Roberts v QBE Insurance (Australia) Ltd - [2025] NSWPICMP 456

DETERMINATION OF REVIEW PANEL
CITATION:	Roberts v QBE Insurance (Australia) Ltd [2025] NSWPICMP 456
CLAIMANT:	Roberts
INSURER:	QBE Insurance (Australia) Ltd (QBE)
REVIEW PANEL
MEMBER:	Terrence Stern OAM
MEDICAL ASSESSOR:	Dr Sophia Lahz
MEDICAL ASSESSOR:	Dr Margaret Gibson
DATE OF DECISION:	26 June 2025
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; review of Medical Assessment Certificate (MAC); claimant suffered injury in a motor vehicle accident; Medical Assessor (MA) determined the claimant’s whole person impairment (WPI) as a result of the accident was 19%; insurer made an application under section 7.26 for referral of assessment to the Review Panel; the Review Panel conducted its own examination and found that WPI as a result of injuries sustained in the accident totalled 3%; Held – MAC revoked; Review Panel substituted a 3% WPI as a result of the accident.
DETERMINATIONS MADE:	1. The Review Panel revokes the certificate of Medical Assessor James Bodel of 30 September 2024 and substitutes the determination that the following injuries were caused by the accident and give rise to a whole person impairment (WPI) of 3%, being less than 10% (Table 64, page 85 of AMA 4 Guides): · right knee – mild anterior cruciate ligament laxity, and · left knee – soft tissue injury giving rise to 0% WPI. 2. The Review Panel revokes the certificate of Medical Assessor James Bodel of 30 September 2024 and substitutes the determination that the following injuries were not caused by the accident: · cervical spine – soft tissue injury with radiculopathy into the upper limbs; · lumbar spine – soft tissue injury with radiculopathy into the lower limbs; · injury to right shoulder – soft tissue injury/ referred pain from the cervical spine; · injury to left shoulder – soft tissue injury/ referred pain from the cervical spine; · injury to right knee – medial meniscus – undisplaced intrasubstance tear at the posterior from, and associated cartilage ulceration, and undulation of the subchondral plate, a tear of the anterior cruciate ligament, and a joint effusion of tended sheath of the popliteus sheath; · injury to left knee – significant cartilage loss as the medial femoral condyle has grade 3 chondromalacia with undulation of the subchondral plate and cartilage ulceration. There is a located effusion within the popliteus tendon sheath and a mild soft tissue oedema overlying the patella and the patellar tendon; · injury to right hip – soft tissue injury due to referred pain from the knees and lower back; · injury to left hip – soft tissue injury due to referred pain from the knees and lower back; · injury to right leg – soft tissue injury due to referred pain from the hips and knees, and · injury to left leg – soft tissue injury due to referred pain from the hips and knees.

STATEMENT OF REASONS

INTRODUCTION
Background

On 29 January 2021 the claimant, David Roberts (Mr Roberts), was injured in a motor vehicle accident (the accident).
A medical dispute about the degree…

Grounds of appeal

[14] The appellant contends that the primary judge erred in finding that the respondent had discharged the onus of establishing the matters required under the relevant provision.

[15] It was submitted that his Honour failed to give adequate weight to the evidence of the second witness, and that the findings of fact were not reasonably open on the material before the Court.

[16] The respondent, for its part, submits that no error is disclosed, and that the conclusions reached were well within the range of outcomes available to the primary judge.

Consideration

[17] It is convenient to deal first with the question of construction, as the resolution of that issue informs the remaining grounds advanced by the appellant.

[18] For the reasons that follow, we are of the view that the appeal should be allowed in part and the matter remitted for further determination.

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Details

Case: [2025] NSWPICMP 456
Decision Date: 26 June 2025

CaseChat Overview and Summary

In Roberts v QBE Insurance (Australia) Ltd, the claimant, who suffered injuries in a motor vehicle accident, challenged a Medical Assessment Certificate (MAC) issued by a Medical Assessor (MA). The MA had determined that the claimant's whole person impairment (WPI) was 19% due to the accident. The insurer, QBE Insurance (Australia) Ltd, sought to review this assessment by applying under section 7.26 of the Motor Accident Injuries Act 2017 for the assessment to be referred to a Review Panel. The Review Panel conducted its own examination and found that the claimant's WPI was actually 3% as a result of the injuries sustained in the accident.

The primary legal issues in this case revolved around the statutory framework governing the review of medical assessments under the Motor Accident Injuries Act 2017 and the extent to which the Review Panel's findings could override the initial assessment by the MA. The court needed to determine whether the Review Panel's assessment was valid and if it could legally revoke the original MAC and substitute a new WPI.

The court found that the Review Panel's assessment was conducted in accordance with the statutory requirements and that the Panel's findings were well-supported by the evidence presented. The court held that the Review Panel had the authority to revoke the original MAC and substitute its own WPI assessment. Consequently, the court revoked the original MAC and substituted the Review Panel's finding of a 3% WPI as a result of the accident.

The final orders of the court were that the Medical Assessment Certificate issued by the MA, determining a 19% WPI, was revoked. The court substituted the Review Panel's assessment, recognising a 3% WPI as a result of the injuries sustained in the motor vehicle accident.

Orders