of the treatment in the dispute;
(b) the avialbility of alternative treatment;
(c) the cost effectivess of the treatment;
(d) that actual or potential effectiveness of the treatment and,
(e) the acceptance by medical experts of the appropriateness of the treatment.
Whilst the observations in Diab were directed to the test of “reasonably necessary” in the workers compensation legislation, the Panel adopts them insofar as they have relevance, although not determinative, of the stricter test of “reasonable and necessary”.
The Panel notes as significant the findings of Medical Assessor Rosenthal who determined Ms Huynh’s physical injuries as causally related to her accident and that ongoing home and nanny service were necessary. His examination findings were similar to the Panel’s in that he did not find that Ms Huynh had neurological deficits in her arms or legs, examining that she had mostly full range of motion except for neck movement at extremes. He found that no examination results explained the extent of her problems and recommended further opinion from a neurologist.
The Panel acknowledged that when Medical Assessor Rosenthal assessed Ms Huynh, he did not have access to the reports of Dr Venkat who had diagnosed her with Functional Neurological Disorder in his report of 28 November 2023.
The Panel considers as significant the opinion of Dr O’Neill, neurologist, who assessed Ms Huynh after Medical Assessor Rosenthal. He considered the Ms Huynh had sustained a minor soft tissue injury without ongoing physical disability. He acknowledged that she has since had severe anxiety and depression and psychosomatic symptoms. Dr O’Neill recommended that she be seen by a psychiatrist, start on medication and have psychological counselling.
The Panel further notes the recent diagnosis made by Dr Richa Rastogi, psychiatrist, of 15 April 2024, post-dating Dr Rosenthal’s assessment. He diagnosed Ms Huynh with post- traumatic stress disorder and major depressive disorder. He made similar recommendations to Dr O’Neill to address Ms Huynh’s mental health.
At the home assessment conducted by the Panel on 15 July 2024, the Medical Assessors could not verify Ms Huynh’s self-report of physical complaints, particularly her high levels of pain and functional limitation.
The Panel acknowledges Dr Venkat’s diagnosis of Functional Neurological Disorder in his report of 23 July 2024 and agrees with his treatment recommendations including physiotherapy, exercise physiology, occupational therapy, psychiatric and psychological support.
The Panel notes that Dr Venkat also recommended that Ms Huynh have assistance with her care needs at home and daycare services to look after her children. Dr Rosenthal also agreed this was a need related to her injury.
The Panel considers that as Ms Huynh’s youngest child is now a toddler and more physically independent, replacing her role in parenting and domestic tasks is not the most effective strategy to help her to self-manage her condition and maximise her participation in home, community or work activities. The Clinical Framework of the Delivery of Health Services indicates that independence does not mean symptom-free, but rather living a functional, productive life while self-managing symptoms.
The Panel further considers that the Clinical Framework for the Delivery of Health Services indicates self-management as the best way forward. The Framework highlights that failure to empower an injured person to become independent may result in dependency on treatment, which reinforces illness behaviour and can lead to persistent pain and long-term disability.
Therefore, the ongoing provision of commercial care to replace Ms Huynh’s parenting and domestic roles is not an effective long-term solution.
The Panel found no evidence in the Initial Needs report dated 16 November 2022 or Rehabilitation Progress Report No.2 dated 31 March 2023 from OT Rehab Consulting that Ms Huynh had ever received occupational therapy intervention to increase her capacity and build self-management strategies, nor had she been prescribed equipment for energy conservation during domestic or parenting tasks. This was consistent with Ms Huynh’s reporting.
Building self-management strategies through occupational therapy intervention for task simplification, energy conservation training and use of adaptive equipment would facilitate her independence and reduce the likelihood of dependency further reinforcing illness behaviour and long-term disability. Other allied health services, such as exercise physiology to help her set-up a self-managed exercise program, could also benefit her.
While learning and implementing self-management strategies taught by her occupational therapist, and receiving psychological support, Ms Huynh would benefit from domestic assistance for heavy household cleaning and laundry to maximise her energy to participate in those programs. That would include mopping floors, vacuuming, cleaning the bathrooms, changing bedding, and laundering sheets and towels.
The Medical Assessors determined that 4 hours per week for three months is reasonable and necessary for domestic assistance.
She would also benefit from support with parenting tasks (nanny). The nanny could accompany Ms Huynh for community outings with Camellia on a non-day care day to help her to practice physical handling strategies taught by the occupational therapist. That would help Ms Huynh become more confident taking Camellia out herself.
The Medical Assessors recommended that two hours, twice a week for three months is reasonable and necessary for parenting support, bringing it to a total of four hours per week.
CONCLUSION
The Panel revokes the determination of Medical Assessor Middleton and substitutes the determination to certify that the following treatment and care is reasonable and necessary in the circumstances:
(a) eight hours a week home and nanny services for three months.
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