Sekuloska v Insurance Australia Limited t/as NRMA Insurance

DETERMINATION OF REVIEW PANEL
CITATION:	Sekuloska v Insurance Australia Limited t/as NRMA Insurance [2023] NSWPICMP 657
CLAIMANT:	Ankica Sekuloska
INSURER:	IAG Limited trading as NRMA Insurance
REVIEW PANEL
MEMBER:	Alexander Bolton
MEDICAL ASSESSOR:	Thomas Newlyn
MEDICAL ASSESSOR:	Gerald Chew
DATE OF DECISION:	7 December 2023
CATCHWORDS:	MOTOR ACCIDENTS – REVIEW OF CERTIFICATE OF MEDICAL ASSESSOR (MA) MASON DATED 15 JUNE 2022 WHO FOUND THE CLAIMANT HAD AN ADJUSTMENT DISORDER WITH MIXED ANXIETY AND DEPRESSED MOOD AND A PERMANENT IMPAIRMENT OF 8%; CLAIMANT INJURED IN AN ACCIDENT ON 19 JUNE 2016 WHEN ANOTHER CAR DROVE INTO HER CAR RESULTING IN BOTH PHYSICAL AND PSYCHIATRIC DISABILITIES; CLAIMANT SOUGHT A REVIEW ON THE DECISION OF THE MEDICAL ASSESSOR CONCERNING CLASSIFICATIONS IN CLASSES OF SOCIAL AND RECREATIONAL ACTIVITIES, CONCENTRATION PERSISTENCE AND PACE, AND ADAPTATION SUBMITTING THAT THE MA HAD NOT TAKEN INTO ACCOUNT ALL RELEVANT FACTS; CLAIMANT WAS EXAMINED ON BEHALF OF THE PANEL AND THE MA SATISFIED THAT THE MA HAD ERRED IN HIS ASSESSMENT OF THESE THREE CLASSIFICATIONS; THE PANEL ASSESSED THE CLAIMANT AS HAVING A PERSISTENT DEPRESSIVE DISORDER WITH A MAJOR DEPRESSIVE EPISODE AND ANXIOUS DISTRESS WITH THE CLAIMANT ASSESSED AS HAVING A WHOLE PERSON IMPAIRMENT OF 19%; HELD – CERTIFICATE OF MA MASON REVOKED.
DETERMINATIONS MADE:	REPLACEMENT CERTIFICATE OF DETERMINATION The assessment made by the review panel under s 63(4) is as follows: 1. The Panel revokes the Certificate of Medical Assessor Mason dated 15 June 2022. 2. The Panel finds that as a result of an accident on 19 June 2016, the claimant developed: (a) persistent depressive disorder with major depressive episode with anxious distress. 3. The claimant has a whole person impairment of 19%.

STATEMENT OF REASONS

INTRODUCTION

The claimant, Ankica Sekuloska, seeks a review of the assessment of 14 June 2022 by Medical Assessor Mason (Medical Assessor), and recorded in the Certificate dated 15 June 2022.
For the purposes of this application, the claimant says that she accepts the assessments made by the Medical Assessor in relation to the Categories of ‘Self-Care and Personal Hygiene’, ‘Travel’ and ‘Social Functioning’. However, it is submitted that the assessment of the Categories of ‘Social and Recreational Activities’, ‘Concentration, Persistence and Pace’ and ‘Adaptation’ are wrong in a material respect. Rather, the claimant submits that a proper assessment of these Categories should result in a finding of a minimum of ‘moderate impairment’ for ‘Social and Recreational Activities’ and ‘Concentration, Persistence and Pace’, and for ‘Adaptation’, a minimum rating of a ‘severe’ or ‘total’ impairment.
The Medical Assessor found that the following injuries caused by accident gave rise to a permanent impairment of 8%:
· adjustment disorder with mixed anxiety and depressed mood.
The parties have each presented their respective bundles of documents upon which they rely. The Panel have read all the documentation. If a particular document is not referred to by the Panel, this does not mean that the Panel or a Panel Member has not read it, in much the same manner as parties not referring to or not specifically relying on a document in their own bundle and submissions.

The accident

On 19 June 2016, the claimant was driving along Campbell Street, Liverpool in a westerly direction. The insured car, on her left side, drove out of the Westfield Shopping Centre car park into the claimant’s lane, colliding with the left side front bull bar on the claimant’s car.
The claimant was able to drive her car home. The insured car could not be driven home due to the extent of damage to it.

Claimant’s submissions

It is submitted that the Medical Assessor has ignored or failed to adequately consider the history provided by the claimant, facts presented to him during the medical assessment and the supporting evidence provided by the claimant’s treating psychiatrist, psychologist and assessment opinion of Dr Bertucen, psychiatrist and, in the process, created a reasonable cause to suspect that an error has been made in his classification of the claimant within the disputed categories.
The claimant says that although it is acknowledged that the Medical Assessor is not required to base his assessment upon the earlier findings of other doctors, even if the opinions are medico-legal or those of a treating specialist, the claimant submits that the Medical Assessor has failed to adequately provide his path of reasoning in sufficient detail to support his classification of the claimant within the disputed categories based on the information before him. The claimant submits that the failures of the Medical Assessor are material in that they are capable of altering the classification of the claimant and impact the whole person impairment rating.
The claimant has made submissions regarding specific categories of the psychiatric impairment rating scale (PIRS).
Concerning Category 2, Social and Recreational Activities, the claimant notes that the Medical Assessor classified the claimant in Class 2 on page 13 of his Certificate. The claimant says that the Motor Accident Guidelines (the Guidelines) outline the criteria for Class 2 as: “Mild impairment. Able to occasionally go out to social events without needing a support person, but does not become actively involved; for example, in dancing, cheering favourite team”.
The claimant says to that the reasons for the classification of Class 2 provided by the Medical Assessor, and based on the medical assessment, were as follows:
“The claimant said she is not seeing friends because she cannot go out due to pain. She is also embarrassed to let her friends see how physically impaired she is. She is unable to attend community events such as Macedonian dancing because of the pain. She said she has a lot of relatives but does not see them for the same reason. She very rarely goes to her son's place. She said he has 2 children and she loves to see them but they are closer to their other grandmother. She is severely impaired because of the pain.”
The claimant however refers to paragraph 7 of her statement dated 8 April 2021, submitted as part of the claimant’s Reply and where she states:
“In the past few years, I have become more withdrawn from friends and have stopped socialising and attending Church and Church-based activities. I also stopped doing things that I previously enjoyed, which included entertaining friends, cooking, some dress making and regular walking.”
The claimant submits that her treating psychiatrist, Dr Hyde, in the context of reporting to the claimant’s general practitioner (GP), states: “She spends most days inside the home. She gave up on her usual activities and rarely goes out and socialise” in his report dated 14 April 2020.
Further, the claimant says that the report of Dr Bertucen, psychiatrist, dated

6 January 2021 provides an opinion that rates the claimant as satisfying Class 3 on the basis that:
“as a result of chronic pain and demotivation Ms Sekuloska has experienced significant reduction in ability to participate in recreations, socialising, religious and cultural events and family activities. She rarely received visitors at home and does not conduct any external socialising or attend Church as previously.”
The claimant’s treating psychologist, Dr Protulipac, assessed the claimant as satisfying Class 3 in his report dated 23 March 2020 for the relevant Category on the grounds that the claimant “does not attend any social events. Not actively involved, remains quiet and withdrawn”.
The claimant says that the Guidelines outline the criteria for Class 3 as:
“Moderate impairment. Rarely goes to social events, and mostly when prompted by family or close friend. Unable to go out without a support person. Not actively involved, remains quiet and withdrawn.”
The claimant says that based on the medical assessment, submitted medical documents and the relevant Guidelines, the claimant submits that the appropriate application of the facts should merit a rating of Class 3 for the relevant ‘Social and Recreational Activities’ Category.
The claimant submits that, as a result of the subject accident, her impairment would exceed a Class 2 ‘mild impairment’. The claimant submits that the Medical Assessor should have classified a ‘moderate impairment’ based on the facts ascertained by him at the time of the medical assessment, his ‘Reason for Decision’, and on the weight of documentary evidence available to him.
The claimant submits that the Medical Assessor’s reasons and categorisation fail to adequately consider the history provided to him by the claimant during the medical assessment, the claimant’s statement, the opinion of the claimant’s treating psychologist, treating psychiatrist and Dr Bertucen. The claimant says that this failure “cannot be dismissed as trivial, insignificant or immaterial” as such consideration is capable of altering the classification of the claimant.
Furthermore, it is submitted that the Medical Assessor failed to adequately explain his path of reasoning in sufficient detail so as to justify his conclusion to categorise the claimant in a Class 2 based on the information before him. The claimant says that as part of the Medical Assessor’s ‘Reason for Decision’, the Medical Assessor failed to adequately comment on the psychological impact of her assessed psychiatric condition on the claimant’s Social and Recreational Activities and the reasons for the warranting of a ‘mild impairment’ classification.
The claimant submits that this is significant, particularly as the Medical Assessor found that the claimant is ‘severely impaired because of the pain’. It is submitted that this failure is material as it is capable of altering the classification of the claimant within the Category.
Regarding Category 5. Concentration, Persistence and Pace, the claimant says that the Medical Assessor classified the claimant in Class 2. The claimant says that the Guidelines outline the criteria for Class 2 as:
“Mild impairment. Can undertake a basic retraining course, or a standard course at a slower pace. Can focus on intellectually demanding tasks for up to 30 minutes; for example, then feels fatigued or develops headache.”
The claimant says that reasons for the classification of Class 2 provided by the Medical Assessor, and based on the medical assessment, were as follows:
“The claimant told me her ability to concentrate is very poor and she cannot even read a small newspaper article. She said she is affected by the pain and cannot look down but then the psychological impact also prevents her. She said her memory is also poor and when she goes to do something she forgets what it is. This again is due partly to pain and partly due to her psychiatric condition. When asked about persistence she said she is unable to finish and "cannot follow instructions". I commented to her that she had no difficulty with her concentration throughout the interview and that her memory for highly detailed events associated with injuries going back to 2009 was very clear. I also pointed out she had been able to persist with the interview for an hour and a half. She stated this was because she was trying very hard.”
By way of example, the claimant makes reference to paragraph 15 of her statement dated 8 April 2021 where she states:
“My ability to concentrate and my memory has also been impacted, which I believe, is directly related to my chronic pain and my sleep disturbance, which I continue to have to date. It is not uncommon for me to be woken by pain during the night.”
The claimant says that her treating psychiatrist, Dr Hyde, in the context of reporting to the claimant’s GP indicated: “The other symptoms reported were sad mood, insomnia, lack of energy, poor concentration, loss of motivation and anhedonia” on page 2 of his report dated 14 April 2020.
The claimant notes that further, the report of Dr Bertucen, dated 6 January 2021 provides an opinion that rates the claimant as satisfying Class 3, finding “Moderate impairment of attention, concentration and memory due to the effects of pain on sleep regulation”.
The claimant says that the Guidelines outline the criteria for Class 3 as: “Moderate impairment. Unable to read more than newspaper articles. Finds it difficult to follow complex instructions; for example, operating manuals, building plans, make significant repairs to motor vehicle, type detailed documents, follow a pattern for making clothes, tapestry or knitting.”
The claimant says that her treating psychologist, Dr Protulipac, assessed her as satisfying Class 4 for the relevant Category on page 14 of his report dated

23 March 2020 on the basis that the claimant has a,
“Severe impairment. Neurocognitive deficit, impairment to concentration, attention and memories following simple instructions. Concentration deficits obvious even during brief conversation. Constant fear, excessive worrying and apprehension caused by elevated anxiety.”
The claimant says that the relevant Guidelines outline the criteria for Class 3 as:
“Severe impairment. Can only read a few lines before losing concentration. Difficulties following simple instructions. Concentration deficits obvious even during brief conversation. Unable to live alone, or needs regular assistance from relatives or community services.”
The claimant says that based on the medical assessment, medical opinions and documents before the Medical Assessor and the relevant Permanent Impairment Guides and Motor Accident Guidelines (the Guidelines), the claimant submits that the appropriate application of the facts should justify a rating of Class 3 or Class 4 for the relevant ‘Concentration, Persistence and Pace’ Category. The claimant submits that, as a result of the subject accident, her impairment would exceed a ‘mild impairment’ rating and the Medical Assessor should have classified a ‘moderate impairment’ or ‘severe impairment’ based on the facts ascertained by the Medical Assessor at the time of the medical assessment and on the weight of medical evidence available to the Medical Assessor.
The claimant submits that the Medical Assessor’s failure to adequately consider the information before him and provide sufficient detail to justify his classification has resulted in a material error.
Regarding Category 6, Adaptation, the claimant says that the Medical Assessor classified the claimant in Class 2. The claimant says that reasons for the classification of Class 2 provided by the Medical Assessor, and based on the medical assessment, were as follows:
“The claimant said she was unable to return to work due to pain, but also due to her psychiatric problems. She said she is also unable to help out at home due to pain and the impact of her psychological conditions. She told me she does not have the strength to cook or to do any of the heavy housework or laundry. I note she has been awarded the disability support pension which she said is partly due to her physical conditions and partly due to her psychiatric conditions.”
The claimant says that the relevant Guidelines outline the criteria for Class 2 as:
“Mild impairment. Able to work full-time in a different environment. The duties require comparable skill and intellect. Can work in the same position, but no more than 20 hours per week; for example, no longer happy to work with specific persons, work in a specific location due to travel required.”
The claimant relies on paragraph 16 of her statement dated 8 April 2021 where she states that:
“I have not been able to return to my pre-accident work or any type of work since the subject motor vehicle accident. I have been in receipt of Centrelink benefits in the form of Jobseeker/Newstart Allowance and from about October 2020, Centrelink Disability Support Pension. I am not hopeful of returning to any form of employment although I would very much like to return to the workforce in some capacity if I am able to.”
The claimant says that her treating psychiatrist, Dr Hyde, in the context of reporting to her GP, clearly states: “Ankica is not able to work or study due to neuro-cognitive deficits secondary to her primary diagnoses”, on page 3 of his report dated

14 April 2020.
Further, the claimant says that the report of Dr Bertucen, dated 6 January 2021 provides an opinion that rates the claimant as satisfying Class 4 stating “Ms Sekuloska, in my opinion, is highly unlikely to return to any form of employment although possibly could engage in part timework from home at her own pace (maximum of 15 hours a week).”
The claimant says that the relevant Motor Accident Guidelines outline the criteria for Class 4 as: “Severe impairment. Cannot work more than one or two days at a time, less than 20 hours per fortnight. Pace is reduced, attendance is erratic.”
The claimant says that her treating psychologist, Dr Protulipac, assessed her as satisfying Class 5 for the relevant Category in his report dated 23 March 2020 on the basis that the claimant is “Totally impaired. Cannot work at all.”
The claimant refers to the relevant Guidelines which the claimant says outline the criteria for Class 5 as: “Totally impaired. Cannot work at all.”
The claimant says that based on the medical assessment, medical opinions and documents before the Medical Assessor and the relevant Guides and Guidelines, that the appropriate application of the facts should justify a rating of Class 4 or Class 5 for the relevant ‘Adaptation’ Category.
The claimant submits that, as a result of the accident, her rating would exceed a ‘mild impairment’. The claimant says that the Medical Assessor should have categorised a ‘severe impairment’ or total impairment based on the facts ascertained by the Medical Assessor at the time of the medical assessment and on the weight of evidence available to the Medical Assessor.
Furthermore, the claimant submits that the Medical Assessor failed to adequately explain his path of reasoning in sufficient detail to justify his conclusion to categorise the claimant in a Class 2 based on the information before him. The claimant says that as part of the Medical Assessor’s ‘Reason for Decision’, the Medical Assessor failed to explain the reason for classifying the claimant as mildly impaired. The claimant says that this is significant, particularly when considering the medical assessment, the factual background of an inability to return to work since the date of the subject accident, the assessments of Dr Bertucen, and Dr Protulipac that indicate the claimant satisfies a higher class and the opinion of her treating psychiatrist. It is submitted that this failure is material as it is capable of altering the claimant’s category classification.

Insurer’s submissions

Regarding the submission by the claimant that the Medical Assessor misapplied the PIRS assessment criteria, the insurer noted that the Medical Assessor made the following assessment under the PIRS Category:
(a)   Self-care and personal hygiene: Class 2;
(b)   Social and recreational activities: Class 2;
(c)   Travel: Class 2;
(d)   Social functioning: Class 3;
(e)   Concentration, persistence and pace: Class 2, and
(f)     Adaptation: Class 2.
The insurer says that the claimant submits that the ratings should have been as follows:
(a)   Self-care and personal hygiene: Class 2;
(b)   Social and recreational activities: Class 3;
(c)   Travel: Class 2;
(d)   Social functioning: Class 3;
(e)   Concentration, persistence and pace: Class 3 or 4, and
(f)    Adaptation: Class 4 or 5.
The insurer referred to the claimant submitting that the Medical Assessor ought to have found the claimant was,
(a) More appropriately assessed in PIRS Categories (b),(e) and (f) greater than that which Medical Assessor Mason said applied in accordance with the claimant’s own statement, treating evidence and report of Dr Bertucen.

The insurer says that submission overstates the relevance of the treating and qualified opinions of the claimant’s experts on the exercise of the Medical Assessor’s statutory function. In this regard the insurer says that it is relevant to note that the Medical Assessor was obliged by the Guidelines to assess the claimant’s psychiatric impairment under the PIRS as at the date of his assessment only.
The insurer says the claimant proffers no reason why the Medical Assessor’s assessment is incorrect in a material respect other than to assert that an alternate PIRS would be more appropriate based on the subjective history provided by both the claimant in providing history during the assessment and in her supporting documentation.
The insurer submits that the claimant does not point to any evidence provided to the Personal Injury Commission (Commission) aside from what the insurer submits are the largely subjective reports provided by the claimant, that supports a greater assessment on the PIRS than that provided by the Medical Assessor.
The insurer submits that the claimant’s submission appears to be relating to a disagreement with the Medical Assessor’s opinion that she belongs in a lower category, rather than one that pertains to an error within the assessment.
The insurer has referred to each of PIRS Categories (b),(e) and (f) that are disputed.
Regarding Social and Recreational Activities, the insurer says that in the Medical Assessor’s reasons, he noted that the claimant reported she was not seeing friends because she could not go out due to pain, and she is also embarrassed to let her friends see how physically impaired she is. She also says that she is unable to attend community events such as Macedonian dancing because of the pain. She said she has a lot of relatives but does not see them for the same reason. She says that she is severely impaired because of the pain.
The insurer noted that the Medical Assessor applied a PIRS rating of Class 2 for mild impairment. The insurer says that the limitations with respect to Social and Recreational Activities are wholly or primarily due to alleged physical injury and resultant pain. The insurer says that the psychological injury does not appear from the claimant’s own self reporting to be restricting her from Social and Recreational Activities.
The insurer says that the claimant’s submission that Class 3 should be applied because she is unable to attend events due to pain is erroneous given this was a psychiatric assessment.
The insurer refers to cl 6.215 of the Guidelines which states ‘the PIRS must not be used to measure impairment due to somatoform disorders or pain.’ The insurer submits that the allocation of Class 2 for Social and Recreational Impairment overstates the psychiatric impairment level. The insurer submits a Class 1 impairment represents a better fit having regard to the psychiatric complaints only.
Regarding Concentration, Persistence and Pace the insurer says that in his reasons, the Medical Assessor noted that the claimant reported her ability to concentrate was very poor and she could not even read a small newspaper article. She said she is affected by the pain and cannot look down but then the psychological impact also prevents her. The insurer said that the claimant says that her memory was poor and when she goes to do something she forgets what it is. The insurer says that this again is due partly to pain and partly due to her psychiatric condition. The insurer says that when asked about persistence, the claimant said she is unable to finish and "cannot follow instructions". The insurer says that the Medical Assessor commented that she had no difficulty with her concentration throughout the interview and that her memory for highly detailed events associated with injuries going back to 2009 was very clear. He also pointed out she had been able to persist with the interview for an hour and a half.
The Medical Assessor allocated a PIRS rating of Class 2 for mild impairment. The insurer says that the claimant submits a Class 3 or even Class 4 impairment should have been applied in this Category having regard to the claimant’s statement, treating evidence and report of Dr Bertucen.
However, the insurer submits that it is immediately apparent on the face of the Medical Assessor’s Certificate that he has again appropriately considered the available materials and history from the claimant, noted her appearance on examination and then distinguished between physical and psychiatric impairment when coming to his assessment of Class 2.
The insurer submits there is no reasonable cause to suspect the assessment of concentration, persistence and pace is incorrect in a material respect.
Regarding Adaptation, the insurer says that in his reasons, the Medical Assessor noted that the claimant said she was unable to return to work due to pain, but also due to her psychiatric problems. She said she was also unable to help out at home due to pain and the impact of her psychological conditions. She told the Medical Assessor that she did not have the strength to cook or to do any of the heavy housework or laundry. The Medical Assessor noted she had been in receipt of the disability support pension which she said was partly due to her physical conditions and partly due to her psychiatric conditions.
The Medical Assessor allocated a PIRS rating of Class 2 for mild impairment. The claimant submitted a Class 4 or even Class 5 impairment should have been applied in this Category having regard to her statement, treating evidence and report of

Dr Bertucen.
In response, the insurer submits that it is immediately apparent on the face of the Medical Assessor’s Certificate that he has again appropriately considered the available materials and history from the claimant, noted her appearance on examination and then distinguished between physical and psychiatric impairment when coming to his assessment of Class 2 - mild impairment.
The insurer submits that there is no reasonable cause to suspect that the medical assessment was incorrect in a material respect.

Medical evidence

Dr Vickery examined the claimant for the insurer. He provided a report dated

19 January 2021.
The claimant reported there was incapacitating chronic pain in her back, neck, chest, shoulders, arms, fingers and leg pain. There are mood swings, anxiety, low concentration and memory. There were headaches, dizziness, blurred vision, muscle spasms and cramps.
The claimant reported “the pain stops me from moving normally and if I’m walking then I feel like I’m falling and I’m dizzy and I have to support myself against something.” She said that she spends her time either sitting or lying down when she is at home.
The claimant reported that she was only driving locally due to her pain and “I have to pull over every ten minutes to stretch and I use the TENS machine and I go to the local shopping centre which is quite close to where I live and I drive to my GP.”
She said there had been the loss of friends as “I have too much pain to sit and talk to them.” She has her two relatives who visit several times a week. Her eldest son lives with her and her husband who continues to be her full-time carer. The claimant reported some decrease in concentration and “I can’t read or watch television because I can’t get my head comfortable.” There is also some forgetfulness.
Dr Vickery said that the claimant satisfied DSM 5 diagnosis of Somatic Symptom Disorder which he said was not directly due to the accident. Dr Vickery said that there was no psychiatric treatment required directly due to the accident. He assessed a whole person impairment (WPI) of 0%. Dr Vickery said that there was no medical basis for the claimant’s incapacitating pain being due to the accident.
Dr Sheridan, neurosurgeon, reporting the claimant’s GP said that she had classic symptoms of C7 radiculopathy. This was before the accident in 2013. The claimant also had disc bulging at C5/6.
Ms Fung, psychologist, provided a report to the claimant dated 4 December 2017, she said the claimant presented with symptoms consistent with an adjustment disorder with depressed mood as per the Diagnostic and Statistical Manual of Mental Disorders, 5^th edition (DSM 5).
Ms Fung said that the claimant experienced ongoing stress from chronic pain, a reduced capacity to engage in daily tasks and activities and financial difficulties due to an inability to work.
The claimant suffered injury at work when she pulled a fire door producing acute soft tissue injuries to her shoulder. She was examined by Dr Cassikar for the workers compensation insurer. He confirmed a soft tissue injury to her shoulder.
The claimant was also involved in another motor vehicle accident on

17 December 2013. For that accident and claim, she was examined by Dr Shatwell. He said the claimant had alleged aggravation of her neck, left shoulder and left upper limb symptoms by the motor vehicle accident of 17 December 2013. Dr Shatwell said that the amount of energy dissipated by the low speed ‘clipping’ of the claimant’s bull bar by the tail light of the colliding vehicle would not have caused any injury or aggravation of injury.
Dr Shatwell said that the claimant was fully fit and able to manage her usual duties prior to 17 December 2013 for 38 hours per week and considered that she was fully fit for activities.
Dr Keller provided a report for the insurer dated 25 February 2019.
Dr Keller noted that the claimant reported the onset of neck pain, forehead pain and knee pain following the motor vehicle accident on 19 June 2016. He said that her investigation reports showed only degenerative changes with no evidence of acute traumatic injuries attributable to the subject accident.
He said that the claimant’s physical examination findings were inconsistent and appeared voluntarily exaggerated. Dr Keller commented that he had seen photographs of the subject accident showing minimal scrapes to the front bulbar of her vehicle indicating a low force accident not expected to cause any injuries.
Dr Shatwell said that there was no clear objective evidence available to him to suggest that the claimant suffered any genuine or lasting injuries attributable to the accident.
Dr Keller said that based on the history provided, the photographs of the accident, the investigation reports and his examination physical findings, he was unable to make a diagnosis of any persisting musculoskeletal complaints caused by the subject accident.
Dr Harrison provided a report of 8 February 2018 for the claimant’s solicitors.

Dr Harrison said the claimant had an aggravation of minor pre-existing degenerate changes in her neck. He said that she had been left with neck pain and restricted movement in her neck as a result of an exacerbation of what had been relatively asymptomatic pre-existing degenerate changes in her neck before that motor vehicle accident occurred. He said that this was despite the prior incidents in 2013 and 2014 involving a heavy door opening occurring in her in workplace before. Dr Harrison assessed a 34% WPI.
The claimant also provided a statement of 29 April 2019 explaining her activities and limitations following the accident.
A physical assessment by Medical Assessor Wilding was provided on

23 October 2019.
The Medical Assessor reported that there was significant inconsistency in the claimant’s presentation, and she was given an opportunity to address the inconsistencies when these were pointed out to her. He said that her explanations were implausible.
As far as both shoulders are concerned, there was evidence of pre-existing pathology in both shoulders. The Medical Assessor did not consider that the shoulders were injured in the motor accident.
In particular, the Medical Assessor noted that regarding the left shoulder, on examination there was virtually no movement in the shoulder yet there was no wasting in the left shoulder or upper arm. The Medical Assessor said that this was not conceivable with this degree of restriction of active movement demonstrated in the left shoulder.
Furthermore, the Medical Assessor noted that although the claimant stated that elevation of both shoulders aggravated her neck pain, he did not consider that the Nguyen principle could be applied because of the inconsistencies in the ranges of movement in both shoulders. Consequent upon this, the Medical Assessor invoked the section on Inconsistency in the Guidelines ss 1.40 and 1.41, page 12, and used his clinical experience and judgement in assessing the shoulders when there is inconsistency.
The Medical Assessor said that as far as the neck pain and the intermittent sharp pain down the left arm were concerned, there was no evidence of radiculopathy.
All reflexes in the upper limbs were present and equal and power on gross testing was normal.
There was no wasting in either arm. The sensory changes in the left upper arm are in a non-anatomical distribution. The Medical Assessor said that the criteria of radiculopathy as outlined in the Guidelines cl 1.6.2018, pages 33-34, were not satisfied.
In particular, sensory loss (diminished sensation in the left arm) did not localise to a spinal nerve root distribution. Additionally, the Medical Assessor said that the multiple cervical MRI scans which had been performed showed no evidence of nerve root impingement.
As far as the lumbar spine was concerned, the claimant said that she experienced low back pain with referred pain down the left leg. However, the Medical Assessor said that the pain was not in a radicular pattern and therefore did not qualify as non-verifiable radicular pain.
The Medical Assessor said that there was no clinical evidence of radiculopathy in the lower limbs. All reflexes were present and equal. There was no wasting in the lower limbs. Power in the lower limbs was normal and the sensory changes in the left leg were in a non-anatomical distribution. The stretch tests were negative.
The Medical Assessor assessed 0% WPI for the claimant’s cervical spine and lumbar spine.
St George Hospital pain management clinic records show that the claimant first attended on 6 November 2019. The records summary noted "Ankica is a 52-year-old lady with widespread pain, decreased functioning with very limited activities; requires assistance for most activities of living including dressing; fear avoidance of movements causing pain, becomes anxious, dizzy while driving requires breaks. Described low mood, worry, social withdrawal, anhedonia, sleep disturbance and 10 kg weight increase".
Pain management physician Dr Rajeepan diagnosed chronic widespread pain with central sensitisation. He also arranged referral to rheumatology. The claimant attended three sessions with pain psychologist Ms Rebecca Norwood.
Psychologist Dr Protulipac provided a report dated 23 March 2020. He diagnosed post-traumatic stress disorder, chronic in partial remission and major depressive disorder, recurrent and moderate. Depression was in the moderate range using the Beck depression inventory. Anxiety was in the moderate range using the Beck anxiety inventory. He attributed her conditions entirely to the accident. He also noted that the claimant and her husband were sleeping in separate rooms and facing the prospect of divorce. He assessed WPI at 26%. Dr Protulipac treated the claimant by way of 34 consultations from March to October 2020.
Dr Hyde, treating psychiatrist, provided a report dated 14 April 2020. He diagnosed an adjustment disorder with mixed anxiety and depressed mood and post-traumatic stress disorder. He suggested increasing amitriptyline to 75 mg at night and later to 100 mg in the morning. He recommended cognitive behavioural therapy treatment by a psychologist. On 9 June 2020 he noted the claimant remained anxious and depressed. He recommended continued medication and psychological treatment.
Dr Bertucen, psychiatrist, provided a medico-legal report dated 6 January 2021. He noted the claimant had received the disability support pension since October 2019. Her husband was also on the disability support pension due to a chronic back injury. Dr Bertucen diagnosed a predominant chronic adjustment disorder with features of depressed mood, although with an admixture of chronic post- traumatic stress disorder in substantial remission. He assessed WPI at 17%
Clinical record of Forest Mall Medical Centre Hurstville date from 1 March 2021. The claimant’s GP, Dr Ristevski noted anxiety/depression since 2016. A K10 questionnaire to measure psychological distress on 2 March was 36/50. On 26 March 2021,

Dr Ristevski increased amitriptyline to 50 mg twice daily. He also then referred her to Dr Hyde who she had seen previously.
The Panel notes that, as discussed by the Medical Assessor and by way of a brief summary of the psychiatric medical evidence, the claimant has been treated by three psychologists who had provided different diagnostic opinions. Ms Fung diagnosed an adjustment disorder with depressed mood in 2017. In November 2019, Ms Rebecca Norwood, the psychologist associated with the St George Hospital pain clinic, noted a multitude of psychological symptoms and fear avoidance associated with her symptoms. In 2020 Dr Protulipac diagnosed both post-traumatic stress disorder and major depressive disorder. Psychiatrist Dr Vickery diagnosed only a Somatic Symptom Disorder. Psychiatrist Dr Jeff Bertucen diagnosed an adjustment disorder with features of depressed mood and an admixture of post-traumatic stress disorder symptoms which were in partial remission. Her treating psychiatrist Dr Hyde diagnosed both an adjustment disorder with mixed anxiety and depressed mood and a major depressive disorder.
The Certificate and reasons giving rise to this review was prepared by Medical Assessor Mason and dated 15 June 2022.
The Medical Assessor found that the claimant had suffered a jolt which aggravated pre-existing neck, shoulder and back injuries resulting in markedly increased pain levels. He confirmed that there had been no surgical intervention to treat her pain.
The Medical Assessor noted that the claimant was referred to the St George Hospital pain clinic but declined further attendance after three sessions saying it was making her pain worse. As a consequence of the pain the Medical Assessor said that the claimant had developed generalised symptoms of anxiety and depression together with a significant degree of concerns regarding her health. The claimant had experienced fears of heart attacks and strokes and had made multiple attendances to hospital. She reported severe anxiety episodes resembling panic attacks. She also reported dreams of the motor accident in which people were injured or killed.
The Medical Assessor said that the claimant’s behaviour during the interview was suggestive of extreme abnormal illness behaviour. There were significant efforts to demonstrate the degree of pain that she was suffering. There was also some degree of depression and tearfulness evident throughout the interview, which at times was noted to have been at a disabling level while at other times the claimant was not affected.
The Medical Assessor said that in his opinion, the claimant’s symptoms were best explained by the diagnoses adjustment disorder with mixed anxiety and depressed mood and somatic symptom disorder. The Medical Assessor said that while there were symptoms suggestive of post-traumatic stress disorder, the claimant did not meet criteria A for a diagnosis of this condition.
The Medical Assessor provided the following PIRS assessment;

Psychiatric diagnoses	1. Adjustment disorder with mixed anxiety and depressed mood	2.
Psychiatric diagnoses	3.	4.
Psychiatric treatment description	Psychological counselling Psychiatric consultation Psychiatric medication

Category	Class	Reason for Decision
1. Self-Care and Personal Hygiene	2	The claimant said she needs to be prompted to shower every 2 or 3 days and she needs a carer to assist her while she is in the shower. She said because of her physical injuries she cannot bend, she cannot wash her hair, and she would not feel safe without a carer present. She is afraid she would fall. She said she is unable to cook because she has no strength in her hands and for similar reasons she cannot do the housework or laundry. She said in fact her son and the carer do the laundry. She is clearly severely impaired from a physical point of view.
2. Social and Recreational Activities	2	The claimant said she is not seeing friends because she cannot go out due to pain. She is also embarrassed to let her friends see how physically impaired she is. She is unable to attend community events such as Macedonian dancing because of the pain. She said she has a lot of relatives but does not see them for the same reason. She very rarely goes to her son's place. She said he has 2 children and she loves to see them but they are closer to their other grandmother. She is severely impaired because of the pain.
3. Travel	2	The claimant said she is able to drive short distances such as to the Liverpool shopping Centre which is 10 minutes away. She said however she does have to stop frequently due to pain and for psychiatric reasons. She said she has not used public transport for 6 years because she has to wait at railway station and bus stops. She also would have to sit and stand for long periods and she is unable to do this. She said if she goes on a long car journey she has to be
driven by someone else and has to lie down. She said during these trips she has to use her TENS machine. When asked if she had travelled overseas since the motor accident she said she had been back to Macedonia with her son in 2017. Her impairment in this area is largely due to pain. She has been able to drive and travel overseas.
4. Social Functioning	3	The claimant told me she has a bad relationship with her husband and they are sleeping in separate rooms. She said there is no intimacy between them and there has been talk of divorce on and off on many occasions. I note he also suffers from a chronic back pain condition. She said she does get along well with her children although she believes she annoys them. She said she does not visit relatives and does not have relatives visit her.
5. Concentration, Persistence and Pace	2	The claimant told me her ability to concentrate is very poor and she cannot even read a small newspaper article. She said she is affected by the pain and cannot look down but then the psychological impact also prevents her. She said her memory is also poor and when she goes to do something she forgets what it is. This again is due partly to pain and partly due to her psychiatric condition. When asked about persistence she said she is unable to finish and "cannot follow instructions". I commented to her that she had no difficulty with her concentration throughout the interview and that her memory for highly detailed events associated with injuries going back to 2009 was very clear. I also pointed out she had been able to persist with the interview for an hour and a half. She stated this was because she was trying very hard.
6. Adaptation	2	The claimant said she was unable to return to work due to pain, but also due to her psychiatric problems. She said she is also unable to help out at home due to pain and the impact of her psychological conditions. She told me she does not have the strength to cook or to do any of the heavy housework or laundry. I note she has been awarded the disability support pension which she said is partly due to her physical conditions and partly due to her psychiatric conditions.
List classes in ascending order: 2 2 2 3 2 2
Median Class Value: 2
Aggregate Score: 13
% Whole Person Impairment: 7%

WPI was assessed by the Medical Assessor at 7%.

Panel examination

The claimant was examined on behalf of the Panel by Medical Assessor Chew and Medical Assessor Newlyn. Their report follows:
“Who Attended the Assessment
·   Mrs Sekuloska’s statements are printed in italic font.
Mrs Sekuloska was 56 years of age. She was at her home in Hoxton Park. Her son Vasko set up the Teams video link and was present during the assessment interview. Vasko who is 31, lives separately with his wife and 2 children. Assessor Newlyn explained the process of the assessment. When asked who was in the house Mrs Sekuloska said her husband was home in another room. She said they had lived in separate rooms after the 19 June 2016 Motor Vehicle Accident (MVA). (Mrs Sekuloska stood and moved away from the chair in front of the camera.) When asked who else lived in the house Mrs Sekuloska replied that her son Vladko Sekuloska, aged 33 years, lived there. He is our carer and is off today.
Preamble Interaction
I have issues with my back, neck and sciatica. I have to stand for 5 to 10 minutes. I might walk 5-10 minutes, I can’t lie down too long and I wake with anxiety, depression and pain. I get up and sit down.
(Mrs Sekuloska cried and was distraught.)
My sleep is very disturbed. I sleep for half an hour to an hour. Panic attacks wake me and I can’t go back to sleep. I have to sit and have something to drink. I go back to bed for minutes or hours. I go to bed late, between 10 PM and 1 AM.
I wake early at 4 or 5 AM or whatever. I then go back to bed and rest a little. I get up between 6 or 7 AM. I don’t fall asleep during the day. I feel tired but I don’t sleep. I spend the day sitting, standing and walking.
Vasko comes when Vlad is not here and his wife can also act as a carer. I have 2 other carers. One is full-time. She may spend the day taking me to the doctor. I have another part-time carer. Sue is just my carer and Vladko is on a carer allowance. Because of the accident I can’t care for myself for hygiene or daily living. I need help with dressing. They cook, clean and change sheets. They help me shopping and take me to appointments and support me. I have a fractured thoracic disc and lumbar disc. I could not move for 2 months after the accident. I became psychologically depressed. I feel I have too many psychological issues. I have depression, anxiety and panic attacks. They put out my medicine boxes and massage me. They do other stuff.
History
9.   Psychosocial History and Pre-accident History
Medical History
Mrs Sekuloska was 159 cm.
She said she had lost 13 kg but did not know her weight.
·   She reported a 13 kg weight loss to Assessor Mason.
Right-handed.
I never had a major problem before the accident. I was working happily. I was living happily and providing for the kids. Now the medicine is giving me extra symptoms.
Operations: None recalled.
ALLERGIES: Panadol [the analgesic medication paracetamol].
Education History
Mrs Sekuloska school in Macedonia to year 10 the equivalent of year 9 in Australia.
She studied dressmaking after school, worked in her local community and trained privately as a hairdresser. In Australia I had so many TAFE certificates. I had a Cert IV ins Workplace Health and Safety and Cert IV in Office Management. I had thought of a diploma but did not do it because of the injury.
Employment History
I can’t remember the year I came to Australia. It was 1986 or something. I studied and did work experience before I met my husband. Then I started to work in a transport company doing office work. I took time off when I had my kids and paid someone to look after the company. I was a director of my husband’s transport company until he sold it. Then I worked in a radiology private practice in Liverpool. When I was retrenched I began to work at St George Private Hospital for the same company. Then I worked at St George for a year and then worked at Liverpool Hospital in radiology administration. I stopped work for a month before the motor accident and can’t see myself returning to work. I was terminated about 4 years ago. I had planned to start in other jobs but after accident I had to resign from everything.
Economic Status
I applied for the disability support pension 5 years ago. I had a 20% psychological disability. I don’t believe there was a physical disability. (Mrs Sekuloska repeated there was no physical disability when asked.)
Psychosocial History
Family History
My father is in his 90’s and my mum is in her 90’s. I can’t remember what I told Assessor Mason their ages were. Mrs Sekuloska recalled her father was a builder in Macedonia but did not remember what work he did in Australia. She did not recall if her mother worked. I have a 2 sisters in Macedonia. I have 4 brothers in Australia. My younger brother is in Melbourne.
Developmental History
I had an excellent childhood. I was treated well by my parents and had respect.
No childhood sexual or physical trauma was reported. I was never harmed.
Relationship History
Marital status: Married.
Marriage history: Mrs Sekuloska met her husband in Australia and married in 1989. There were no problems before the accident. I can say he had an injury but I can’t remember the year. When asked about her husband’s injury she said she did not wish to give any further information. I have no authority to tell you because everything is dead between us. It happened almost immediately after the accident. We were talking of divorcing but have done nothing. It was a lot of psychological issues. I can’t fulfil my duties. In response to a question about carers for her husband she said that her sons cared for their father. He has no other carers.
Her 33-year-old son had a carer allowance for caring for his parents. Her 31-year-old son lived separately with his wife and children.
Chemical Dependency History
No use of alcohol, street drugs or cigarettes reported.
Forensic History
Mrs Sekuloska reports anger management problems at present. Since the accident I am agitated, anxious and I can’t communicate in a nice way. I scream and yell. I sometimes feel explosive. I have broken glass. Mrs Sekuloska denied hitting anyone.
Mrs Sekuloska does not have a history of legal problems.
There was no gambling problem.
Mrs Sekuloska said she had made 2 compensation claims before the motor accident of Sunday, 19 June 2016.
In 1999 she filed a compensation after she slipped in Coles, I didn’t fall. I had left hip injury and I recovered quickly. I was off work for not too long. I can’t remember how long.
An August 2013 workers compensation claim was for left shoulder, arm and left middle finger injury from opening a heavy fire door at Liverpool Hospital. I recovered quickly.
In December 2013 she was involved in a MVA but a claim did not proceed. Mrs Sekuloska said that her GP did not correctly record the accident. I screamed and yelled at the other driver. There was no collision.
In 2016 I had the same injury as in August 2013 and was getting ready to go back to work when the accident happened.
Psychiatric History Before the 19 June 2016 MVA
Mrs Sekuloska denied mental health problems before the MVA.
Pre-Accident Functioning
I was trying to get back to normal and had help from the family after the work injury.
Before that there were no issues with my health. I worked full-time. I was doing home duties, paying bills and maintaining the house. I was going to community events like weddings and christenings. I was going to dancing parties, out for coffee and liaising with people. I went to friends’ houses. I was studying online, at TAFE and work. Her hobbies were sewing and traditional Macedonian dancing. Vladko is a musician and I loved to attend his music. After the accident I stopped because of my psychological problems.
10.History of the 19 June 2016 MVA
In response to a request to describe the 19 June 2016 MVA Mrs Sekuloska began, I don’t feel comfortable about talking about the accident. I can only say I was destroyed by the accident. It left me unable to do the physical things I used to be able do before. Now I can’t support my family.
I was driving home from Liverpool Hospital by myself. From my left side another car cut me off. I was injured, disabled and lost my job. When the accident happened I had a shock and sat for a time. I was jolted, shocked and the seatbelt compressed my chest. I sat in the car. I called the police and ambulance who didn’t come. We exchanged information but no one came. I drove home slowly.
I could not see my GP until a few days later. I saw a colleague of my GP a few days after.
I was coughing blood. I was given extra Nexium [the proton pump inhibiting medication esomeprazole used for gastro-oesophageal reflux disease] and when my doctor came back I was sent for a CT. I wasn’t able to move for 2 months. Then a few months after I asked to see a specialist neurosurgeon. He wrote everything down but he didn’t say I was in a motor vehicle accident. I was being treated with normal pain killers. He said I should have conservation treatment. An MRI scan found a broken disc that spiked my mental health.
The GP said I should take Panadol that I am allergic to and also prescribed Panadeine Forte [the combination analgesic medication codeine and paracetamol].
I have been on conservative treatment. The pain is worse but I am most concerned by the psychological problems. I used to study, read books, complete home duties and work. In the month before the accident I opened a fire door at work. It was awkward and I injured my left shoulder again. I was recovering to go back to work when this accident cut me off from everything.
11.History of Mental Health Symptoms and Treatment After the 19 June 2016 MVA.
The psychological problem was shock. I had pins and needles in my chest. It was hard to believe. I had depression that was more severe than the pain. I was depressed thinking of what could have happened to the people in front of me. I was scared when I bumped into them. There were nightmares straight after the accident. I worried about my health and became a vegetable. I couldn’t liaise with my family.
I became aggressive and agitated. After the accident my son took over caring for the house. I had been my husband’s carer. As his wife I was not receiving a carer allowance. I was working 3 jobs before the work accident. I have not been able to return to work as I am psychologically and physically unfit. Nothing makes me happy. I can’t go out for coffee. I am not comfortable to go out.
I feel like a burden if I meet someone who knows me and asks me questions. I can’t have a conversation. I think of the accident constantly and can’t stop.
Treatment
I don’t remember the names of the medicines.
·   The documents provided list prescriptions of amitriptyline [a tricyclic antidepressant medicine], duloxetine [a serotonin and noradrenaline reuptake inhibiting antidepressant medicine] and escitalopram [a serotonin reuptake inhibiting antidepressant medicine] with escitalopram being the most recent prescription.
My GP treated me for pain at first. My pain specialist put me on Lyrica [the pain-modulating anticonvulsant pregabalin], Advil [the over-the-counter non-steroidal anti-inflammatory medication ibuprofen] and Periactin [the antihistamine medication cyproheptadine]. The Periactin is for sleep.
I don’t remember the names of the medicines I was on before.
I was seeing Dr Hyde monthly until he went overseas in 2022.
·   Dr Gordon Hyde, Consultant Psychiatrist.
I stopped seeing Dr Hyde and Vladko changed me to another psychiatrist. Vasko said the psychiatrist was Dr Goran Stevans. He changed the dose of escitalopram for my depression and anxiety.
Mrs Sekuloska was referred to Miss Michelle Fung, Forensic Psychologist in 2017. Treatment was described as partially helpful. She then saw Dr Zoran Protulipac, Clinical Psychologist until 2022. This was helpful at the time but the effects had not lasted. She then began to see Mr Goran Josifoski, Registered Psychologist [Vasko provided his name].
I saw Michelle and then Zoran. I stopped seeing him last year when Dr Hyde was overseas. I see the current one every month.
I have tried physiotherapy, cupping and massage but there is not much help.
12.Details of Any Relevant Injuries or Conditions Sustained After the 19 June 2016 MVA
There have been no relevant injuries or conditions sustained since the motor accident.
13.Current Symptoms
I think I was psychologically destroyed when I saw Assessor Mason. I was very severe back then and there have been ups and downs. Sometimes my GP may have to call me every day. It may be 3 times a day for a few days or every 2 weeks. Recently I had severe panic attacks and my GP tried to help when I couldn’t talk to my psychologist.
My depression, anxiety, panic attacks and physical injury are worse. I can’t do what I used to do and that is because I can’t function.
Asked why it took until May 2017 to ask for psychological help Mrs Sekuloska said it was her GP’s job to realise that she needed that help. In the beginning I was not prescribed the correct treatment. I changed GP’s. I stayed with them until 3 years ago. Now I am seeing Dr Ristevski, a GP in Hurstville or another nearby GP. I go to Liverpool Hospital emergency often for panic attacks and physical symptoms. There is no help at all. I was taken to Liverpool Hospital with back pain last Easter. I was sent home until the GP was open.
14.Current and Proposed Treatment
30 mg of escitalopram daily.

Lyrica 150 mg twice a day.
Advil 4 to 6 a day.
Nexium daily. Nexium is for my digestive system because of bleeding in my throat. I have blurry vision.
Mrs Sekuloska receives GP care from Dr Kiro Ristevski.
Mrs Sekuloska receives psychiatric care from Dr Goran Stevans and psychological care from Mr Goran Josifoski. I sometimes see my psychologist face-to-face. I prefer to see them without leaving home.
Now I have seen Prof Sheridan my concerns are more psychological. I had physiotherapy at the end of last year, which increased my anxiety and depression.
I have severe anxiety and panic attacks and that increased my psychological problems.
Mrs Sekuloska did not expect a change in current treatment. I am not seeing much change with the treatment and all the anxiety and panic attacks are coming back. I am following instructions.
Clinical Examination
15.Mental State Examination
Grooming: Somewhat dishevelled despite having carers responsible for her well-being. I don’t care how I look. I have not had a haircut for years.

Clothes: Casual at home clothing. Most of the time my carers choose my clothes but I don’t care. Before everything used to be perfect.

Activity: Pain symptoms noted with 14 periods of standing during the assessment
No psychomotor retardation or agitation observed.

Aggression: Hostile acts towards peers and family reported.
Interaction: Cooperative throughout the interview. She asked for a break in the last 10 minutes of the assessment but could continue without stopping.
Eye contact: Good.
Facial Expression: Anxious.

Language: Rate: Rapid.
Volume: Average.
Coherence: Goal-directed.
Affect: Anxious with intense focus on mental health disability. No evidence for cyclic mood changes. Suicidal ideation is absent.

Perceptions: No anomalies reported.
Sensorium: Clear.
Memory: She reported difficulties in retrieving items usually recalled from long-term memory.
Concentration: Clinical observation of her concentration during the assessment interview showed moderate impairment. Variable focus was observed because the claimant often strayed from the topic asked. Severe concentration deficits were not seen.
16.Current Functioning
I need a carer to help me shower. I am distressed and need help. Every 2 or 3 days there is one there. I have no motivation to shower and they force me to shower. It is not safe in the shower.
I need a stool in the shower. I have back, neck and a sciatic leg problem. That makes me worry even more. I need help with dressing and combing or drying my hair. I have not worn a bra for a year because it compressed my factures and psychologically affects me. I have no interest in clothing. The carers change my clothes.
I can’t hold more than 3 kg with my hand problem. I am depressed and I can’t think straight.
I can’t think of what to put in the saucepan. I can’t do cooking, cleaning or washing. I don’t shop.
My mood is up and down. Sometimes from the pain but mostly it is by itself. The depression and panic attacks started from being in the accident.
My treatment people want me to go out to shopping centres to walk. I tried at the end of last year and the beginning of this year but it didn’t help.
I have missed family events. If needed I would go to my son’s wedding.
I would go to a christening. I have lost so many events. I don’t go because of my psychological problems. I worry I can’t control myself. I may cry because I can’t do what I used to do. Physically it is not a problem. I could use a walking stick or a shopping trolley.
My closest brother in Liverpool helps me. I have not been to his place in many years. He comes to my place. I sometimes have contact with my other brothers. I am a burden for my sons and a pain in the neck. I mistreat them.
My husband and I live separately in different rooms.
I have lost my friends due to the psychological problems. I don’t feel secure in crowds. Physically it affects me a bit.
I will go to chemist if needed and get help from the shop assistant. I did not stop going out completely but it is rare now.
If I need to drive I can drive locally but I have panic and anxiety. I am psychologically unwell. I can drive without a carer for a short distance. On a long trip a carer drives me.
I can’t think or concentrate on tasks because of my psychological problems. Everything is dead to me. I am a vegetable. I can’t finish anything. I cannot do things. I used to make bridal dresses and men’s suits. It is a psychological problem. I was studying before the accident but now I can’t read even a little.
Mrs Sekuloska has not returned to the workforce.

I rarely go to Church now. I have to be taken but I can’t remember when.
17.Comment on Consistency
There was consistency between the history of current psychiatric symptoms, presentation at the assessment interview and findings on mental state examination because when asked about the effect of pain symptoms Mrs Sekuloska consistently denied pain was a cause of her mental health problems. She described an inability to function because of physical symptoms and pain separate from her mental health problems.
PANEL DELIBERATIONS
18.Diagnosis and Reasons
On 14 September 2023 Mrs Sekuloska met DSM-5-TR criteria for the diagnosis of Persistent Depressive Disorder with Major Depressive Episode with Anxious Distress. She described depressed and anxious mood that began after the 19 June 2016 MVA with symptoms present for over 2 years. She describes sadness, lack of pleasure and anxiety with symptoms of:
Depressed mood most of the day
Markedly diminished interest or pleasure in all activities most of the day
Significant weight loss without dieting.
Insomnia nearly every day.
Fatigue nearly every day.
Feelings of worthlessness nearly every day.
Feeling worried with a sense of loss of control nearly every day.
Diminished ability to concentrate nearly every day.
Persistent worry.
A feeling of being unsafe.
A general feeling of uneasiness.
19. Causation and Reasons
Mrs Sekuloska says she did not have a mental health disorder before the 19 June 2016 MVA asserting there was no mental health disorder caused by the 2013 work accident. She showed no obvious mental health disability in the years before June 2016. Before the 19 June 2016 MVA, her physical symptoms were never referred for mental health assessment or treatment.
After the 19 June 2016 Mrs Sekuloska said she should have been referred for mental health treatment by her GP saying it was his responsibility to record her mental health problems. She said that her physical problems were first on her mind in the months after the MVA.

A mental health treatment plan was written in May of 2017. Ms Michelle Fung, writing in December 2017 after completing 8 treatment session, noted that following the MVA there had been a progression of low mood, hopelessness, rumination and reduced self-esteem. Dr Hyde diagnosed an Adjustment Disorder. Dr Protulipac diagnosed Major Depressive Disorder with comorbid Posttraumatic Stress Disorder in partial remission. No records from her current treating mental health professionals, Dr Stevans and Mr Josifoski were provided by the parties. The Independent Medical Examination (IME) psychiatric assessment of Dr Vickery resulted in a DSM-5 diagnosis of Somatic Symptom Disorder while the IME of Dr Bertucen diagnosed an Adjustment Disorder with comorbid Posttraumatic Stress Disorder in substantial remission.
The most common mental health diagnoses are of a mood disorder that commenced after the 19 June 2016 MVA and has continued to the present. The diagnosis of Posttraumatic Stress Disorder cannot be made because criterion A severity criteria were not met.
The symptoms described on 14 September 2023 are of a Persistent Depressive Disorder with Major Depressive Episode with Anxious Distress caused by the MVA. The panel identified no other plausible causes of the condition and there is no evidence of significant pre-existing condition.
20. Conclusion on Issues Raised by the Parties
The insurer accepted that Mrs Sekuloska suffered from a mental health condition but disputed that the 19 June 2016 MVA caused the condition. The insurer claimed the impairment from the MVA did not give rise to a greater than 10% WPI.
While supporting Assessor Mason’s Certificate the insurer noted that allocating a Class 2 for Social and Recreational Impairment overstated the psychiatric impairment level arguing a Class 1 impairment represented a better fit for the psychiatric complaints. The Concentration, Persistence and Pace and Adaptation assessments as Class 2 were correct.
The Claimant wrote that Assessor Mason’s assessment of the Categories of ‘Social and Recreational Activities’, ‘Concentration, Persistence and Pace’ and ‘Adaptation’ were wrong in a material respect. Instead, a proper assessment of these Categories would result in a finding of a minimum of ‘moderate impairment’ for ‘Social and Recreational Activities’ and ‘Concentration, Persistence and Pace’, and for ‘Adaptation’, a minimum rating of a ‘severe’ or ‘total’ impairment.
The Panel calculated Mrs Sekuloska’s Whole Person Impairment, based on the assessment of 14 September 2023 as greater than 10% impairment from mental health injuries.”

Review panel decision

The degree of whole person permanent impairment of the injuries caused by the accident was calculated as follows:
“Psychiatric Impairment Rating Scale

Psychiatric diagnoses	Persistent Depressive Disorder with Major Depressive Episode with Anxious Distress
Psychiatric treatment description	Psyciatric consultation Psychological Counselling Psychotropic medicine

Category	Class	Reason for Decision
1. Self-Care and Personal Hygiene	3	Moderate impairment. Mrs Sekuloska reports she does not care to shower and must be forced to do so. Her physical problems also mean she needs help to shower and dress. She reports not interest in what she wears. Her carers supervise her medicines. A combination of physical symptoms and a lack of ability to plan meal preparation means she cannot live independently without regular support.
2. Social and Recreational Activities	3	Moderate impairment. She avoids social events because of concerns about self-control, her dislike of crowds and therefore rarely attends. She describes becoming agitated, anxious and screaming and yelling. She said she could not go out for coffee. She claimed she could not have a conversation. She denied that physical problems caused her to avoid Social and Recreational Activities.
3. Travel	2	Because she can drive alone in her local neighbourhood but does this rarely. Because she can drive alone even infrequently, this is a mild impairment.
4. Social Functioning	2	Mild impairment. The relationship with her husband is strained. They sleep separately while living in the same house. They have not formally separated. She reports losing contact with friends because of her mental health problems.
5. Concentration, Persistence and Pace	3	Moderate impairment. She reports significant problems following pattern instructions to make the clothing she used to make. She says she cannot persist and finish jobs. She denies ability to follow television, read books or to study. There was variable focus during this assessment interview.
6. Adaptation	4	Severe Impairment. She reports she could not see herself returning to work because of her depression, panic and anxiety. She could not maintain workplace focus with her depressed mood. Her lack of motivation to work is related to her depression as well as physical symptoms. She could not work more than one or two days at a time. Her attendance would be erratic and she could only work for brief periods.
List classes in ascending order: 2,2,3,3,3,4
Median Class Value: 3
Aggregate Score: 17
% Whole Person Impairment: 19%

*%WPI ^{= Percentage Whole Person Impairment}
Permanent Impairment
21.        Apportionment
22.        Pre-existing Impairment
Mrs Sekuloska did not have a pre-existing mental health problem.
23.        Effects of Treatment
No treatment effect noted from psychiatric consultations, psychological counselling or psychotropic medicine.
24.        Final % Permanent Impairment
A Current % permanent impairment            19%
B Pre-existing % permanent impairment     0%
C Adjustments % for effects of treatment    0%”

Causation

The Panel has noted that the claimant had no mental disabilities prior to the accident. She showed no obvious mental health disability in the years before June 2016. Before the 19 June 2016 motor vehicle accident, her physical symptoms were never referred for mental health assessment or treatment the Panel is satisfied that such mental disabilities did arise after the accident, and are attributable to the accident, as noted in the body of the medical examination report.

CONCLUSION

The insurer’s submissions do not dispute the findings of Categories (a), (c), and (d) of the Medical Assessors findings.
Regarding Social and Recreational Activities, the Medical Assessor categorised this as class 2. The insurer submitted that class 1 was appropriate. The Panel found that the claimant demonstrated a moderate impairment and assessed this as class 3. The claimant avoids social events because of her concerns about self-control and her dislike of crowds. The Panel accepts that the claimant would be agitated and anxious given her presentation and comments. The Panel has not reached this assessment by way of measurement of impairment due to somatoform disorders or pain.
With the classification of concentration, persistence and pace, the Medical Assessor provided an assessment of class 2. The insurer says that the claimant’s difficulties with her memory and concentration is that they are due partly to pain and partly due to his psychiatric condition. The Medical Assessor reported that the claimant had no difficulty with her concentration throughout his interview. However, when the Panel assessed the claimant, observation of her concentration during the assessment interview showed moderate but not severe impairment. Variable focus was observed because she often strayed from the topic asked.
Regarding adaptation, the Medical Assessor assessed this classification as class 2. The insurer has no dispute about the assessment of the Medical Assessor for this Category 2. The Panel assessed this as class 4. On the assessment of the Panel, the claimant had severe impairment. She could not see herself returning to work because of her depression, panic and anxiety. It was the assessment of the Panel that this was a reasonable position. As the Panel stated, her lack of motivation to work as primarily related to her depression rather than to her physical symptoms.
Attendance at work would be erratic and would only ever be for brief periods.
The assessment of the Panel was reached following close clinical observation and assessment. The Panel did not find inconsistencies in its assessment by the claimant. The provision of her history and the claimant’s presentation were consistent.

DETERMINATION

The Panel revokes the Certificate of Medical Assessor Mason dated 15 June 2022.
The Panel finds that as a result of an accident on 19 June 2016, the claimant developed;
(a) persistent depressive disorder with major depressive episode and anxious distress.
The claimant has a WPI of 19%.

[2023] NSWPICMP 657

7 December 2023