Kamereddine v QBE Insurance (Australia) Limited
[2024] NSWPICMP 790
•25 November 2024
| DETERMINATION OF REVIEW PANEL | |
CITATION: | Kamereddine v QBE Insurance (Australia) Limited [2024] NSWPICMP 790 |
CLAIMANT: | Mohamad Kamereddine |
INSURER: | QBE Insurance (Australia) Limited |
REVIEW PANEL | |
MEMBER: | Belinda Cassidy |
MEDICAL ASSESSOR: | Michael Couch |
MEDICAL ASSESSOR: | Drew Dixon |
DATE OF DECISION: | 25 November 2024 |
CATCHWORDS: | MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; claimant’s application for assessment of treatment dispute and insurer’s application for WPI assessment; both assessments undertaken by Medical Assessor Cameron; claimant’s two applications for Review under section 7.26; claimant sustained multiple injuries in t-bone collision between his van and the side of a minibus; contemporaneous notes recorded injuries to the rib (fracture) and soft tissue injuries and abrasions to the neck, right hand, left ankle, thoracic spine and right shoulder; claimant complained about two months later of right hip and right knee pain; issue of causation and method of impairment assessment; claimant re-examined and conceded most of his injuries had recovered including the injury to his shoulder; claimant’s main complaints were of right hip pain and right knee pain; Panel was satisfied that the mechanism of the accident could have and did give rise to injuries in all the listed parts of his body including the hip; claimant’s WPI assessed at 3% as most of his injuries had recovered and resulted in no assessable impairment; right shoulder had minor impairment which Panel found was resulting from the accident and right hip impairment assessed at 2%; treatment considered reasonable and necessary and related to the injuries; Held – certificates revoked; no issue of principle. |
DETERMINATIONS MADE: | CERTIFICATE OF DETERMINATION Issued under Division 7.5 of the Motor Accident Injuries Act 2017 1. The Review Panel revokes the replacement certificate of Medical Assessor Cameron issued on 9 May 2024 and: (b) in proceedings numbered R-M20294/24, the Review Panel certifies that the disputed treatment is reasonable and necessary in the circumstances and relates to the injury caused by the accident, and (c) in proceedings numbered R-M20917/24, the Review Panel certifies that the degree of the claimant’s permanent impairment resulting from the injuries caused by the accident is 3% which is not greater than 10%. |
STATEMENT OF REASONS
INTRODUCTION
Mohamad Kamereddine (the claimant) was involved in a motor accident on 11 January 2022.
Mr Kamereddine says he injured many parts of his body in the accident including his back, neck, hips, ribs, shoulders, knee, ankle and hand. Mr Kamereddine made a claim for statutory benefits and then damages against QBE, the third-party insurer of the vehicle that Mr Kamereddine says caused his accident.
Two medical disputes arose in connection with Mr Kamereddine’s claims and were referred to the Personal Injury Commission (the Commission) for assessment as follows:
(a) a dispute in the statutory benefits claim about treatment related to a hip injury – referred by the claimant in proceedings numbered M20917/24, and
(b) a dispute in the damages claim about whole person impairment (WPI) – referred by the insurer in proceedings number M20294/24.
Both of those disputes were allocated to Medical Assessor Cameron who, on 9 May 2024 determined Mr Kamereddine did not have a WPI of greater than 10% and that the treatment was not related to the accident and was not reasonable and necessary in the circumstances.
The claimant then lodged a single application with the Commission seeking a review of the Medical Assessor’s decision.
On 27 June 2024, a delegate of the President determined there was reasonable cause to suspect a material error in the assessment and allowed the review and on 2 July 2024 the President’s delegate convened this Review Panel (the Panel) to conduct the review.
Following a query from the Panel, the President’s delegate re-issued her first decision and issued a second decision finding reasonable cause to suspect an error in both Medical Assessor Cameron’s certification of the disputed treatment and the claimant’s WPI. The President’s delegate allowed the two Reviews to proceed and convened the same Panel to conduct both reviews. The Panel has determined it would hear and determine the two matters together.
LEGISLATIVE FRAMEWORK
General
Mr Kamereddine’s claim and entitlements to compensation are governed by the provisions of the Motor Accident Injuries Act 2017 (the MAI Act). This legislation provides a scheme for the compulsory third-party insurance of all 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. As noted above, Mr Kamereddine has made both claims and medical disputes have arisen in both claims.
Division 7.5 of the MAI Act provides for the medical assessment of medical disputes by the Commission including provisions relevant to an original medical assessment such as Medical Assessor Cameron, further medical assessments and the review of medical assessments by this Panel.[1]
[1] Sections 7.20, 7.24 and 7.26.
Applications for review of a medical assessment are made to the President of the Commission on grounds that the assessment “was incorrect in a material respect”
(sub-s (1)). If the President, or his delegate is satisfied “there is a reasonable cause to suspect that the medical assessment was incorrect in a material respect” then the President arranges for the application to be referred to a review panel consisting of a member of the Commission and two medical assessors (sub-ss (2) and (2B).The review is not necessarily confined to the issues raised in the application (or the reply) but is “a new assessment of all the matters with which the medical assessment is concerned” (sub-s 3A).
Rule 128 of the Personal Injury Commission Rules (the Rules) 2021 permits the Panel to determine its own proceedings and the Panel is not bound by the rules of evidence and may inquire into relevant matters as it thinks fit.
Treatment and care in a statutory benefits claim
Statutory benefits payable by the “relevant insurer”[2] in accordance with Part 3 of the MAI Act include:
(a) weekly loss of income benefits for “earners” under Division 3.3, and
(b) treatment and care benefits under Division 3.4.
[2] The “relevant insurer” is determined in accordance with s 3.2 of the MAI Act.
Unlike the previous motor accident compensation scheme, damages for treatment and care cannot be recovered by the claimant against the insurer. The mechanism for a claimant to recover the cost of treatment and care they say was caused by the accident is through the 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 -
(c)the reasonable cost of treatment and care,
15. …
(2) No statutory benefits are payable for the cost of treatment and care to the extent that the treatment and care concerned was not reasonable and necessary in the circumstances or did not relate to the injury resulting from the motor accident concerned.”
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)”.
Non-economic loss in a damages claim
In a claim for lump sum compensation, damages are assessed accordance with common law principles as modified by the MAI Act. Under Part 4 of the Act, an injured person can make a claim for damages for both certain types of economic (pecuniary) losses and damages for non-economic (or non-pecuniary) loss.
Damages for non-economic loss are limited and restricted by the provisions in Division 4.3 of the MAI Act. For example, non-economic loss damages are limited to a maximum amount in accordance with s 4.13[3] and entitlement to those damages is restricted by s 4.11 to persons who have a greater than 10% WPI as a result of the injuries sustained in the accident.
[3] The current maximum as of October 2024 is $654,000.
If there is a dispute about the degree of the claimant’s permanent impairment, damages for non-economic loss cannot be awarded and disputes must be referred to a Medical Assessor for determination.[4]
[4] See s 4.12 of the MAI Act.
Permanent impairment is to be assessed in accordance with Chapter 6 of the Motor Accident Guidelines (the Guidelines)[5] which are largely based on the American Medical Association’s Guides to the Evaluation of Permanent Impairment, Fourth Edition (AMA 4 Guides).
[5] Section 7.21. The current version of the Guidelines is Version 9.1 which is effective from 1 April 2023.
Due to the nature of the injuries sustained by the claimant, chapter 3, the musculoskeletal chapter of the AMA 4 Guides is relevant.
ASSESSMENT UNDER REVIEW
Medical Assessor Cameron confirms at section [2] of his reasons that he was asked to assess the following injuries in terms of WPI:
(a) ribs - multiple rib fractures on the right-hand side;
(b) right hand – contusions;
(c) left ankle - abrasions in the region of the left ankle;
(d) right hip injury;
(e) cervical spine – injury;
(f) thoracic spine – injury, and
(g) bilateral shoulder pain.
The Medical Assessor then said at [3] he was asked to assess whether a follow up consultation for the claimant’s right hip with Dr Randhawa, orthopaedic surgeon relates to the injury and is reasonable and necessary in the circumstances.
The Medical Assessor records a history as follows:
(a) the claimant was working as a cabinet-maker at the time of the accident, says he was in good health but smoked 20-30 cigarettes per day;
(b) his airbags deployed and he was taken to Westmead Hospital by ambulance. He was unsure of whether he hit any part of his body in the interior of the car;
(c) he consulted his general practitioner (GP), Dr Nosir and said that his right hip pain became significant several months after the accident. He had a right hip arthroscopy on 12 December 2022 and returned to driving 12 months after the accident, and
(d) he has not returned to work and his father is running the business.
Mr Kamereddine said he had right hip and occasional right rib pain. He was restricted in leisure and work activities and was upset and worried about his future. Mr Kamereddine says he was taking Mobic and Panamax but having no physiotherapy.
On clinical examination it is recorded at [15] that:
(a) there was mild and symmetrical loss of neck motion, no spasm, guarding, dysmetria and no non-verifiable radicular complaints;
(b) cervical nerve root tension signs were negative and there were no neurological abnormalities in the upper extremities;
(c) there was a full range of motion at both shoulders and in all upper extremities;
(d) the thoracic spine showed mild and symmetrical loss of motion with no spasm, guarding, dysmetria or non-verifiable radicular complaints present;
(e) thoracic nerve root tension signs were negative;
(f) in the lumbar spine there was moderately and symmetrical loss of motion with no spasm, guarding, dysmetria or non-verifiable radicular complaints present;
(g) lumbar nerve root tension signs were negative and there were no neurological abnormalities in the lower limbs;
(h) there was a full range of motion at the knees with no crepitus or instability and a full range of motion of all other lower limb joints, and
(i) the claimant walked with a normal gait and his right hip motion was recorded as:
(i)flexion 70 degrees
(i)extension 0 degrees
(i)abduction 40 degrees
(i)adduction 40 degrees
(i)internal rotation 40 degrees
(i)external rotation 20 degrees.
Medical Assessor Cameron said at [16] the claimant’s movements were inconsistent, and the claimant explained this was due to variable pain.
At [17] the Medical Assessor summarises the documentation noting the first consultation with the GP occurred on 14 January 2022 but that it was not until 28 April 2022 that there is mention in the records of the right hip area with a complaint of “right groin” pain for two weeks and there was tenderness over the right hip. He notes Dr Nosir’s letter of 19 February 2024 expressing a view of causation saying that when the claimant’s consumption of Endone stopped, he experienced hip pain.
At [19] Medical Assessor Cameron found the claimant sustained rib fractures and multiple soft tissue injuries. He did not find the right hip labral tear was caused by the motor accident because of the absence of complaints for the first three months. He diagnosed at [21] soft tissue injuries to all other parts of the body and rib fractures.
At [24] he assessed impairment giving reasons for the various injuries all of which attracted a 0% WPI.
Having found the right hip was not injured in the accident he determined at [28] and [29] that the treatment in dispute was not related to the accident and therefore was not reasonable and necessary.
ISSUES FOR DETERMINATION
Claimant’s submissions
The claimant’s submissions of 24 May 2024 allege errors in the Medical Assessor’s assessment of the right hip injury.
The claimant says at paragraph [20] of the submissions that the Medical Assessor ignored evidence from Dr Rahme, orthopaedic surgeon. The claimant says at [24] that the Medical Assessor has relied on the absence of recorded complaints of right hip pain after the accident which is wrong and does not take into account that the right hip may have deteriorated after the accident. The claimant relies on a report of Dr Nosir who said the hip pain would have been masked by the Endone the claimant was taking. Also noted is that Dr Rahme refers to claimant’s other injuries distracting Mr Kamereddine from his right hip pain.
The claimant submits at [31] that even if the labral tear was present before the accident, the Medical Assessor did not consider the possibility of the symptoms developing after the accident because of an aggravation type injury.
The claimant submits at [38] that the correct test is whether the accident could have caused or contributed to the worsening of impairment and whether the accident did cause or contribute to the worsening of impairment.
At [42] the claimant complains that the Medical Assessor did not give adequate reasons.
The claimant submits at [47] that the Medical Assessor failed to assess the left hip. At [50] the claimant says the Medical Assessor did not provide range of motion measurements and did not disclose his reasons.
The claimant asserts at [52] that the Medical Assessor considered degenerative labral tears were not uncommon which is an irrelevant consideration in someone only 22 years of age at the time of the accident.
The claimant asserts he was denied procedural fairness by the Medical Assessor’s failure to ask him why there was no recorded complaint of hip pain and there was a denial of procedural fairness in proceeding with the medical examination in the absence of the further medical evidence from Dr Randhawa.
The claimant’s submissions dated 18 July 2024 set out at [1]-[2] a detailed chronology relevant to the issue of the scope of the review (one Review or two) which, in the light of the Delegate’s most recent decisions is no longer an issue in the proceedings.
At [3] the claimant refers to the clinical records of Dr Randhawa, orthopaedic surgeon and based on his notes now seeks the assessment of the claimant’s right knee in addition to the other injuries and confirms the following injuries are to be assessed:
(a) ribs;
(b) left ankle;
(c) left hip;
(d) right hip;
(e) cervical spine;
(f) thoracic spine;
(g) left shoulder;
(h) right shoulder, and
(i) right knee.
The claimant requested at [4] a re-examination.
The submissions at [5] relate to timeliness of the claimant’s applications for review and the insurer’s reply and are not relevant. The Panel will be considering the applications and supporting submissions and documents and the replies and supporting documents. Paragraph [6] and [7] of the submissions also concern the scope of the review.
The claimant submits at [8] that Medical Assessor referred to one orthopaedic surgeon but not two. The claimant has been referred to both Dr Rahme and Dr Randhawa. The claimant refers to Dr Rahme’s report in relation to the commencement of hip pain and says Medical Assessor Cameron did not refer to Dr Rahme at all and did not refer to Dr Randhawa’s report about causation of the right hip injury.
The claimant submits that Medical Assessor Cameron did not put the inconsistency with regards to causation to the claimant’s attention and ask for comment.
Insurer’s submissions
The insurer submits that the Medical Assessor did consider the relevant history and documents in connection with the right hip noting that on the day of the accident the claimant complained of no hip pain and did not report hip pain for 15 weeks after the accident.
In respect of the failure to mention Dr Rahme’s reports the insurer says the Medical Assessor is not required to answer every medical opinion that may differ from the Medical Assessor’s opinion.
The insurer submits that the Medical Assessor did ask the claimant about causation of the hip problem and that the Medical Assessor addressed the absence of medical records.
The insurer refutes that the claimant was denied procedural fairness by abandoning the medical assessment and waiting for Dr Randhawa’s opinion regarding a hip replacement.
Finally, the insurer submits the Medical Assessor did provide reasons and explain his findings.
Procedural matters
On 4 July 2024, after the Panel had been convened, directions were issued to the parties. The parties were advised that in order to ensure the Panel had all relevant documentation before it, the parties were to provide bundles of the documents they relied on.
The claimant was also requested to confirm whether both treatment and WPI were in dispute noting that the submissions dealt only with the latter. There was a short delay while the issue of “one Review or two” was clarified by the President’s delegate.
On 9 September 2024, upon receiving the second review allocation, the Panel issued directions to the parties advising them that the Panel would be hearing both Review proceedings together and requested a single combined bundle of documents from each party to be lodged in proceedings R-M20917/24.
On 23 September 2024 the Panel met to discuss the two matters and reported to the parties the next day. The Panel noted the seven injuries assessed by Medical Assessor Cameron and the additional injuries requested by the claimant (right knee and left hip) and advised that subject to any further submissions all injuries would be assessed.
The Panel asked the claimant to point to the evidence to support the alleged multiple rib fractures noting that the radiology only indicated one. The Panel also queried whether the right wrist or hand injury and left ankle injury needed to be assessed as the claimant’s expert, Dr Bodel had indicated they had resolved.
The Panel advised the parties of the re-examination date.
Final responses
The claimant responded on 2 October 2024 as follows:
(a) he relied on reports from Dr Nosir and Dr Bodel who diagnosed two rib fractures but accepts they have healed and result in no impairment;
(b) the claimant accepts his right wrist and hand injuries have resolved and results in no impairment;
(c) the claimant requested a re-examination of the left hip to confirm there has been no deterioration since Dr Bodel examined it, and
(d) the claimant sought a right knee assessment on the basis Dr Randhawa said the claimant had a right knee injury in the accident which was causing chronic pain.
The insurer responded on 21 October 2024 as follows:
(a) in relation to the rib fractures and right wrist/ hand the insurer agreed with the claimant that these have resolved and result in no impairment;
(b) in respect of the left hip the insurer points to Dr Bodel’s examination on 18 May 2023 that the claimant’s left hip was normal, the clinical records of Dr Nosir and his report of 19 February 2024 do not refer to the left hip and says the claimant has failed to explain how his left hip could have deteriorated. The insurer says there is no injury and therefore no impairment, and
(c) the insurer says there is no reference to the right knee in the clinical references shortly after the accident, in May 2023 Dr Bodel found no restriction in either knee and did not diagnose a knee injury and Medical Assessor Cameron found a full range of motion. The insurer says there is no evidence of knee injury or ongoing symptoms and therefore no impairment. The insurer also says if there is chronic knee pain it does not relate to the accident.
The claimant attended the re-examination with Medical Assessor Couch who had noted the discrepancy in the hospital and ambulance records in terms of the mechanics of the accident and whether the claimant was driving a van or a bus. The claimant showed Medical Assessor Couch a photograph of his vehicle and indicated he had others of the crash. The Panel requested the parties upload any relevant photos to the portal.
The claimant had also informed Medical Assessor Couch that soon after the accident when his GP, Dr Nosir was away, he attended a Vietnamese doctor near his home. This was paid for, the claimant recalled by Medicare and Mr Kamereddine was given a script for Tramadol. The Panel asked the claimant to make efforts to obtain a record of this attendance.
The claimant uploaded photographs to the portal, but no further records were provided by either party. The Panel determined to proceed in the absence of any additional records.
REVIEW OF THE EVIDENCE
Claim form and claim documents
The claimant’s claim form is dated 25 January 2022.[6] The claimant lists his injuries as:
(a) fractured right ribs;
(b) injury to the right hand;
(c) left ankle abrasions;
(d) neck stiffness;
(e) pain behind right shoulder, and
(f) thoracic spine injury.
[6] Page 40 in the insurer’s bundle.
The Panel notes there is no allegation of a knee injury or hip injury in this list of injuries.
The ambulance report[7] has the claimant driving at 50kmph and that the bus was a minibus that was t-boned by the claimant’s vehicle and that it was the bus that flipped and not the claimant’s vehicle. The claimant was said to be ambulant at the scene complaining of upper back pain and pain to his right ankle with no swelling or deformity. No other injuries were detected.
[7] Page 47 of the insurer’s bundle.
The Westmead Hospital discharge summary[8] records the claimant was the driver of a minibus which t-boned another bus at 50-60kmph. The claimant was not sure if the airbags had deployed but he was complaining of right upper thoracic pain which was gradually getting worse. He said he was holding very tight to the steering wheel. There was no evidence of a head injury, cervical spine injury, upper limb injury, no seatbelt injury and the hips and pelvis were said to be normal.
[8] Page 53 of the insurer’s bundle.
There was evidence of an old rib fracture and an undisplaced right posterior fifth rib fracture seen on X-ray.
The insurer obtained rehabilitation advice from Ms Kim, psychologist and rehabilitation consultant of Rehab Focus. She wrote a report dated 17 April 2022[9] after a meeting on 5 April 2022 noting that the claimant reported fractured ribs, an injured right wrist and left ankle. The claimant said he was conscious but unable to respond (to police, ambulance and fire brigade) as he was shaken. She notes “Mr Kamereddine reported he was taking Endone during the first week after the MVA, however he now takes no pain medication as he does not like to.” Ms Kim noted the claimant was not having any treatment and Dr Nagpal said at the case conference that physiotherapy was not needed but that counselling may help.
[9] Page 56 of the insurer’s bundle.
The claimant reported constant pain in his chest, anxiety when he sees a bus, lifting anything increases pain in his chest and his sleep is disturbed.
In a second report from Ms Kim dated 4 July 2022, return to work strategies were discussed and it was identified this was difficult in the family kitchen cabinet business as there was no meaningful light duty work available. Ms Kim recommended the claimant participate in exercise physiology.
Certificates of fitness have been provided by Dr Nosir as follows:
(a) 21 January 2022 – with injuries noted as fractured right ribs, injury right hand and left ankle abrasions. The treatment plan was for analgesics;
(b) 21 February 2022 and 14 March 2022 – same injuries listed;
(c) 11 April 2022 the same injuries were listed with “anxious” added. Analgesics were still mentioned in the treatment plan and psychotherapy was added;
(d) 11 May 2022 same injuries listed;
(e) 10 June 2022 – the same injuries were listed, and the same treatment plan was noted but the claimant was certified fit to work for five hours a day for four days a week; 8 July 2022 same, 6 August 2022 same;
(f) 2 September 2022 the claimant was certified fit to work as above but it was noted he was going overseas and needed a longer certificate (to 30 November 2022), and
(g) 9 December 2022, the same injuries were listed and the same treatment plan but surgery was noted to have occurred the day before.
The photographs provided by the claimant include the following:
(a) the first shows a patient on the grass on the kerb with an ambulance officer. The front of Mr Kamereddine’s van can be seen in the background with significant deformation damage to the front and what appears to be both airbags deployed;
(b) the third photographs shows a close up of the front of the van with the front squashed in towards the cabin;
(c) the fourth shows clearly both airbags deployed, and
(d) the fifth shows the significant damage to the middle third of the minibus and a direct t-bone type hit to the bus.
Treating medical records and reports
Pre-accident records from Dr Nosir have been provided dating back to 2001 when the claimant was two years of age.[10] Obesity was first recorded in April 2009. The claimant was referred to Dr Kwok for treatment of his obesity in March 2012 and it was noted “he plays Nintendo Wii as his exercise. He could spend the whole day in front of screens”. Dr Kwok referred the claimant to Westmead Children’s Hospital obesity clinic on 23 April 2012.
[10] Page 72 of the insurer’s bundle.
The claimant was involved in an accident on his way to work on 14 July 2016. A car ran over his right foot. The claimant complained of pain in his foot on 17 August 2016. On 30 January 2018 the claimant attended with pain in his left knee for two to three weeks and an X-ray was requested. This showed no significant abnormality but suspected suprapatellar fluid. An MRI was recommended but there is no further imaging on file.
On 26 August 2019 the claimant had pain in his lower back due to an infected pilonidal sinus. This reoccurred in February 2020 and December 2020 and surgery was performed. The claimant attended on multiple occasions for dressing of the surgical wound.
On 11 December 2020 the claimant’s BMI was recorded as 42.2 with a weight of 100kg.
The claimant had a lacerated hand on 21 December 2020 which had been stitched at another medical centre. The claimant attended for multiple wound reviews and dressing changes.
On 16 January 2021 one of Mr Kamereddine’s complaints was of left knee pain on and off for a long time. His last MRI had been done on 25 August 2020 and apparently it showed an Anterior Cruciate Ligament (ACL) rupture, and the claimant was seen by an orthopaedic surgeon. The claimant had a flare up of pain and requested Tramadol. He was not interested in Nurofen when it was offered.
After the accident the claimant attended Dr Nosir on 14 January 2022. The claimant was tender in the ribs and was provided with Endone, Nurofen and Panamax. There is no mention of any other injured body part.
On 21 January 2022 the claimant attended complaining of pain in his right chest, right hand and left foot. An X-ray of his right hand was requested which reported a suspected undisplaced fracture of the hamate bone. On 1 February 2022 the claimant was still sore in the right wrist and an MRI was requested. This showed severe arthropathy and developmental variants. There was some sign of a contusion but no sign of a fracture.
On 21 February 2022 the claimant was still complaining of right chest, right wrist and left ankle pain. On 14 March the claimant was still getting pain in the right chest and was depressed and crying. He complained of no other injured parts of his body.
On 28 April 2022 the claimant complained of pain in his right groin for two weeks and he was tender in the right hip but had a normal range of motion.
The claimant had a right hip X-ray on 5 May 2022 due to pain – there was no fracture or dislocation seen. On 6 May 2022 the claimant was referred to Dr Rahme.
On 23 May 2022, “backache” was mentioned. The claimant had decreased range of motion but no tenderness. On 3 June 2022 the claimant complained of right groin, lower back and rib pain. He was prescribed Mobic and referred for an MRI of the lumbosacral spine.
The claimant attended on 24 June 2022 and there is a record of right hip pain despite the injection occurring the day before. The claimant still had pain on 8 July 2022 and on 8 August 2022 the hip pain was said to have improved.
On 14 September 2022 the claimant attended for other reasons. He was getting married and concerned about matters unrelated to the accident. His weight was 96.5kg and his BMI 31.35. He was prescribed Panadeine Forte as he was going overseas.
The claimant had right hip arthroscopy and debridement of the cyst at Norwest Private Hospital on 8 December 2022. The claimant was identified as a one pack per day smoker.
The claimant was seen on 15 December 2022. He was still in pain and taking Endone and reported to be using crutches and was prescribed Panadeine Forte and Mobic. On 3 January 2023 the claimant was still complaining of limited mobility in the right hip.
On 27 March 2023 a telehealth appointment occurred. The claimant was overseas. His right hip was painful, and he was getting pain in his left hip. On 11 May 2023 the claimant had returned from overseas and was seen in the surgery with pain in his left hip and his right hip movement was better. On 16 May 2023 the claimant had put on 20kg and was reported to be experiencing pain in both hips.
Dr Nosir wrote to the claimant’s solicitor dated 19 February 2024 and listed Mr Kamereddine’s injuries as:
(a) fractured ribs and a soft tissue chest wall injury which have healed;
(b) soft tissue injury to the right wrist which has healed;
(c) whiplash injury to the neck which has healed;
(d) musculoligamentous or soft tissue injury to the lower back still causing issues,
(e) pubic symphysis causing discomfort;
(f) a right hip injury being a labral tear with paralabral cyst causing pain and difficulty walking;
(g) anxiety and insomnia, and
(h) obesity due to a sedentary life.
Dr Nosir says the claimant sustained multiple injuries and the claimant was prescribed Endone which had masked his hip pain. When the Endone stopped and the rib fractures healed, the claimant noticed hip pain. Dr Nosir says he has committed an error by not including the right hip injury in the certificates of fitness because he did not update the list of injuries after the first certificate.
He expressed the view that the claimant would be unable to return to his employment as a cabinet maker.
The Panel notes Dr Nosir does not mention a right knee or any knee injury and also does not mention any injury to either of the claimant’s ankles.
Dr Rahme, orthopaedic surgeon wrote to Dr Nosir on 17 May 2022 following a referral. He had a history of the bus running a give way sign and says that “symptoms in the hip commenced in the weeks after the car accident”. He refers to the claimant having sustained “distracting injuries” including the rib fractures. He undertook X-rays of the pelvis which were normal and arranged for an MRI of the right hip.
On 2 June 2022 Dr Rahme wrote again to Dr Nosir after the MRI had been done. This showed an anterior labral tear with paralabral cyst, and the claimant was complaining of increasing sharp groin pain which was a sign of impingement due to the labral tears.
Dr Rahme wrote a further letter dated 1 July 2022 to Dr Nosir after having the right hip paralabral cyst aspirated and injected. As there was no improvement in the immediate post injection period (when the local anaesthetic would have been in effect) it was considered the cyst and tear might not have been the source of the claimant’s problems and he referred the claimant to a colleague. Dr Rahme’s notes suggest the pain was worse after the injection.
Dr Randhawa wrote a series of letters to Dr Nosir. The first is dated 16 August 2022. He has a history of the claimant being hit front on by a bus that failed to stop at a give way sign. The claimant was said to have been braking firmly just before impact which caused a high vector force to his right leg, jarring his right knee and right hip. The claimant reported severe right hip and right knee pain with the hip worse than his knee which was causing him to limp. Dr Randhawa described a “massive labrum tear and paralabral cyst.” He advised hip arthroscopy surgery.
The arthroscopy was done on 13 December 2022 noting mild acetabular chondromalacia adjacent to the labral tear.
On 30 January 2024 the claimant was reviewed a year after his surgery. The claimant was said to be “still quite debilitated with right hip pain” and he could only flex to 130 degrees with 20 degrees of that causing pain. There were no neurological signs or suggestion of radiculopathy. He requested an updated MRI and further review.
On 27 February 2024 after the 6 February 2024 MRI showed the labrum repair was intact. He said there “is nothing further which needs to be undertaken with his right hip.” Although he did foreshadow the degeneration of the hip in the future and total hip replacement was an option, he said the claimant needed to pursue physiotherapy and exercise.
The claimant relies on a report from Dr Randhawa dated 15 July 2024. It is not a standard report as such but answers to a series of questions put to him by the claimant’s solicitor and dated 6 March 2024.
Dr Randhawa says that the claimant sustained a right hip labrum tear and chondral damage and a right knee injury resulting in chronic pain. He says the right hip injury “was definitely caused by the accident.” Dr Randhawa says the claimant suffers from right hip joint degeneration and chronic right knee pain. He was of the view the claimant would require a right total hip replacement within eight years. He considered the claimant unfit for any role involving physical labour but could work in sedentary office-based roles.
Medico-legal reports
Dr Bodel, orthopaedic surgeon provided a report to the claimant’s lawyers dated 18 May 2023.
He has a history of the claimant being a cabinet maker who had not worked since the accident. He lists the injuries sustained by the claimant as:
(a) multiple rib fractures;
(b) contusion to the right hand – now resolved;
(c) abrasions in the region of the left ankle – now resolved;
(d) left and right hip injuries;
(e) injury to the neck;
(f) injury to the thoracic spine, and
(g) pain in both shoulders.
The claimant says he was driving his HiAce van when he hit a bus on the left-hand side which lifted the van up onto its wheel, rolling the van onto the driver’s side sliding across the road and spinning 90 degrees. He got out of the vehicle and went to Westmead Hospital and was kept overnight. The claimant’s main areas of pain were the ribs and thoracic spine.
The claimant complained of pain in both hips, the right groin and right trochanteric region, right sided rib cage pain, intermittent neck pain, right wrist pain, and lower back and interscapular pain.
The claimant’s left and right shoulders were examined with restricted movement in both. There was no restriction of elbow wrist or hand movement and no wasting in the upper limbs.
There was dysmetria and guarding in the cervical spine but no signs of radiculopathy. There was tenderness and guarding in the lumbar spine and pain in the right groin and right hip. Left hip motion was normal but right hip motion was slightly reduced. There was no restriction in the knee, ankle or subtalar movement and no signs of radiculopathy.
Dr Bodel expressed the view the claimant was incapacitated for work and his prospects of working as a cabinet maker were limited.
Dr Bodel, in a separate report assessed WPI at 23% on the basis of:
(a) cervicothoracic 5%;
(b) lumbosacral 5%;
(c) left shoulder 6%;
(d) right shoulder 6%, and
(e) right hip 4%.
The insurer relies on a report from Dr Home, occupational physician dated 21 August 2023. He has a history of the bus coming from the claimant’s right and that the claimant t-boned the side of the bus. His airbags deployed. He was taken by ambulance to Westmead Hospital.
The claimant’s initial complain was of rib pain and that he noticed pain in his neck and right wrist in the days after the accident. His right wrist pain settled. The claimant also recalled pain in his right ankle which resolved.
The claimant said his right hip pain commenced about three months after the accident, had it investigated, saw Dr Rahme and Dr Randhawa and had surgery. He says there was “no significant analgesic benefit”.
The claimant was taking Paracetamol or Ibuprofen neither of which were effective.
The claimant did not complain of neck pain or right wrist pain. He denied upper or lower back pain. He described occasional right axial discomfort and constant pain in the right hip.
The claimant was single living with his parents and with his fiancé living in Lebanon awaiting her visa. He recalled a pre-accident left knee injury relating to a trampolining accident.
The claimant weighed 108kg.
On examination of the neck there was no guarding and normal range of motion. There was no neurological deficit noted.
Active range of motion of both shoulders was measured and full and normal. The right wrist was pain free and no loss of motion.
In the thoracolumbar spine motion was full and there was no guarding.
The right hip motion was restricted but knees and ankle movements were full. There was no wasting from disuse in the right lower limb.
Dr Home has a history of no complaints of left hip symptoms.
He considered the right hip complaints were not related to the accident on the basis of the absence of complaints of pain in the first three months saying, “a traumatic capsular tear would cause acute pain within several days of the subject accident.”
In a separate report he found a 0% WPI.
RE-EXAMINATION FINDINGS
Medical Assessor Couch re-examined the claimant on 29 October 2024 over a period of 90 minutes. The examination took place in the Commission’s medical suites.
Mr Kamereddine attended alone having driven himself from Guildford West. He looked rather stiff and sore on arrival and explained that he had parked downhill from 1 Oxford Street on Wentworth Avenue and had walked uphill.
The following history was obtained directly from Mr Kamereddine.
Pre-accident medical history and relevant personal details
Mr Kamereddine said his parents emigrated to Australia from Lebanon in the 1980s. He was born here, living in Lakemba and later moving to Guildford West. When asked about school, he described playing multiple musical instruments. He had no difficulty academically. He completed his School Certificate and left school at the end of Year 11. He said it had always been his plan to complete his trade qualification and go into his father’s cabinet making business. At the time of the accident in January 2022, he was working full-time with his father and a cousin in the family cabinet making factory. They made cabinets for kitchens, bathrooms and wardrobes and did both commercial and residential work.
The notes show the claimant had attended the same GP (Dr Nosir) since the age of two. He had some childhood health difficulties, particularly with his weight, and treatment had included from Dr Louise Baur, a childhood obesity specialist at Westmead Children’s Hospital. General practitioner records mention an injury to his right foot when it was run over by a car tyre in 2016. Mr Kamereddine said he made a full recovery from this. He also had surgery for a pilonidal sinus in 2020, with rather prolonged wound healing.
Before the subject accident, Mr Kamereddine said he was working a full 40-hour week, sometimes with additional hours on a Saturday. Time was spent approximately equally between working in the factory and installation onsite. He described himself as very physically active and having no difficulty with the physical demands of the work. He said that in addition, he was physically active in his leisure time, including going to the gym, playing some basketball and also Oztag.
Mr Kamereddine has married since the accident. His wife recently emigrated from Lebanon and they have an 11-month-old son. His wife has not yet tried to re-enter the workforce. They are living with his parents.
History of the motor vehicle accident
Mr Kamereddine said that on 11 January 2022, he was driving a work Toyota HiAce van alone along Wanda Street in Merrylands at about 50kmph. He drew a diagram to clarify the mechanism of the crash and explained he was approaching the intersection with Rupert Street. A Toyota Coaster 20-seater bus approached from his right along Rupert Street and failed to give way at the white line. Mr Kamereddine explained that because of trees and parked vehicles on the corner his vision was restricted. At the last moment he saw the bus in his path. He said that he did not have time to swerve but braked “hard”.
His van “T-boned” the left side of the bus in front of its nearside rear wheel. Mr Kamereddine referred to photographs of both vehicles which were later made available to the Panel. They show a large indent on the left side of the bus from the impact of the van. The bus was pushed over onto its side. There was extensive damage to the front of the HiAce, particularly on the right (driver’s) side, with damage extending up to the lower edge of the windscreen. Mr Kamereddine was wearing a seatbelt and both front airbags activated. He said that after the impact, which was more on the right front corner of his van, the van veered to the left and he thought that he might have hit his chest on a bulge on the driver’s door, which could have caused his fractured ribs. He also thought there may have been a heavy load through his right leg as he braked hard, followed by the sudden deceleration from the collision between the two veihcles. He was taken by ambulance to Westmead Hospital, where he was kept overnight.
History of symptoms and treatment following the motor vehicle accident
The ambulance officer’s report described the accident and noted that the bus which he had hit was lying on its side. The claimant was said to be fully conscious, lying supine on the road and complaining of upper back pain. At that time, he denied chest pain and did not have pain on inspiration. Mr Kamereddine also denied cervical spine tenderness, but was complaining of upper back pain with pain on movement and palpation, and pain in the right ankle without swelling or deformity. He was given analgesia and transferred to Westmead Hospital.
The Westmead Hospital Emergency Department discharge summary stated that the claimant was not sure if the airbags had deployed (the Panel has been able to confirm this by viewing the photographs). At that time, Mr Kamereddine was complaining of the immediate onset of right upper thoracic back pain which was gradually getting worse. Examination showed severe tenderness over the right paravertebral upper thoracic region with the comment “IMP: most likely severe muscle sprain given the non-impact mechanism but also consider avulsion fracture of transverse process of the upper [thoracic] spine”.
CT scans of the cervical and thoracic spine and chest were performed. The cervical spine was described as normal with no fracture, and no fracture was seen in the thoracic spine. In the chest it was reported:
“There is a fused segment on the right, between the fourth and fifth ribs likely to be secondary to an old fracture. Inferior to this along the lateral aspect of the fifth rib, there is a fracture line, in keeping with a new, undisplaced fracture. Dependent opacity seen in the left lung base, non-specific, which may be due to atelectasis or pneumonitis. Conclusion: undisplaced right posterior fifth rib fracture”.
The claimant was discharged home with Paracetamol, Ibuprofen and Targin to take twice a day for three days, and Endone for breakthrough pain. He was given the advice:
“Continue [to] use Incentive Spirometry at least four times a day - this is important to prevent chest infections”.
Mr Kamereddine was asked about the onset of any right hip symptoms. He replied:
“I was feeling pain everywhere all over the body after the accident – I thought all the pain was coming from my ribs – it was only when that eased off I realised the hip – the GP did a scan just to be sure”.
On further questioning about specific pain in the right hip, he replied:
“I had pain everywhere. It was too hard to tell where from – I couldn’t move a finger without screaming in pain”.
Mr Kamereddine said that resting at home he got quite depressed, and friends used to come round and persuade him to get up and help him into the car – this was apparently about six weeks after the accident. He confirmed that he had been resting in bed for six weeks saying:
“I couldn’t move – showering was a disaster – I had a chair in the shower – mum helped me sometimes”.
The claimant indicated this level of assistance was required for at least the first couple of weeks after the accident.
Mr Kamereddine was asked about his recollection of resuming walking. He said that his mother had purchased aluminium elbow crutches from the hospital pharmacy, and he thought he might have been using these for about three weeks or so after the accident. He was also asked when he first recalled walking outside the home and he thought this might have been after about six weeks, commenting:
“I tried going out with my mother once – before my mates started coming to take me out”.
The Panel notes this history may be incorrect. The records suggest the claimant was on crutches after the right hip arthroscopic surgery. There is no record of crutches before that. The Panel also notes that in the first six weeks after the accident the claimant left the home attending on Dr Nosir at least four times.
Mr Kamereddine recalled taking strong analgesia in the form of Endone, Tramadol and Panadeine Forte initially. He described a brief supply from Westmead Hospital Emergency Department and then said he got some more from his GP, commenting that this was “only for a short period – he didn’t want me to get addicted”.
The claimant was asked more specifically about how long and how much opiate analgesia he took. He thought that he had only taken Endone for one or two weeks, commenting that it was too strong to take for longer. Subsequently, he thought that he had taken Panadeine Forte or Tramadol – possibly for two months or more. Since then, he had been taking Nurofen and the anti-inflammatory Mobic.
At this stage of the interview the Medical Assessor referred the claimant to the computerised records of his usual GP, Dr Nosir. The claimant’s first attendance at the surgery was three days after the accident on 14 January 2022, when the main complaint appeared to be pain from the right chest and Dr Nosir found tenderness over the right side of the chest. The claimant was given Endone 5mg three times a day, Panadol two tablets four hourly, and Nurofen two tablets three times a day. At a review in the surgery, one week later, the claimant reported he had pain in the chest, right hand, left foot and was found to be tender over the right fifth metacarpal in the hand, with an abrasion on the dorsum of the left ankle. He subsequently had an X-ray of the right hand and then an MRI of the right wrist.
Two months after the accident on 14 March 2022, the claimant was still complaining to Dr Nosir of pain in the right chest and was depressed and tearful. The first mention of the right hip was on 28 April 2022, “pain in R groin for two weeks. O/E tender R hip anteriorly. NROM x-ray then review”.
Medical Assessor Couch took Mr Kamereddine to the notes which suggested there was no record of prescription analgesia (Endone or Panadeine Forte) after the first attendance. The claimant replied that he had also seen a different GP near his home (Dr Tien Nguyen). He said that at that time he had needed more painkillers and Dr Nosir was away and this was a Medicare consultation, not funded by the insurer. He thought that he had received one pack of Tramadol. The Panel has been unable to confirm this.
At this stage of the interview, Mr Kamereddine also said that his memory was “a bit blurry with the details because I was on painkillers”.
He was then asked about any possible injury or symptoms in the left hip. He replied that his left hip was not injured in the accident but had become painful he thought, “because of all the weight I’m trying to take off the right hip”. He thought that maybe that was causing some pain, but he had seen Dr Nosir and understood that imaging of the left hip suggested there was no injury and it was satisfactory.
He was asked about the right knee. He said that he did not think he had struck it in the accident and that he had felt pain all down the right leg and also in the right ankle. He said that these symptoms later settled, and he no longer has pain in these areas but he still had pain in the right hip.
Mr Kamereddine was asked about shoulder symptoms, and he said the shoulders had been painful from the time of the accident.
He was asked more about his recollection of specific symptoms immediately after the crash. He recalled the right chest being very painful, with extreme pain if he ever sneezed. He said that he was given breathing exercises to do for a prolonged period. He also described back and neck pain from the time of the accident, commenting that he wondered if this had come from his rib fractures, and again saying that his whole body felt like it was in pain initially.
He confirmed seeing Dr Randhawa, hip knee and trauma surgeon, for his right hip. When asked about the result of the arthroscopic surgery, Mr Kamereddine said it did not help and that Dr Randhawa had told him he would eventually need a total hip replacement. He said that he had not been given an exact likely timeframe for this but said that it could be in 10 years or possibly later than that.
When asked about any physical treatment, the claimant said that he had seen an exercise therapist who visited him at home mainly for the right hip. He continues to do exercises every one or two days. He said that he had not consulted any medical specialists for other body areas other than the right hip.
Current symptoms and activities
When asked about returning to work in the family cabinet making business, he replied:
“No – I wish – don’t get me wrong – sometimes I go down to the factory and sit and supervise – my little brother has just started – in our type of business it’s all heavy lifting”.
When asked, he said that his father had cut down on the amount of work done by the business and had reduced staffing levels. He said this had caused a lot of stress and he felt guilty about this. At home, he commented that he cannot sit for long and has to get up and walk around for relief of hip pain.
Right hip
Mr Kamereddine said he could cope with any other more minor symptoms if his right hip could be fixed. He described these symptoms in more detail in particular pain in the right hip, (pointing to the right groin and laterally across to the right hip joint area). He says there is always some pain which can vary between fairly dull and very sharp stabbing pain.
The commonly-used Visual Analogue Scale (VAS) for rating pain severity was explained to him. He estimated the pain during the re-examination was 6/10, and said this recently had been the average. He though the minimum on a good day would be 5/10 and the worst when it became sharp and stabbing as 8 to possibly 9/10.
He described difficulty with prolonged sitting and often gets up and walks around briefly for relief. He feels somewhat more comfortable in standing, but again cannot stand still for long. He estimated his walking tolerance as about five minutes on a good day and said that he cannot run at all. Stairs are difficult and he leads with his left (uninjured) leg and uses a handrail if present. He finds it difficult to squat.
Neck, back and ribs
Mr Kamereddine said that he no longer had pain in his neck, thoracic or lower back and has fully recovered from these injuries.
In relation to his ribs while he agreed his chest was not sore, during the physical examination he did report chest pain at the extreme of shoulder movement.
Shoulders and upper limbs
He said that both his left and right shoulders were now satisfactory and were no longer bothering him. He agreed he had fully recovered from any shoulder injury.
Mr Kamereddine denied any ongoing symptoms in his right hand or arm.
Left hip
As detailed above, Mr Kamereddine did not think that he had injured his left hip in the accident but reported some symptoms more recently. He said that it was milder and in the same area as on the right, and only occurs if he is on his feet for too long.
Right knee
Mr Kamereddine responded that this was “not a 100% but OK”.
Left ankle
Mr Kamereddine described his left ankle as “fine” and that he had no problems with either ankle
Present medication
Mr Kamereddine said that he had been taking the anti-inflammatory Mobic daily but had now cut it down to about every three days. He also takes Nurofen, perhaps every three days.
Mr Kamereddine said that he smokes 20 cigarettes a day and realises this is bad for him. He does not drink alcohol at all.
Physical examination
Mr Kamereddine attended alone. He presented as a friendly, co-operative young man who presented in a genuine and straightforward manner. While there were some parts of his history that may have been inaccurate, Medical Assessor Couch noted that Mr Kamereddine seemed to be searching his memory carefully to answer specific questions, but (as detailed above) he could not remember some details.
His affect was within normal limits, and he could smile and laugh appropriately. During the examination he showed good effort, was co-operative throughout, and there were no abnormal pain behaviours or evidence of self-limitation or inconsistency. The Panel notes the claimant conceded that most of his injuries had recovered.
The claimant’s height was measured at 172cm and his weight 113kg. He was moderately obese with a BMI of 38. Chest girth was 126cm, waist 124cm and hips 121cm. He was wearing tracksuit pants and a loose-sleeved top and undressed to his underwear for lower limb examination.
He was able to sit throughout the interview but did stand up to stretch for relief at one time during the 90 minute period. He walked at a moderate pace without an obvious limp. It was noted that he seemed to find it difficult to reach from sitting position to remove and replace his shoes and socks which related to his obesity rather than any injury.
Cervical spine
Posture of the head and neck was within normal limits. There was no significant tenderness to palpation over the cervical spine or adjacent muscles. Active cervical spine measurements were:
(a) flexion as about two-thirds of normal while extension was full. Flexion was limited by contact of the claimant’s chin with his chest and related to his body habitus. Medical Assessor Couch did not consider that there was true dysmetria;
(b) rotation was full bilaterally, and
(c) lateral flexion was full on both sides.
There was no detectible muscle guarding or spasm. The claimant complained of no symptoms of radiating or shooting pain or symptoms in his upper limbs that could be considered non-verifiable radicular complaints.
Thoracic spine
Posture of the thoracic spine was normal. There was no significant tenderness to palpation over the thoracic spine.
Spinal rotation (which occurs mainly in the thoracic spine) was tested with Mr Kamereddine seated to stabilise the pelvis. The movement was full bilaterally. To the left, he was comfortable but on full rotation to the right he complained of slight pain to the right of the T12 level.
There was no associated muscle spasm or guarding and he did not describe any non-verifiable radicular complaints around the chest.
Lumbosacral spine
On palpation, Mr Kamereddine did not report any tenderness. There was no muscle guarding or spasm. Active range of motion of the lumbar spine was tested with Mr Kamereddine standing with knees straight. Flexion, extension and lateral flexion bilaterally were all full, with no complaint of back pain. He was noted to flex forward with fingertips to the mid-shins, with a smooth and full expansion over the lumbosacral segment. At the limit of flexion, he did complain of some right hip pain, but no back pain.
Mr Kamereddine did not complain of any symptoms that could be considered as non-verifiable radicular complaints in relation to the lumbosacral spine.
Upper extremities
The hands were very soft and clean without any calluses consistent with his reported inactivity at work and home. Mr Kamereddine said that they had been very rough and callused when working in the cabinetmaking workshop before the accident. A small well-healed scar was noted at the base of the left thumb. He said that this had come from a previous laceration in the kitchen at home.
Elbow, hand and wrist movements were all normal.
The right upper arm measured 40cm in circumference, the left 39cm which is not a clinically significant difference for someone who is right-handed. Both forearms measured equally at 30cm. Biceps, triceps and brachioradialis reflexes were normal and symmetrical. Power of all muscle groups was normal in both upper limbs, including grip strength and hand intrinsic muscles. Sensation to light touch was preserved and equal on both sides.
Both shoulders were normal to inspection, with no deformity or visible muscle wasting. He did not report any tenderness to palpation over either shoulder joint. The active range of the shoulders was carefully measured with a goniometer with repetition, as tabulated below:
Right
Left
Flexion
180
180
Extension
50
50
Abduction
180
180
Adduction
40
40
External rotation
90
90
Internal rotation
70
80
The slight restriction of internal rotation on the right was confirmed with further examination in that Mr Kamereddine could reach his left thumb a little further up behind his back than the right.
At the limit of initial right shoulder flexion, Mr Kamereddine cried out and complained of pain in the right chest rather than in the shoulder, commenting that he had not felt that for a while. On palpation of the chest, he was mainly slightly tender over the right costal margin.
Lower extremities
Measured 10cm proximal to the patella, the right thigh measured 60cm circumference, the left 59cm. The right calf measured 43cm and the left 42cm. This is not a clinically significant difference in the view of the Panel noting the claimant’s obesity and difficulties with measurement.
Both lower limbs were neurologically normal:
(a) knee jerks and ankle jerks were normal and symmetrical;
(b) power of extensor hallucis longus (L5 nerve roots) at ankle eversion (S1 nerve roots) was normal and symmetrical;
(c) light touch was preserved in both lower limbs, and
(d) straight leg raising was 50 degrees on the right and 60 degrees on the left.
Both knees were clinically normal with no deformity, effusion and normal alignment. There was no tenderness or crepitus on movement. Ligaments were intact and no patellofemoral pain could be reproduced on patellofemoral grinding or Clarke’s test.
Active range of motion when measured was slightly greater on the left at 0-130 degrees, compared with 0-120 degrees on the right, but both these ranges were within normal limits and no pain was reported.
Both ankles and hindfeet were also clinically normal with active range of motion pain-free and full, as tabulated below:
Right
Left
Plantar flexion
40°
30°
Dorsiflexion
20°
20°
Inversion
30°
30°
Eversion
15°
15°
In the lower limb. abnormalities were restricted to the right hip.
Medical Assessor Couch initially noted that when Mr Kamereddine was asked to flex the knee and hip for testing the ankle jerk reflex, he complained of some discomfort in the right hip. There was marked tenderness to palpation over the right groin. The average range of motion of the hips was carefully measured with a goniometer with repetition, as tabulated below:
Right
Left
Flexion
90°
110°
Extension
10°
20°
Abduction
40°
50°
Adduction
20°
30°
External rotation
70°
70°
Internal rotation
15°
40°
Mr Kamereddine made good effort during hip movements. He did describe pain at the limits on the right, including in flexion. The most painful movement was internal rotation, with quite marked pain in the right groin. In relation to this, Mr Kamereddine pointed out that “twisting my hip” is particularly painful and causes a sharp pain.
At the end of the re-examination, Mr Kamereddine was asked to perform a few functional activities after they were demonstrated these to him. He was able to take a few steps with weight on the balls of his feet and heels off the floor, and then with weight on his heels and forefeet off the floor. He was able to squat about halfway down to the floor before stopping and recovering without needing hand support but complained of right hip pain during this.
CONSIDERATION OF THE ISSUES – DIAGNOSIS AND CAUSATION
The Panel notes the accident was a significant “T-bone” crash when Mr Kamereddine’s utility struck a larger minibus, tipping it on its side. His airbags activated. The photos show significant frontal deformation of the claimant’s van.
The claimant complained to ambulance personnel of upper back pain and right ankle pain and to hospital personnel of chest pain. The claim form records (10 days after the accident) injuries to the right ribs, right hand, left (not right) ankle, neck stiffness, thoracic spine injury and pain behind the right shoulder. There were no knee or hip injuries noted. The first five GP entries after the accident record left ankle abrasions, right chest and right-hand pain
The Panel is satisfied on the basis of these contemporaneous records that the claimant sustained injuries to his back, neck, rib, right hand, left and possibly right ankle. The Panel is of the view that leaving aside the fractured rib, the other injuries were soft tissue injuries from which the claimant has largely recovered.
The Panel notes the hospital radiology suggests an old rib fracture and an acute (accident related) rib fracture. In the absence of any further specialist radiological evidence the Panel is satisfied that the claimant sustained a fracture of only one rib being an undisplaced right posterior fifth rib fracture.
The claimant complained of a right shoulder injury in the claim form and Dr Bodel took a history of pain in both shoulders. The claimant gave a history to Medical Assessor Couch of no further problems in his shoulders and, apart from some minor restriction of motion, the claimant’s shoulder examination was normal. The claimant has given a clear history of gripping the steering wheel before impact and the airbags deployed. The Panel accepts that the claimant could have and did sustain upper limb injuries including a soft tissue injury to the shoulders (and the reported right-hand injury).
Mr Kamereddine’s only significant complaints now are in relation to the right hip, which is clinically clearly irritable. Considering his moderate obesity, the Panel is of the view that the sudden and significant frontal impact of his vehicle with the minibus, while the claimant’s extended right leg was planted heavily on the brake pedal, could have created an excessive load through the right leg and into the right hip causing injury.
Whether the accident did cause a right hip injury has been raised by the insurer due to the delay in formal recording of this by his longstanding general practitioner, Dr Nosir, and the claimant’s failure to include a right hip injury in the claim form completed less than a fortnight after the accident. The Panel notes that Mr Kamereddine reported an unusually great and prolonged amount of pain from his right rib fracture and a period of prolonged inactivity and bed rest, initially receiving help from his mother with showering. The claimant was also taking some pain killers prescribed by Dr Nosir and according to him, Dr Nguyen. The Medical Assessors considered it plausible that in these circumstances, the claimant would not have noticed any significant hip pain until he became more mobile.
The claimant was not sure whether he hit his right knee on anything in the vehicle during the accident, but the claimant said he did have at some stage right knee pain. Medical Assessors have considered whether the right knee pain, reported to and by Dr Randhawa may be referred pain from the right hip joint. It is the clinical experience of the Medical Assessors that hip pain can sometimes be felt more in the knee.
The Panel is therefore satisfied that the claimant did sustain an injury to his right hip in the accident including the labral tear and paralabral cyst. The Panel is not satisfied that the claimant injured his right knee in the accident but that any symptoms in the right knee are likely related to the right hip injury.
IMPAIRMENT ASSESSMENT
Spine
Assessment of the spine requires consideration of Chapter 3 of AMA 4 Guides. Only the diagnostic related estimate (DRE) method of assessment is allowed (cl 6.111). The spine is divided (cl 6.131) into three regions: the cervical, thoracic and lumbar.
If injury to the spine is alleged, then each of the regions is assessed and the percentage impairments combined to obtain a total spinal impairment (6.119).
There are five diagnostic related categories, and a number of indicia provided (see Table 7). The first is DRE category I which is selected if there are symptoms which may include pain. In the circumstances of this claim the usual DRE categories of II and III are relevant.
A category DRE II impairment requires there to be:
(a) pain with guarding or
(b) non-uniform range of motion – dysmetria or
(c) non-verifiable radicular complaints defined in Table 6.8 as:
(i)symptoms (shooting pain, burning sensation, tingling)
(ii)which follow the distribution of a specific nerve root but no objective clinical findings such as loss or diminished sensation, loss or diminished power or loss or diminished reflexes.
The most common DRE III finding requires radiculopathy to be present which is defined in cl 6.138 as
“… the impairment caused by dysfunction of a spinal nerve root or nerve roots when two or more of the following clinical signs are found on examination …
(a) loss or asymmetry of reflexes;
(b) positive sciatic nerve root tension signs;
(c) muscle atrophy and/or decreased limb circumference;
(d) muscle weakness that is anatomically localised to an appropriate spinal nerve root distribution, and
(e) reproducible sensory loss that is anatomically localised to an appropriate spinal nerve root distribution.”
Mr Kamereddine did not complain of any pain in his neck and back and said he had recovered from these injuries. He reported some pain on moving his thoracic spine which he had not felt for a while.
In his cervical spine, there was no guarding of true dysmetria (the asymmetry of flexion and extension was explained by Medical Assessor Couch as due to the claimant’s obesity and not because of neck symptoms) and Mr Kamereddine did not complain of any non-verifiable radicular symptoms. The upper limb examination did not reveal any of the signs of a cervical radiculopathy.
In the lumbar spine, there was no guarding, dysmetria or complaint of a non-verifiable nature. The lower limb neurological examination did not reveal any of the signs of a lumbar radiculopathy.
The Panel is of the view the claimant’s cervical spine and lumbar spine injury have recovered and attract no assessable impairment.
The Panel is of the view the claimant’s thoracic spine injury is still causing mild and infrequent symptoms of pain and should be assessed as DRE I which attracts a WPI of 0%.
Chest and ribs
The Panel notes cl 6.23 of the Guidelines provides that certain injuries do not attract an impairment, and the clause gives the example of “uncomplicated sternal and rib fractures.”
Mr Kamereddine’s right sided fifth rib fracture was undisplaced and there is no evidence of any complication. The claimant complained of pain in his chest on extremes of right shoulder flexion and was mildly tender in the chest.
While he may have continued symptoms of pain in the chest, these do not attracted an impairment in accordance with the Guidelines.
Upper limbs
The assessment of upper limb or upper extremity impairment (UEI) is governed by Chapter 3, section 3.1 of the AMA 4 Guides. The upper extremity is divided into four regions: the shoulder, the elbow, the wrist and the hand. There are specific rules for combining certain impairments and adding others. Regional impairments are combined to obtain a total UEI which is then converted to a WPI using Table 3 on page 20 of AMA 4 Guides.
The claimant’s right wrist movement was normal and there is no assessable impairment. The claimant confirmed he had recovered from this injury.
In terms of his shoulders, there are several methods of assessment permitted. In Mr Kamereddine’s case, the Panel’s view is that the most appropriate method of assessing shoulder impairment is in accordance with part 3.1d, the abnormal range of motion method. This requires the measurement of six functional units of motion:
(a) flexion and extension;
(b) abduction and adduction, and
(c) internal and external rotation.
Measurement of motion is done using a goniometer and only active (not passive) motion is measured. Figures 38, 39, 41, 42, 44 and 45 provide for the calculation of the UEI for each of the six units of motion. These are added to get a total UEI percentage impairment which is then converted to a WPI in accordance with Table 3 page 20 of AMA 4 Guides.
Mr Kamereddine’s range of shoulder motion was mostly normal and is recorded below
Normal motion
Right (and UEI)
Left (and UEI)
Flexion
180
180
180
Extension
50
50
50
Abduction
180
180
180
Adduction
50
40 (0% UEI)
40 (0% UEI)
External rotation
90
90
90
Internal rotation
90
70 (1% UEI)
80 (0% UEI)
While Mr Kamereddine did not complain of pain in his shoulders to Medical Assessor Couch and was of the view he had recovered from his injury, he has minor restrictions of motion and a right shoulder impairment of 1% UEI which translates to a WPI of 1% using Table 3. This may be due to injury or it may be constitutional and related to his obesity. In the light of the significant forces involved in this accident (the claimant was gripping the steering wheel hard at the time of impact) the Panel has accepted the claimant sustained shoulder injuries and accepts these injuries did cause or materially contribute to the recorded impairments
The claimant therefore has a WPI of 1% for his right shoulder injury.
Lower limbs
The assessment of lower extremity impairment is governed by Chapter 3, section 3.2 of the AMA 4 Guides. There are 13 methods of assessment provided for. Each limb is assessed and each injury (if there are multiple injuries in each limb) is assessed separately. Clause 6.70 and Table 6.5 of the Guideline states which methods can and cannot be combined and Table 6.6 provides guidance is selecting the most appropriate method. The Guidelines at cls 6.76 to 6.110 provides specific interpretation and guidance on the various methods of assessment.
In Mr Kamereddine’s case, the Panel considers the range of motion method the most appropriate.
Mr Kamereddine’s ankles were normal, and he considered he had recovered from any injury.
In the right knee Mr Kamereddine reported he was nearly normal. He had a slight reduction in flexion movement in the right knee (0-120 degrees compared to 0–130 degrees in the left). Table 41 at page 78 of AMA 4 Guides requires there to be less than 110 degrees of flexion for any impairment percentage to be awarded. The claimant therefore has no assessable right knee impairment.
Table 40 provides for mild (2% WPI), moderate (4% WPI) and severe (8% WPI) hip motion impairment. There are six units of motion provided. Clause 6.85 of the Guidelines provides:
“Tables 40 to 45 (page 78, AMA4 Guides) are used to assess range of motion in the lower extremities. Where there is loss of motion in more than one direction/axis of the same joint, only the most severe deficit is rated - the ratings for each motion deficit are not added or combined. However, motion deficits arising from separate tables can be combined.”
The Guidelines require in cl 6.21 for the impairment to be assessed on the day of the re-examination. Clause 6.22 provides that the evaluation of impairment cannot include any allowance for predicted deterioration.
The claimant’s hip measurements were measured and the WPI provided for in Table 40 has been noted.
Right (and WPI)
Left (and WPI)
Flexion
90 degrees - mild 2%
110 degrees - 0%
Extension
10 degrees – 0% (no flexion contracture)
20 degrees - 0% (no flexion contracture)
Abduction
40 degrees - 0%
50 degrees - 0%
Adduction
20 degrees - 0%
30 degrees - 0%
External rotation
70 degrees - 0%
70° degrees - 0%
Internal rotation
15 degrees - mild 2%
40° degrees - 0%
There is impairment to two directions or axes in the same (hip) joint. In accordance with cl 6.85 these are not combined or added. The claimant has two mild impairments and therefore has an overall mild impairment of hip motion assessed at 2% WPI.
Is the treatment related and reasonable and necessary?
The treatment in dispute is a single follow up consultation for the claimant’s right hip with Dr Randhawa requested in January 2024. It appears from the claimant’s history that the insurer had paid for the right hip arthroscopy, acetabular osteoplasty, labrum repair and debridement of cyst in December 2022.
As the Panel has found that the claimant could have and did sustain an injury to the right hip, the Panel is of the view the follow up consultation with Dr Randhawa is related to the injuries sustained in the accident particularly with the claimant’s history of continued symptoms in the right hip.
The Panel is also of the view that the treatment is reasonable and necessary in the circumstances noting that there were continued complaints in the right hip and the treatment and surgery was not successful. It is also reasonable and necessary for him to have a follow up consultation to ensure there has been no deterioration of the injury and to assess his progress.
CONCLUSION
In proceedings numbered R-M20294/24 (the treatment dispute Review proceedings), the Panel has come to a different conclusion to Medical Assessor Cameron and therefore his certificate must be revoked.
In proceedings numbered R-M20917/24 (the WPI Review proceedings), the Panel finds the claimant’s WPI is as follows:
(a) rib fracture resolved – no assessable impairment;
(b) right hand resolved – no assessable impairment;
(c) left ankle resolved – no assessable impairment;
(d) cervical spine resolved – no assessable impairment;
(e) thoracic spine DRE I – 0% WPI;
(f) lumbar spine resolved – no assessable impairment;
(g) left shoulder no assessable impairment;
(h) right shoulder 1% WPI;
(i) left hip injury no injury and no impairment, and
(j) right hip injury 2% WPI.
The claimant’s total WPI is 3% which is of course not greater than 10%. While the Panel’s ultimate outcome is the same as Medical Assessor Cameron’s (not greater than 10%). The Panel has made findings which are different to his in relation to causation and in relation to the degree of WPI. The Panel therefore revokes Medical Assessor Cameron’s certificate as to impairment.
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