Lim v QBE Insurance (Australia) Limited
[2022] NSWPICMP 529
•23 December 2022
| DETERMINATION OF REVIEW PANEL | |
| CITATION: | Lim v QBE Insurance (Australia) Limited [2022] NSWPICMP 529 |
| CLAIMANT: | Kong Lim |
INSURER: | QBE Insurance Australia Limited |
| REVIEW Panel | |
| MEMBER: | Susan McTegg |
| MEDICAL ASSESSOR: | John Carter |
| MEDICAL ASSESSOR: | Michael Couch |
| DATE OF DECISION: | 23 December 2022 |
| CATCHWORDS: | MOTOR ACCIDENTS – The claimant suffered injury in a motor vehicle accident on 20 December 2018; the dispute related to the assessment of permanent impairment under the Motor Accident Injuries Act 2017; traumatic injury alleged to groin/male reproductive organs; review of certificate of Medical Assessor Korbel; Held – no evidence of traumatic injury to male reproductive/groin caused by the accident; no objective evidence of injury to the bladder and urethra associated with urinary incontinency as per clause 6.252 of the American Medical Association’s Guides to the Evaluation of Permanent Impairment, Fourth Edition Guides (AMA 4 Guides); no assessable impairment of urinary incontinence; no objective pathology for male sexual dysfunction as per clause 6.251 of AMA 4 Guides; no assessable impairment of male sexual dysfunction; certificate of Medical Assessor Korbel affirmed. |
| DETERMINATIONS MADE: | MOTOR ACCIDENT INJURIES ACT 2017 WHETHER THE DEGREE OF PERMANENT IMPAIRMENT OF THE INJURED PERSON AS A RESULT OF THE INJURY CAUSED BY THE MOTOR ACCIDENT IS GREATER THAN 10% Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017 The Review Panel affirms the Certificate of Medical Assessor Edward Korbel dated 29 July 2022. |
REVIEW PANEL REASONS FOR DECISION
INTRODUCTION
On 20 December 2018 Mr Kong Lim (the claimant) was driving a taxi when his vehicle was struck from behind by a light truck propelling it into the vehicle in front causing Mr Lim to sustain injury (the accident).
Mr Lim asserts he sustained injury including, relevantly, a traumatic injury to the male reproductive organs/groin.
Mr Lim has brought a claim for common law damages under the Motor Accident Injuries Act 2017 (the MAI Act).
QBE Insurance (Australia) Limited (the insurer) is the relevant insurer with liability to pay any damages to Mr Lim under the MAI Act.
Section 4.11 of the MAI Act provides that there is no entitlement to damages for non-economic loss unless the degree of permanent impairment of the injured person as a result of the injury caused by the accident is greater than 10%.
This dispute is in relation to whether the degree of permanent impairment sustained by Mr Lim as a result of the injury caused by the accident is greater than 10%. This constitutes a medical assessment matter pursuant to Schedule 2, cl 2 of the MAI Act.
A medical assessment matter is determined in accordance with Division 7.5 of the MAI Act by a Medical Assessor[1].
[1] Section 7.20 of the MAI Act.
The dispute as to permanent impairment of the male reproductive/groin was referred to Medical Assessor Edward Korbel. He assessed Mr Lim on 26 July 2022 and issued a certificate dated 29 July 2022. Medical Assessor Korbel found Mr Lim did not sustain injury to the male reproductive/groin and assessed a 0% whole person impairment (WPI).
Mr Lim has sought a review of the medical assessment of Medical Assessor Korbel.
REVIEW PROCEDURE
An application for review of the medical assessment of Medical Assessor Korbel was lodged on 26 August 2022 within 28 days of the date on which the Certificate of Assessor Korbel was made available to the parties.[2]
[2] Section 7.26(1)(b) of the MAI Act.
On 21 September 2022 the delegate of the President being satisfied there was reasonable cause to suspect that the medical assessment was incorrect in a material respect referred the medical assessment to the Review Panel (the Panel).[3]
[3] Section 7.26 of the MAI Act, AD2 p 6.
Clause 14F of Schedule 1 of the Personal Injury Commission Act 2020 (the PIC Act) provides that the new review provisions apply in relation to a decision of a new decision-maker. A “new decision maker” is defined in cl 14A(1) of Schedule 1 of the PIC Act. As the medical assessment the subject of the review was made on or after 1 March 2021, the new review provisions apply.
The new review provisions provide that a review panel consists of two Medical Assessors and a Member assigned to the Motor Accidents Division of the Personal Injury Commission (the Commission) [4]. Accordingly, the President’s delegate referred the matter to this Panel to assess.
[4] Section 7.26(5A) of the MAI Act.
Part 5 of the PIC Act enables the Commission to make rules with respect to the practice and procedure before the Commission including proceedings before a panel reviewing a decision of a Medical Assessor[5].
[5] Section 41(2) of the PIC Act.
Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the PIC Act. A review panel determines how it conducts and determines the proceedings and may determine the proceedings solely based on the written application.[6]
[6] Rule 128 of the PIC Rules.
The review is by way of a new assessment of all matters with which the medical assessment is concerned. However, s 7.25 of the MAI Act provides that the review of a medical assessment can be made on the basis of any agreement by the parties as to the degree of permanent impairment from a particular injury and whether a particular injury was caused by the accident, without those matters having to be the subject of assessment.
RELEVANT LEGAL AUTHORITY
Section 7.21 of the MAI Act provides that the degree of permanent impairment of an injured person is to be assessed in accordance with the Motor Accident Guidelines (the Guidelines).
The Guidelines were issued pursuant to Division 10.2 of the MAI Act and adopt the American Medical Association’s Guides to the Evaluation of Permanent Impairment, Fourth Edition (AMA 4 Guides). The Guidelines are definitive with regard to the matters they address but where they are silent on an issue, the AMA 4 Guides should be followed.[7]
[7] Clause 1.2 of the Guidelines.
Causation of injury is addressed under Part 6 of the Guidelines dealing with permanent impairment:
“6.6 Causation is defined in the Glossary at page 316 of the AMA4 Guides as follows:
'Causation means that a physical, chemical or biologic factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following:
1. The alleged factor could have caused or contributed to worsening of the impairment, which is a medical determination.
2. The alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination.'
This, therefore, involves a medical decision and a non-medical informed judgement.
6.7 There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be a sole cause as long as it is a contributing cause, which is more than negligible. Considering the question 'Would this injury (or impairment) have occurred if not for the accident?' may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes.”
ASSESSMENT UNDER REVIEW
Medical Assessor Korbel issued a certificate dated 29 July 2022.[8]
[8] AD1 P 170
The injury referred to Medical Assessor Korbel was described as:
·Male reproductive/Groin – Traumatic injury.
Medical Assessor Korbel reported Mr Lim complained of some urological symptoms and erectile dysfunction, however, no investigations had been provided.
Medical Assessor Korbel determined that the groin injury was not related to the accident.
OTHER MEDICAL ASSESSMENTS
Medical Assessor Jungfer
Mr Lim was assessed by Medical Assessor Patricia Jungfer. She reported Mr Lim’s behaviour, his stuttering, his referencing to pain, the severity of pain behaviour and the bizarreness of the behaviour was not consistent with a known psychiatric disorder and concluded his presentation, in part, was consistent with a somatic symptom disorder, noting there was no evidence to indicate Mr Lim was consciously able to control or produce the symptoms.
Medical Assessor Jungfer issued a certificate dated 10 August 2020 certifying Mr Lim had sustained a major depressive disorder with psychotic features and a somatic symptom disorder which was not a minor injury for the purposes of the MAI Act.[9]
[9] AD1 P 73.
Medical Assessor Cameron
Mr Lim was assessed by Medical Assessor Ian Cameron.[10] On examination he reported Mr Lim demonstrated emotional distress, his speech was often indistinct, and he hit himself on occasions. He reported abnormal posturing of different parts of the body involving the cervical spine, thoracic spine, lumbar spine and both shoulders. He reported movements were generally inconsistent.
[10] AD3 p 25.
Medical Assessor Cameron disagreed with the diagnosis of Dr Teychenne of an incomplete spinal cord injury noting the imaging did not show any abnormality of the spinal cord.
Medical Assessor Cameron issued a certificate dated 16 August 2020 certifying Mr Lim had sustained a soft tissue injury to the lumbar spine and a soft tissue injury to the cervical spine which was a minor injury for the purposes of the MAI Act.[11] He found Mr Lim had sustained a soft tissue injury to the head which had resolved. He also certified the following injures were not caused by the accident:
· cervical spine – spinal cord injury;
· right shoulder/upper limb;
· right lower limb;
· brain/brain stem, “motor neurones – right side of head, body and limb”;
· left knee;
· left hip, and
· groin.
[11] AD1 p 88.
Medical Assessor Cameron did not report any complaint pertaining to urinary incontinence or erectile dysfunction.
EVIDENCE BEFORE THE REVIEW PANEL
The Panel issued a Direction to the parties on 6 October 2022 (the first Direction) requiring each party to file an indexed, paginated bundle of documents. In response to this Direction the solicitor for the claimant uploaded to the portal a bundle of documents marked AD1 paginated from pages 1 to 1,021. The solicitor for the insurer uploaded to the portal a bundle of documents marked AD3 paginated from pages 1 to 524.
The Panel issued a report to the parties on 8 December 2022 stating, inter alia:
“The Panel considers a re-examination of the claimant is not required where the Panel is able to form an opinion as to causation and permanent impairment having regard to the available medical reports including the reports of Dr Thompson, urologist”.
The Panel directed the parties to advise the Commission in writing that they agreed to the Panel proceeding to determine the issues in dispute without re-examination.
On 13 December 2022 a message was uploaded to the portal stating the insurer agreed to the Panel determining the matter without re-examination. On 20 December 2022 a message was uploaded to the portal stating the claimant also agreed to the Panel determining the matter without re-examination.
Photographs of the vehicles
Photographs of the taxi driven by Mr Lim show extensive damage to both the front and rear of the vehicle.[12]
[12] AD1 p 884.
Application for personal injury benefits
The Application for personal injury benefits dated 27 December 2018 lists the injures received as a result of the accident but does not reference any groin or injury to the male reproductive organs.[13]
Pre-accident treating evidence
[13] AD1 p 195.
Report of Dr Min of Singapore General Hospital re groin pain in 2010
A report of Dr Joshua Tung Yi Min of Singapore General Hospital dated 22 April 2022 states the claimant was first seen by the SGH Department of Urology on 2 July 2010 when he presented with left groin pain of six months duration which had progressively worsened and was constant in nature.[14] Mr Lim was referred to Colorectal surgery for further investigation of his left iliac fossa pain and was discharged from care on 2 September 2010.
Post-accident treating evidence
[14] AD1 p 901.
St George Hospital
Mr Lim was admitted to St George Hospital following the accident 20 December 2018.[15] The discharge summary states: “He was wearing a seatbelt and subsequently had neck pain, a headache and some numbness to bilateral hands. He underwent CT brain and C-spine on that presentation, which was clear of fractures and bleed and was subsequently discharged from ED with codeine”. He re-presented to the hospital shortly thereafter with an anaphylactic reaction to the codeine and was observed overnight before discharge on 21 December 2018.
[15] AD1 p 531.
Dr Sebastian Calvache-Rubio, general practitioner (GP)
Dr Calvache-Rubio provided a report following an initial presentation on 7 January 2019. He reported Mr Lim was a driver involved in an accident. He listed the symptomology as “neck pain, shoulder pain, back pain, chest pain, L) leg and knee pain, anxious, stressed, trouble sleeping, flashbacks, more cautious when driving”.
He diagnosis a cervical spine strain, a lumbar spine strain, a left knee strain, left hip and groin strain and an acute stress disorder.
Dr Lim, GP
Dr Lim provided a report dated 21 February 2019 with the same opinion as to diagnosis as Dr Calvache-Rubio. He reported a spinal surgeon had recommended a cortisone injection to assist with recovery and ongoing back pain. Certificates of Capacity/certificate of fitness issued by Dr Lim and dated 7 January 2019, 9 January 2019, 14 January 2019, 21 January 2019, 24 January 2019, 7 February 2019 and 21 February 2019 include left hip and groin strain as injuries sustained in the accident.
On 4 February 2019 Mr Lim consulted Dr Amika Jangwal, GP. She recorded he was very teary, mentally and emotionally weak and reported he also said he had erectile dysfunction.[16]
[16] AD1 p 10.
Mr Lim consulted Dr Jangwal in relation to his injuries, in particular his psychological injury thereafter on a regular basis but with no reported complaint of groin pain, erectile dysfunction or urinary difficulty.
Dr Bisham Singh, orthopaedic surgeon
Dr Singh assessed Mr Lim on 14 February 2019 in respect of lower back and left buttock pain which he considered secondary to L4-5 minor disc bulging.[17]
[17] AD1 p 763.
Jemma Doley, psychologist
Reports of Jemma Doley, psychologist refer to treatment over 14 sessions between July 2019 and December 2019 for symptoms including concentration difficulties, reduced appetite, low mood, reduced motivation, feelings of helplessness, suicidal thoughts and occasional panic attacks. She also reported Mr Lim advised he was experiencing ongoing neck and back pain from the accident.[18] She reported on 5 September 2019 Mr Lim reported speech difficulties and he presented with a hunched posture.
[18] AD1 p 46.
On 15 August 2019 Ms Doley wrote to Dr Jangwal seeking an urgent psychiatric referral and review for Mr Lim based on her assessment of his potential suicide risk.[19]
[19] AD1 p 318.
Dr Raymond Tint Way, psychiatrist
Mr Lim was referred to Dr Raymond Tint Way, psychiatrist for treatment. The first consultation was on 27 August 2019 when he diagnosed major depression and prescribed a trial of antidepressant medication and psychotherapy.[20]
[20] AD1 p 279.
Dr Way provided a report dated 6 November 2020 after reviewing the Certificate of Medical Assessor Jungfer.[21] He diagnosed major depression with melancholic features and somatic symptom disorder caused by the accident.
[21] AD1 p 259.
Dr Omprakash Damodaran, neurosurgeon
Dr Damodaran assessed Mr Lim on 26 August 2019.[22] He reported following the accident he developed significant back pain and neck pain. He reported Mr Lim denied any radicular symptoms, numbness or weakness. On examination he found Mr Lim had a very limited range of lumbar flexion and extension movements and even gentle palpitation of his lower limbs caused significant pain. He reported the MRI of the lumbar spine demonstrated multilevel degenerative changes and a small disc prolapse at the level of L4-5.
[22] AD1 p 768.
On 23 September 2019 Dr Damodaran reported Mr Lim continued to suffer from significant neck pain with intermittent paraesthesias affecting both his arms. He also noted his abnormal neck position similar to torticollis and his perceived need to hold his arm up in a fixed flexion deformity position. Dr Damodaran concluded Mr Lim had mainly facetogenic neck pain and recommended he undergo physiotherapy and hydrotherapy.
On 11 December 2022 Dr Damodaran reported the lumbar spine MRI demonstrated multilevel degenerative disc disease with facet arthropathy but no severe canal stenosis or nerve compression. He suggested Mr Lim’s pain issues had been exacerbated by his underlying psychological issues and recommended multidisciplinary pain management.
Dr Paul Teychenne, neurologist
Mr Lim was referred to Dr Teychenne for treatment. In a report dated 24 February 2020 he recorded a very detailed history of Mr Lim’s developing symptoms.[23]
[23] AD1 p 272.
In a report dated 23 October 2019 Dr Teychenne reported:
“Two months after the accident he noted urinary urgency and at times urinary incontinence losing up to half a cup or urine. He did not however have any bowel disturbance. He noted two months after the accident a 60% decrease in his erections. He could only achieve a 40% erection.”
In a report dated 11 December 2019 Dr Teychenne reported:
”He has not had any erections for six to seven months. He states that when he has to go to pass urine he has to go. He has urinary urgency. This has been more marked over the past three months and occurs every half an hour to one hour. He can lose a significant amount of urine during incontinence.”
Dr Teychenne found the clinical picture was consistent with an incomplete cervical cord lesion predominantly affecting the right side of the body with potential brainstem involvement.
In undertaking an assessment of WPI Dr Teychenne reported he considered sexual functioning was possible but with difficulty of erection and that whilst Mr Lim had some degree of voluntary control he was impaired by urgency or intermittent incontinence.
Serum chemistry tests
The claimant underwent serum chemistry tests on various dates with no abnormality detected.
Ultrasound renal tract
The report dated 13 July 2021 concludes:[24]
[24] AD1 p 1,014.
“Findings: The right kidney is 111mm in length. In the upper pole of the right kidney, there is a cyst with an irregular shape measuring 13 x 9 x 12mm. In the lower pole, there is a cyst measuring 19 x 17 x 17mm with an 8mm and a 6mm calcification.
The left kidney is 107mm in length.
Both kidneys demonstrate normal cortical thickness and echogenicity. There is no renal cortical cyst, mass or scar.
There is no calyceal calculus or hydronephrosis.
The urinary bladder is 111ml in volume with a post-void residual of 2ml.
The urinary bladder wall is normal in thickness and contour.
The vesicoureteric junctions are patent bilaterally.
The prostrate gland has an estimated volume of 31cc. No protrusion of the gland seen into the bladder base.
Conclusion:
Mild prostatomegaly without an increased postvoid residual.
Right renal cyst as described.”
Dr James Thompson, urologist
On 21 October 2021 the Urology Outpatient Clinic at St George Hospital reported as follows:
“New patient
Presents with LUTS (lower urinary tract symptoms),
Frequency – voiding every hour during the day
Nocturia – 2 -3 times overnight
Nil pain on urination
Nil blood in urine
Slow flow – one continuous stream
Feels empty post void
Symptoms gradual onset”.
Dr Thompson saw Mr Lim on 21 October 2021 at the Urology Outpatient Clinic when he reported he had no particular flow symptoms and no red flags of haematuria, infections, incontinence, pain past urologic history or malignancy risk factors.[25] On examination he noted a normal abdomen, external genitalia and DRE (digital rectal exam). He noted his MSU (mid-stream specimen of urine) was normal, his ultrasound was normal, and his bloods were normal including a PSA (prostate-specific antigen) of 0.2.
[25] AD1 p 907.
Dr Thompson diagnosed a neurogenic sensory urgency but with no severe DO (detrusor overactivity) causing incontinence and no sign of reflux nephropathy from spinal injury. However, the Panel notes this was on the basis he accepted Mr Lim had suffered from a brainstem-cervical spinal cord and lower spinal cord injury.
Dr Thompson suggested a trial of Vesicare at 5mg, then 10mg, bladder re-training exercises, flexible cystoscopy and urine cytology x3.
Dr Thompson reviewed Mr Lim on 24 February 2022 when he reported he had undergone urine cytology x 3 which was normal. Dr Thompson reported the Vesicare 10mg had improved his symptoms by 50% until he ran out.[26]
[26] AD1 p 919
Singapore General Hospital
Mr Lim was admitted to Singapore General Hospital from 11 January 2022 to 16 January 2022 for management of his chronic neck and right sided body pain.[27] The pain history includes the following:
“There has been no worsening of his weakness, numbness, urinary incontinence since described by his Neurologist in Australia. However, this has not improved since his accident.”
Dr Dinesh Patel, urological surgeon
[27] AD1 pp 876 and 881.
Mr Lim consulted Dr Dinesh Patel, urological surgeon on 5 September 2022 in respect of his erectile dysfunction.[28] Dr Patel reported there was no evidence of any spinal injury that could account for erectile dysfunction, and he examined normally. Dr Patel concluded on the basis of documentation provided there was no evidence that the claimant’s erectile dysfunction was a direct consequence of the accident.
[28] AD1 p 902.
Flexible cystoscopy
On 3 May 2022 Mr Lim underwent a flexible cystoscopy under local anaesthetic at St George Hospital.[29] The findings were recorded as:
“Urethra: normal
Prostate: Grade 2 bilobar
Bladder: normal mucosa - no masses/stones/cystitis
UOs: x 2 orthotopic
Retroflexion: normal.”
Medico-legal evidence
[29] AD1 p 955.
Dr Tony Antoun
Dr Antoun assessed the claimant and provided a report following his assessment on 27 September 2019.[30] Dr Antoun thought Mr Lim’s unusual behaviour was either voluntary in nature or the result of an underlying neurodegenerative disease. Dr Antoun diagnosed cervical muscle strain and musculoligamentous strain of the lumbar spine with no radicular signs
[30] AD3 p 81.
Dr Horace Ting, vocational assessor
Dr Ting of Injury Assess undertook a vocational and functional assessment and provided a report dated 22 June 2021.[31] Symptoms and problems described by Mr Lim included frequent micturition every hour with leakage after emptying.
[31] AD1 p 845.
Cipriani Roldan, clinical psychologist
Mr Roldan assessed the claimant at the request of the insurer and provided a report dated 9 June 2021.[32] He reported Mr Lim scored consistently poorly on tests of cognitive performance validity but obtained significantly elevated scores on the Structured Inventory of Malingered Symptomatology which he considered gave rise to the possibility of deliberate symptom over-reporting. However, Mr Roldan also stated that having regard to the bizarre nature of Mr Lim’s presentation he could not discount the possibility that he may suffer from a somatoform type disorder.
[32] AD3 p 42.
Dr John Sheehy, neurosurgeon
Dr Sheehy assessed Mr Lim and provided a report dated 10 December 2021.[33] On examination he reported Mr Lim exhibited an intermittent dystonia-like movement of his right neck and right arm and blepharospasm affecting the right eye. He noted his speech was dysarthric, tone and power in the limbs were normal but his gait was disturbed. He diagnosed a major depressive illness following the accident and a soft tissue injury to the cervical and lumbar spine. The degenerative changes of the cervical and lumbar spine antecede the accident.
[33] AD1 p 862.
Dr Sheehy did not refer to any injury or symptoms referrable to a groin or reproductive injury.
Dr Brian Zeman, rehabilitation medicine specialist
Dr Zeman assessed the claimant on 28 June 2022 and provided a report dated 13 July 2022.[34] He diagnosed the following non-specific low back and neck pain. He found Mr Lim did not have the objective clinical signs of a spinal cord injury. He noted Mr Lim did not have significant organic pathology from the accident but may have had psychological stress. He also found there was no evidence of a head injury. Whilst he found Mr Lim presented as genuinely distressed, he was not able to conclude it was related to the injuries sustained in the accident but deferred to psychiatric or psychological opinion.
SUBMISSIONS
[34] AD3 p 506.
Claimant’s submission
The claimant provided submissions dated 25 August 2022 in support of the application for review.[35] The claimant notes Dr Lim diagnosed groin strain in his initial assessment on 7 January 2019 and referred to in in Certificates of Capacity.
[35] AD1 p 1.
The claimant submits he reported to Dr Jangwal on 4 February 2020 that he had erectile dysfunction. It is also noted that Dr Teychenne in his report of 24 February 2020 noted urinary urgency and at times urinary incontinence and a 60% decrease in his erectile function. Dr Teychenne also recorded Mr Lim said he had no erections for six to seven months after the accident.
Insurer’s submissions
The insurer provided submissions dated 7 September 2022 in response to the application for review filed by the claimant.
The insurer notes there was no mention of traumatic injury to the groin/male reproductive organs in the hospital discharge summary or hospital records. There was no mention of any groin injury, bladder or sexual issues in the reports of Dr Way or Dr Sheehy.
The insurer submits the serum chemistry tests undergone on 27 November 2020 were clearly to assess kidney function noting he was referred for testing on 23 November 2020 following complaints of shortness of breath, stress and chest tightness. He was also referred to a cardiologist.
DETERMINATION
The Panel notes rule 128 of the Personal Injury Commission Rules 2021 and clause 51 of Procedural Direction PIC7 and noting the consent of the parties the Panel considered it was appropriate to determine the review on the papers.
Urological complaints
The Panel accepts that Mr Lim has had urinary symptoms. Dr Korbel, in his report dated 29 July 2022, stated, "he complains of urinary symptoms". Dr Teychenne, in his report dated 24 February 2020, stated that Mr Lim "… also noted urinary urgency and at times urinary incontinence”. Dr Thompson in his report dated 21 October 2021, stated, "he has symptoms consistent with his enlarged prostate” and “he has no particular flow symptoms and has no red flag symptoms of haematuria, infections, incontinence…". An ultrasound of the renal tract dated 13 July 2021 revealed no abnormalities. A cystoscopy on 3 May 2022 was normal, except for a grade 2 bilobar prostate. Dr Thompson concluded that Mr Lim most likely had neurogenic sensory urgency, but with no severe DO causing incontinence.
The most detailed examination from the urological point of view was by Dr Thompson and the panel accepts his opinion with respect to the diagnosis.
There was no mention of traumatic injury to the groin or male reproductive organs in the clinical notes of St George Hospital or in the discharge summary dated 21 December 2018. However, it seems complaint was made to Dr Calvache-Rubio at the time of Mr Lim’s initial presentation on 7 January 2019 where his diagnosis included groin strain. Dr Lim subsequently issued Certificates of Capacity/certificate of fitness on 9 January 2019, 14 January 2019, 21 January 2019, 24 January 2019, 7 February 2019 and 21 February 2019 all of which include left hip and groin strain as injuries sustained in the accident. Mr Lim subsequently came under the care of Dr Jangwal in relation to his injuries and other than a reference to erectile dysfunction on 4 February 2019 no further complaint is reported in respect of either urinary difficulty or erectile dysfunction.
Dr Teychenne reported urinary urgency and incontinence on 23 October 2019 but seems to conclude the clinical picture was consistent with an incomplete cervical cord lesion with potential brainstem involvement.
There is no evidence of any neurological or anatomical abnormalities in the groin region or Mr Lim’s external genitalia. On 21 October 2021 Dr Thompson reported on examination Mr Lim had a normal abdomen, external genitalia and a normal digital rectal examination. On 29 July 2022 Medical Assessor Korbel reported "his external genitalia were normal. He has normal sensation and reflexes in that region".
In accordance with clause 6.252 of the AMA 4 Guides objective evidence of injury to the bladder and urethra associated with urinary incontinence is necessary to assess urinary incontinence due to trauma.
Whilst there was a report of groin strain following the accident there is no evidence of any abnormal neurological or anatomical abnormality in that region and the Panel finds there is no objective evidence of injury to the bladder and urethra due to the accident.
Accordingly, in accordance with clause 6.252 of the AMA 4 Guides and in the absence of objective evidence of injury to the bladder or urethra the Panel is not required to assess urinary incontinence due to trauma.
Erectile dysfunction
On 4 February 2019 Dr Jangwal GP reported Mr Lim had erectile dysfunction. Even though Mr Lim continued to consult Dr Jangwal on a regular basis no further complaint of erectile dysfunction was recorded.
On 23 October 2019, Dr Teychenne stated "… two months after the accident, a significant decrease in his erections. He could only achieve a 40% erection". On 11 December 2019, Dr Teychenne reported "he has not had any erections for six to seven months".
As noted at paragraph 81 above, Dr Teychenne suggested the presence of an incomplete cervical cord lesion. The Panel understands that such a lesion, if present, could cause erectile dysfunction. However, multiple other examiners, including treating specialists, Dr Damodaran, neurosurgeon, Dr Sheehan, neurosurgeon, Dr Patel, urologist, Dr Zeman, rehabilitation physician, and Medical Assessors Cameron and Korbel, described normal neurological examination. MRI of the cervical spine showed no cord abnormality. The Panel does not accept Dr Teychenne’s diagnosis.
Mr Lim consulted Dr Patel on 5 September 2022 in respect of his erectile dysfunction. Dr Patel was not satisfied on the evidence available to him that the claimant’s erectile dysfunction was a direct consequence of the accident.
No complaint of sexual dysfunction was recorded by Dr Thompson and there are no other available records pertaining to sexual dysfunction.
In accordance with clause 6.251 of the AMA 4 Guides objective pathology should be present for an impairment percentage to be given of permanent impairment for male sexual dysfunction.
The Panel notes both Dr Patel and Medical Assessor Korbel recorded that Mr Lim examined normally. The panel finds it difficult to comment upon the presence or absence of erectile dysfunction but finds there is no clinically identifiable pathology relating to sexual dysfunction. Whether or not the claimant suffers from erectile dysfunction the Panel is not satisfied, on the available evidence, that the claimant suffers from erectile dysfunction which was caused by a traumatic injury to the groin or the male reproductive organs.
Furthermore, in the absence of objective pathology the Panel is unable to undertake an assessment of permanent impairment.
The Panel is not satisfied on the available evidence that Mr Lim sustained injury, namely “male reproductive/groin – traumatic injury” caused by the accident.
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