Toor v Insurance Australia Limited t/as NRMA Insurance

[2023] NSWPICMP 225

DETERMINATION OF REVIEW PANEL

CITATION:

Toor v Insurance Australia Limited t/as NRMA Insurance [2023] NSWPICMP 225

CLAIMANT:

Usman Mushtaq Toor

INSURER:

Insurance Australia Limited trading as NRMA Insurance

REVIEW Panel

MEMBER:

Susan McTegg

MEDICAL ASSESSOR:

Mohammed Assem

MEDICAL ASSESSOR:

Margaret Gibson

DATE OF DECISION:

24 May 2023

CATCHWORDS:

MOTOR ACCIDENTS – The claimant suffered injury in a motor vehicle accident on 6 March 2021; Medical Assessor (MA) Woo found the following injuries were threshold injuries: lumbar spine, soft tissue injury; pelvis and sacroiliac joints, soft tissue injury; right shoulder, soft tissue injury; right hip/pelvis, soft tissue injury; KUB ultrasound and MRI of left hip/pelvis not related to injuries caused by accident and not reasonable and necessary; complaints of pain to the sacroiliac joint; Held – small partial thickness intrasubstance tear of the subscapularis was an incidental finding and not causally related to accident; no evidence of bruising or complaint until 30 April 2021; consistency of complaint pertaining to lumbar spine; no evidence two or more signs of radiculopathy existed; pain in lumbar spine radiating to the sacroiliac joint; left hip and pelvis and right hip and pelvis normal to examination; no sign of injury to either hip or pelvis; Medical Assessment Certificate of MA Woo revoked; soft tissue injury to lumbar spine with pain radiating to sacroiliac joint is a threshold injury; right shoulder, small partial thickness intrasubstance tear of subscapularis not caused by the accident; soft tissue injury to left and right hip/pelvis not caused by the accident; KUB ultrasound and MRI of the left hip/pelvis not relate to injury caused by the accident and not reasonable and necessary.

DETERMINATIONS MADE:  

CERTIFICATE OF DETERMINATION
Assessment of threshold injury
Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017

The Review Panel revokes the certificate of Medical Assessor Alexander Woo dated   3 July 2022 and determines that the following injury caused by the motor accident is a threshold injury:

·     lumbar spine – soft tissue injury with pain radiating to the sacroiliac joint.

The Panel determines the following injuries were not caused by the accident:

·     right shoulder – small partial thickness intrasubstance tear of subscapularis;

·     left hip/pelvis – soft tissue injury, and

·     right hip/pelvis – soft tissue injury.

Assessment of Treatment and Care –Causation

Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017

The following treatment and care does not relate to the injury caused by the motor accident:

·     the proposed kidney, ureter and bladder ultrasound, and

·     the proposed MRI of the left hip/pelvis.

Assessment of Treatment and Care – Reasonable and Necessary

Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017

The following treatment and care is not reasonable and necessary in the circumstances:

·     the proposed kidney, ureter and bladder ultrasound, and

·     the proposed MRI of the left hip/pelvis.

STATEMENT OF REASONS

INTRODUCTION

1. On 6 March 2021 Mr Usman Mushtaq Toor (the claimant) was driving a Toyota Camry as an Uber driver with three passengers waiting to make a left-hand turn at an intersection when he was rear-ended by a car (the accident).   

2. Insurance Australia Limited trading as NRMA Insurance (the insurer) is the relevant insurer with liability to pay any damages to Mr Toor under the Motor Accident Injuries Act 2017 (MAI Act).

3. Medical Assessor Alexander Woo issued a certificate dated 3 July 2022 in which he certified that the injury caused by the accident was a minor (threshold) injury for the purposes of the MAI Act.

4. As a result, Mr Toor has no entitlement to ongoing statutory payments under the MAI Act.

5. Medical Assessor Woo also certified that the proposed kidney, ureter and bladder (KUB) ultrasound and the MRI of the left hip/pelvis did not relate to the injury caused by the accident and was not reasonable and necessary in the circumstances.

6. The claimant has sought a review of the certificate of Medical Assessor Woo.

BACKGROUND

1. Mr Toor is 36 years of age and at the time of the accident worked in a warehouse and as an Uber driver. 

2. The accident occurred on 6 March 2021.

3. On 22 March 2021 Mr Toor lodged an Application for Personal Injury Benefits.

4. On 23 June 2021 the insurer issued a Liability Notice – benefits after 26 weeks informing the claimant that his injuries were minor (threshold) injuries and that his entitlement to statutory benefits including treatment and care would cease from 4 September 2021 (the minor injury decision).

5. On 1 July 2021 Mr Toor sought an Internal Review of the minor (threshold) injury decision.

6. On 23 July 2021 the insurer issued their Internal Review - Certificate of Determination and Statement of Reasons affirming their earlier minor (threshold) injury decision. 

7. On 23 June 2021 the insurer issued a Liability Notice declining the claimant’s treatment request for an MRI scan of the left hip/pelvis and for a KUB ultrasound (the treatment dispute decision). The KUB ultrasound was declined on the basis there is no evidence of injury to those organs arising from the accident. The MRI of the hip/pelvis was declined on the basis neither treating specialist, Dr Moses nor Dr Kam had recommended the investigation and it was unlikely to alter their management plans. On that basis the insurer concluded the investigation was unlikely to be beneficial.

8. On 12 July 2021 the claimant sought an Internal Review of the treatment dispute decision.

9. On 23 July 2021 the insurer issued their Internal Review – Certificate of Determination and Statement of Reasons affirming the earlier treatment dispute decision.

10. The claimant filed an application with the Personal Injury Commission (Commission) seeking a medical assessment to resolve the minor (threshold) injury dispute and the treatment dispute between the parties.

11. Pursuant to Schedule 2, cl 2 of the MAI Act, various matters are declared to be a medical assessment matter, including (e) “whether the injury caused by the motor accident is a threshold injury for the purposes of the Act”.

12. 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.

THRESHOLD INJURY- STATUTORY PROVISIONS

1. The Motor Accident Injuries Amendment Act 2022 (the MAI Amendment Act) was assented on 28 November 2022 with various amendments commencing on 1 April 2023. From
   1 April 2023 the MAI Amendment Act provides that a “minor injury” is known as a “threshold injury” and “minor injuries” are known as “threshold injuries”.

2. The definition of what constitutes a minor injury has not been amended and continues to apply to a threshold injury.

3. Any reference in these reasons to “minor injury” is a reference to a “threshold injury” and any reference to the word “minor” referring to the injury alleged to have occurred in the accident is a reference to “threshold”.

4. A threshold injury is defined in s 1.6 of the MAI Act and includes a “soft tissue injury” or a “psychological or psychiatric injury that is not a recognised psychiatric illness”. Section 1.6(2) of the MAI Act defines a “soft tissue injury” as:

   “[A]n injury to tissue that connects, supports or surrounds other structures or organs of the body (such as muscles, tendons, ligaments, menisci, cartilage, fascia, fibrous tissues, fat, blood vessels and synovial membranes), but not an injury to nerves or a complete or partial rupture of tendons, ligaments, menisci or cartilage.”

5. Section 1.6 provides that regulations may be made to exclude or include a specified injury from being a threshold injury. Part 1, cl 4 of the Motor Accident Injuries Regulation 2017 (the MAI Regulation) further defines threshold injury to include “an injury to the spinal nerve root that manifests in neurological signs (other than radiculopathy)”.

6. Part 5 of the Motor Accidents Guidelines (the Guidelines) are made pursuant to s 10.2 of the MAI Act. The Guidelines contain the procedure for assessing whether an injury caused by the motor accident is a threshold injury for the purposes of the MAI Act. Version 9.1 of the Guidelines commenced on 1 April 2023 and applies to motor accidents occurring on or after 1 December 2017. In respect of the medical assessment of whether an injury is a threshold injury, the Guidelines relevantly provide:

   “5.3   The assessment will determine whether the injury related to the claim is a soft tissue injury or a threshold psychological or psychiatric injury caused by the motor accident.

   5.4    Insurers should not require injured persons to undergo diagnostic imaging for the purpose of the insurer determining whether the injury related to the claim is a threshold injury. Diagnostic imaging is not considered necessary to assess threshold injury.

   5.5    A diagnosis for the purpose of a threshold injury decision must be based on a clinical assessment by a medical practitioner or other suitably qualified person independent from the insurer.

   5.6     The assessment of whether an injury caused by the accident is a threshold injury for the purposes of the Act should be based on the evidence available and include all relevant findings derived from:

   (a) a comprehensive accurate history, including pre-accident history and pre-existing conditions

   (b) a review of all relevant records available at the assessment

   (c) a comprehensive description of the injured person’s current symptoms

   (d) a careful and thorough physical and/or psychological examination

   (e) diagnostic tests available at the assessment. Imaging findings that are used to support the assessment should correspond with symptoms and findings on examination.”

7. In respect of injury to the neck or spine cls 5.7, 5.8 and 5.9 of the Guidelines provide:

   “5.7   In assessing whether an injury to the neck or spine is a soft tissue injury, an assessment of whether or not radiculopathy is present is essential.

   5.8    Radiculopathy means the impairment caused by dysfunction of a spinal nerve root or nerve roots when two or more of the following clinical signs are found on examination when they are assessed in accordance with ‘Part 6 of the Motor Accident Guidelines: Permanent impairment’.

   (a) loss or asymmetry of reflexes (see the definitions of clinical findings in Table 6.8 in these Guidelines)

   (b) positive sciatic nerve root tension signs(see the definitions of clinical findings in Table 6.8 in these Guidelines)

   (c) muscle atrophy and/or decreased limb circumference (see the definitions of clinical findings in Table 6.8 in these Guidelines)

   (d) muscle weakness that is anatomically localised to an appropriate spinal nerve root distribution

   (e) reproducible sensory loss that is anatomically localised to an appropriate spinal nerve root distribution.

   5.9    Where the neurological symptoms associated with the injured person’s injury of the neck or spine do not meet the assessment criteria for radiculopathy, the injury will be assessed as a threshold injury.”

8. In Briggs v IAG Limited trading as NRMA Insurance[2] his Honour Justice Wright stated at [35]:

   [2] Briggs v IAG Limited Trading as NRMA Insurance [2022] NSWSC 372.

   “The question of causation of injuries was not dealt with in Part 5 of the Guidelines but causation was addressed in Part 6, which related to assessment of permanent impairment. There is no reason to think that different principles were intended to be applied when a medical assessment was being made in relation to causation of minor injuries. Clauses 6.5 to 6.7 provided:

   ‘Causation of injury

   6.5An assessment of the degree of permanent impairment is a medical assessment matter under clause 2(a) of Schedule 2 of the Act. The assessment must determine the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident. A determination as to whether the injured person's impairment is related to the accident in question is therefore implied in all such assessments. Medical assessors must be aware of the relevant provisions of the AMA4 Guides, as well as the common law principles that would be applied by a court (or claims assessor) in considering such issues.

   6.6Causation 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.

   6.7There 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.”

TREATMENT DISPUTE – STATUTORY PROVISIONS

1. Section 3.24 of the MAI Act refers to an injured person’s entitlement to statutory benefits for treatment and care as follows:

   “(1)    An injured person is entitled to statutory benefits for the following expenses (treatment and care expenses) incurred in connection with providing treatment and care for the injured person-      

   (a)The reasonable cost of treatment and care,

   (b)Reasonable and necessary travel and accommodation expenses incurred by the injured person in order to obtain treatment and care for which his statutory benefits are payable,

   (c)If the injured person is under the age of 18 years or otherwise requires assistance to travel for treatment and care, reasonable and necessary travel and accommodation expenses incurred by a parent or other carer of the injured person in order to accompany the injured person while treatment and cate for which statutory benefits are payable is being provided.

   (2)     No statutory benefits are payable for the cost of treatment and care to the extent that the treatment and care concerned was not reasonable and necessary in the circumstances or did not relate to the injury resulting from the motor accident concerned.”

2. Section 3.28(3) of the MAI Act permits payment of statutory benefits for treatment incurred more than 26 weeks after the accident in respect of minor injuries if the treatment will improve the recovery of the injured person, the insurer delayed approval for treatment or in other appropriate circumstances.

ASSESSMENT UNDER REVIEW

1. The dispute was referred to Medical Assessor Alexander Woo who assessed
   Mr Toor on 23 June 2022 and issued a certificate dated 3 July 2022. The injuries referred for assessment were described as follows:

   ·        whether the lumbar spine – L4/L5 mild disc bulging causing nerve root impingement, L4/5 small broad-based disc bulge causing moderate central canal stenosis injury caused by the motor accident is a minor injury for the purposes of the MAI Act;

   ·        whether the left hip/pelvis – sacroiliac joint injury caused by the motor accident is a minor injury for the purposes of the MAI Act;

   ·        whether the right hip/pelvis – sacroiliac joint injury caused by the motor accident is a minor injury for the purposes of the MAI Act, and

   ·        whether the right shoulder – small partial thickness intrasubstance tear of subscapularis injury caused by the motor accident is a minor injury for the purposes of the MAI Act.

2. The following treatment disputes were referred for assessment:

   ·        whether the proposed KUB ultrasound and MRI of the left hip/pelvis is causally related to the motor vehicle accident, and

   ·        whether the proposed KUB ultrasound and MRI of the left hip/pelvis is reasonable and necessary in the circumstances.

3. Medical Assessor Woo reported Mr Toor had a history of lower back pain in 2017. He took medication, had an X-ray and a CT scan of the lumbar spine on 8 September 2020. He reported Mr Toor said his lower back pain was aggravated after the accident.

4. Medical Assessor Woo reported Mr Toor had ongoing lower back pain, on and off left leg pain and stiffness in the middle of his back. He also reported complaints of mild right shoulder pain for the past three weeks.  

5. Medical Assessor Woo found no complete or partial rupture of tendons, ligaments, menisci or cartilage.  He found no clinical signs to satisfy the diagnosis of radiculopathy in the lower limbs related to the lumbar spine injury. 

6. Medical Assessor Woo certified that the following injuries caused by the accident were a minor injury for the purposes of the MAI Act:

   ·lumbar spine – soft tissue injury;

   ·pelvis and sacroiliac joints – soft tissue injury;

   ·right shoulder – soft tissue injury, and

   ·right hip/pelvis – soft tissue injury.

7. Medical Assessor Woo also certified that the proposed KUB ultrasound and the MRI of the left hip/pelvis did not relate to the injuries caused by the accident and were not reasonable and necessary in the circumstances.

REVIEW PROCEDURE

1. The claimant lodged an application for review of the medical assessment of Medical Assessor Woo on 19 July 2022 within 28 days of the date on which the certificate of
   Medical Assessor Woo was made available to the parties.

2. On 22 August 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. 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 clause 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.

4. 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). ^[3]. Accordingly, the President’s delegate referred the matter to this Panel to assess.

   [3] Section 7.26(5A) of the MAI Act.

5. 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.[4]

   [4] Section 41(2) of the PIC Act.

6. 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.[5]

   [5] Rule 128 of the PIC Rules.

7. 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.

1. The solicitor for the claimant filed an indexed bundle of documents paginated from pages 1 to 109 uploaded to the portal as A1 and submissions which were undated but also uploaded to the portal as A1. The insurer uploaded to the portal an indexed bundle of documents paginated from pages 1 to 259 marked as AD1.

2. On 7 October 2022 the Panel issued a Report and Directions to the parties which included the following paragraphs:

   “3.      The Panel notes there is no dispute in relation to the findings of Assessor Woo that the following injuries caused by the accident are minor injuries:

   ·lumbar spine – soft tissue injury with aggravation of pre-existing degenerative changes;

   ·pelvis and sacroiliac joints – soft tissue injury with aggravation of previous injury; and

   ·right hip/pelvis – soft tissue injury with aggravation of previous injury.

   4. The dispute relates to whether injury to the right shoulder was caused by the accident and whether it is a minor injury for the purpose of the Motor Accident Injuries Act, 2017.

   5. The dispute relates to whether injury to the right shoulder was caused by the accident and whether it is a minor injury for the purpose of the Motor Accident Injuries Act, 2017.

   6.       The Panel also considers the treatment dispute can be determined on the papers following receipt of the additional records sought.

   DIRECTIONS

   In order to facilitate the just, quick and cost-effective resolution of the real issues in the Review, the Panel issues the following directions:

   1.       On or before 31 October 2022 the claimant is to upload to the portal the following:

   (a)            clinical records of treating medical practitioners consulted by

   the claimant from 1 January 2017 to date;

   (b)reports of all radiological imaging undergone by the claimant from 1 January 2017 to date including a complete copy of the report of the Musculoskeletal Right Shoulder Ultrasound of 12 May 2021 and a complete copy of the report of the CT scan undergone by the claimant in early 2021 and referred to by Dr Farhan in his referral to Dr Kam on 14 March 2021.

   (c)photographs of the damage sustained to the claimant’s vehicle in the accident.

   2.On or before 7 November 2022, the parties are directed to advise the Commission in writing that they have received this Review Panel Report and to advise whether they agree to the Panel proceeding to determining the issues in dispute without re-examination.”

3. In response to that Direction the claimant uploaded to the portal the following documents on 16 November 2022:

   ·        clinical notes of NAS Advanced Medical Centre (AD2);

   ·        clinical notes of Mawson Lakes Medical Centre (AD3);

   ·        lumbar spine X-ray and left knee X-ray report dated 30 October 2017 (AD4):

   ·        CT guided L4/5 epidural injection report dated 5 May 2021 (AD5), and

   ·        CT guided left L4-5 perineural injection report dated 30 July 2021 (AD6)

4. In response to that Direction on 17 November 2022 the insurer uploaded to the portal an Application to Admit Late Documents with updated submissions (AD7).

5. In those submissions the insurer indicated agreement with paragraphs 3, 4, 5 and 6 of the report and noted the insurer had no objection to the matter proceeding without re-examination.

6. On 22 November 2022 the claimant uploaded to the portal three photographs showing damage to the rear of his vehicle, a Toyota Camry marked AD8, AD9 and AD10 and one photograph showing damage to the front grill of a Jaguar vehicle marked AD11.

7. On 22 November 2022 the claimant indicated he objected to the matter proceeding with an examination. 

8. On 29 November 2022 the Panel agreed an examination was required.

EVIDENCE BEFORE THE REVIEW PANEL

Statement of the insured driver

1. The insured driver Samiul Syed provided a statement dated 15 April 2021 to an investigator for the insurer.[6]  The relevant paragraphs of that statement are as follows:

   [6] AD1 p 218.

   “40.I was travelling very slowly and had only just accelerated after being stationary. I looked to my right to check for traffic and as a I turned back the Camry had stopped in front of me.

   41.           I braked but could not avoid an impact….

   43.           It was a very low speed subtle impact, I would describe as a tap.

   47.The driver never suggested he had any injury or showed any sign of injury. He told me he was fine and it was only a little tap.

   48.           The damage to my car was to the front plastic grill which was broken.

   49.The damage to the rear of the Camry was to the plastic bumper which had a dent.”

Application for personal injury benefits

1. In the online Application dated 22 March 2021 Mr Toor recorded as a result of the accident he suffered “back-muscular injury’ and “lower spine nerves injury”.[7]

Treating records

NAS Advanced Medical Centre, clinical notes

[7] A1 p 16.

1. Mr Toor saw Dr Mohiuddin on 29 October 2017 having fallen over a heavy box at work.  On examination he had tenderness of the left SIJ (sacroiliac joint), painful limitation of left hip flexion and painful limitation of flexion of the left knee.

2. Mr Toor had an X-ray of the lumbar spine. On 31 October 2017 Dr Virk reported the X-ray showed mild degeneration of L5/S1. The X-ray of the left knee was normal.

3. On 3 November 2017 Dr Virk reported the lower back pain was better but Mr Toor was still tender over the lower back with restricted range of movement.  On 5 November 2017 Dr Virk reported the lower back pain had resolved.

4. On 6 February 2018 Dr Virk reported pain over the right gluteal region for three weeks and noted Mr Toor was tender over the back of the hip and thigh. The pain had resolved by 1 March 2018.

5. On 11 July 2020 Dr Mohiuddin recorded low back pain with radiation down the thigh into the left knee and diagnosed mechanical back pain. On 5 September 2020 Dr Farhan reported chronic back pain radiating to bilateral hips. Mr Toor had a CT scan of the lumbar spine on 8 September 2020 and on 5 December 2020 Dr Farhan reported worsening back pain.

6. The next consultation of relevance occurred on 7 March 2021 following the accident.
   Dr Farhan reported Mr Toor’s involvement in the rear end accident the preceding day and reported worsening of chronic back pain with pain radiating to upper spine and lower limbs.

7. Mr Toor saw Dr Farhan on 14 March 2021, 20 March 2021, 24 March 2021, 27 March 2021, 31 March 2021 with complaints of lumbosacral pain and pain down both legs.

8. Dr Farhan, general practitioner (GP) issued certificates of capacity/certificates of fitness commencing 24 March 2021 which include a diagnosis of “radicular lumbosacral Back pain post MVA” certifying Mr Toor with no capacity for work.[8]  As to how the injury was related to the accident Dr Farhan wrote “sustained MVA, impacted from behind by another vehicle. Since then severe lower back pain with bilateral radiculopathy. CT confirmed impingement of L4 region [sic]”.

   [8] A1 p 32.

9. On 8 April 2021 Dr Farhan referred to a letter from Dr Moses and advised re sacroiliac dysfunction and pelvic problem. The physiotherapist ordered an SIJ belt and wedged cushion.

10. On 22 April 2021 Dr Farhan reviewed the MRI of the lumbosacral spine and recorded mild L4/5 disc bulge with impingement.

11. On 30 April 2021 Dr Farhan reported right scapular pain and on examination recorded right shoulder impingement.  This is the first recorded complain related to the right shoulder.

12. On 12 May 2021 Dr Farhan recorded lower back pain, exacerbation of right shoulder pain which he suggested was likely to be related to the accident as it was in line with the seat belt.

13. On 21 May 2021 Mr Toor consulted Dr Farhan in respect of lumbosacral pain and left shoulder pain.

14. On 18 June 2021 Dr Farhan reported two days ago Mr Toor was driving when he went over a road bump and sustained sudden back pain.

15. On 20 June 2021 Dr Farhan reported an acute exacerbation of lumbosacral pain which was not responding to analgesia. Dr Farhan provided a referral for an MRI of the left hip/pelvis.[9] The reason disclosed on the referral was “L4/5 disc buldge [sic] post MVA, with worsening L) sided posterior hip pain? pathology”.  He also provided a referral for a KUB ultrasound.[10] The reason for the referral was “L) flank pain? pathology”.

    [9] A1 p 84.

    [10] A1 p 83.

16. Mr Toor consulted Dr Farhan on 15 July 2021 re lumbosacral pain with left radiculopathy and on 12 August 2021 Dr Farhan recorded:

    “was passenger in car

    ran over divider in car

    screamed in pian

    acute pain

    since then ongoing lumbosacral pain

    usual analgesia.”[11]

    [11] AD2 p 4.

17. On 30 July 2021 Mr Toor had a CT guided left L4-5 perineural injection.[12]

    [12] AD2 p 39.

Step by Step Physio

1. John Zhuang, physiotherapist of Step by Step Physio assessed Mr Toor on 24 March 2021 and recorded severe lower spinal pain post-accident, affecting capacity and tolerance for sitting and standing.  He reported the lumbar spine flexion was 20º, low mood and slight left neck tenderness. He also noted the previous lumbar spine sciatica history.

2. Mr Zhuang issued Allied health recovery requests dated 24 March 2021, 26 April 2021 and 28 June 2021 with a diagnosis of “neck and back pain post MVA. Back pain radiating down to bilat legs”.[13] In terms of pre-existing factors Mr Zhuang reported some sciatica pain down left side previously.

   [13] AD1 p 50.

3. On 20 May 2021 Mr Zhuang reported Mr Toor had also developed shoulder pain, right shoulder bursitis and a subscapularis tear, anterior chest and shoulder pain and diagnosed bursitis.[14]

   [14] AD2 p 10.

4. On 31 May 2021 Mr Zhuang recorded right shoulder pain, sleeping on left side and now left side shoulder pain.  He also recorded an aggravation of right lumbar spine point tenderness in the L5 facet area.[15]

   [15] AD2 p 9.

Mawson Lakes Medical Centre, clinical notes

1. The clinical notes reference consultations on 22 March 2022, 23 March 2022, 12 May 2022, 8 August 2022 and 10 August 2022.[16] The only relevant consultation was on 8 August 2022 when Dr Saluja reported impingement of the shoulder referred Mr Toor for an ultrasound. He recorded the following history:

   “…pain right shoulder MVA 1 year back more at night pain upper chest sneezing work – physical – driving forklift past carrying weights last 1 year working from home.”

   [16] AD3 p 5.

Dr Moses, specialist sports and exercise medicine physician

1. Dr Moses, specialist sports and exercise medicine physician saw Mr Toor on 1 April 2021.[17] After obtaining a history of the accident he reported:

   “Since then, he has had ongoing lower back pain. He localises his pain across his lower pelvis, it is sharp and aching, without a neuropathic component. It can refer up his spine and into his buttocks and left posterior thigh but not his knee. He has no paraesthesia or numbness in his lower limbs. He has no night pain but does have some morning pain at times. He has not experienced any bowel or urine dysfunction. He is aggravated by flexion, prolonged sitting, standing and lying and any prolonged weight bearing activities.” 

   [17] A1 p 65.

2. Dr Moses reported a history of prior intermittent back pain associated with the heavy lifting nature of his work.  He noted a recent CT scan revealed L4/L5 central canal stenosis with possible bilateral L4 impingement but noted there were no interval changes from a CT scan performed in September 2020. He reported Mr Toor was using Endone, Lyrica and Naproxen to manage his pain and had undergone two sessions of physiotherapy.

3. Dr Moses found clinical features of left sacroiliac joint incompetence. He concluded the claimant’s pain was arising from his pelvis rather than his lower back. He recommended the use of a sacroiliac joint belt and wedge cushion and physiotherapy.

4. Dr Moses reviewed the claimant on 17 May 2021. He reported Mr Toor had seen a neurosurgeon and had undergone a CT guided injection at L4/5.[18] He also reported Mr Toor complained about right shoulder pain over the preceding three weeks. Dr Moses noted on ultrasound Mr Toor had a small partial tear in his subscapularis tendinosis and had clear scapulohumeral dyskinesia.  He concluded there was no clear aetiological reason for the shoulder pain other than altered sleeping position due to lower back pain.

   [18] A1 p 67.

Rehab Management

1. Rehab Management completed an Initial Needs Assessment on 12 April 2021.[19] At that time Mr Toor complained of intermittent sharp, stabbing pain in his lumbar region which travels down his right leg and towards the thoracic region of his back. It was reported Mr Toor had pre-existing lumbar region pain which was managed with Lyrica.

   [19] A1 p 72.

Dr Andrew Kam

1. Mr Toor saw Dr Andrew Kam, neurosurgeon on 27 April 2021.[20] He reported a history of lower back pain and left sided sciatica but noted since the accident the symptoms had increased in severity and frequency.

   [20] A1 p 87.

2. Mr Toor underwent a CT guided L4/5 epidural injection on 5 May 2021.[21]

   [21] A1 p 82 and AD5 p 1.

3. On 15 July 2021 Dr Kam reported the epidural block only gave a few days relief and he reported Mr Toor was struggling with his activities of daily living.[22] He suggested he increase the dose of Lyrica and undergo a second injection in the L4/5 foraminal space and if those options fail suggested Mr Toor would need to consider an L4 laminectomy.

   [22] A1 p 89.

4. On 30 July 2021 the claimant underwent a CT guided left L4-5 perineural injection.[23]

Imaging

[23] AD1 p 70 and AD6 p 1.

X-ray lumbosacral spine 30 October 2017

1. The report of the lumbar spine X-ray states:

   “Mild loss of joint space at bilateral L5/S1 facet joints suggest mild degeneration. No other disc or facet joint degeneration is demonstrated.  Sacroiliac joints unremarkable. No acute bony injury.”[24]

   [24] AD2 p 58 and AD4 p 1.

Right hip ultrasound, X-ray right hip, X-ray right femur, 27 February 2018

1. The report of the right hip/femur X-ray was “unremarkable radiograph of the right hip and right femur”.

2. The report of the right hip/hamstrings, gluteus ultrasound was “unremarkable evaluation of the right hip, glutei, and the right hamstrings.”[25]

[25] AD2 p 56 and AD4 p 2.

CT scan lumbar spine, 8 September 2020

1. The clinical history was reported as “chronic lumbar pain and radiculopathy”.[26]  Dr Wang concluded:

   “There is generalised congenital shortening of pedicles predisposing Mr Toor to mild or moderate grade central canal stenosis. This is most prominent at the level of L4/5 with a small broad-based disc bulge causing moderate central canal stenosis and moderate bilateral neural exit foraminal narrowing.”

CT scan lumbar spine, 11 March 2021

[26] A2 p 51 and AD4 p 3.

1. The report concludes:

   “Since 08/09/2020, no significant interval change.

   There is no acute fracture identified. There is generalised congenital shortening of pedicles causing central canal stenosis and neural foraminal narrowing, this is most prominent at the level of L4/L5 with moderate central canal stenosis and bilateral neural exit foraminal narrowing. This may cause impingement of exiting nerve roots.”[27]

   [27] AD2 p 45 and AD4 p 4.

MRI lumbar spine, 14 April 2021

1. The report concludes “L4/L5 mild disc bulging causing nerve root impingement on a background of congenital lumbar spinal stenosis”.[28]

   [28] A1 p 68.

Right shoulder ultrasound, 12 May 2021

1. The report concluded:

   “subacromial/subdeltoid bursitis. Small partial-thickness or instrasubstance tear of subscapularis. The region of interest corresponds to right sternoclavicular joint with demonstrates bony irregularity, consider correlation with CT (this area may be difficult to visualise on X ray).”[29]

   [29] AD2 p 42 and AD4 p 6.

Right shoulder ultrasound, 9 August 2022

1. The report concludes:

   “There is evidence of subacromial bursitis with thickened bursal lining and bursal fluid present. There is bursal impingement on shoulder abduction.

   The biceps, supraspinatus, infraspinatus, teres minor and subscapularis tendons are unremarkable with no evidence of tendinosis or tears. The biceps tendon did not sublux on shoulder rotation. The AC joint is unremarkable and is stable on forward flexion.”[30]

SUBMISSIONS

[30] AD3 p 6.

Claimant’s submissions

1. The claimant provided submissions dated 18 August 2021 in support of the minor injury dispute.  The claimant asserts because of the accident he sustained injury to the:

   ·        low back;

   ·        sacroiliac joint;

   ·        pelvis, and

   ·        right shoulder.

2. The claimant submitted the following evidence supports a finding that the claimant sustained a non-minor injury in the accident:[31]

   ·        certificates of capacity completed by Dr Farhan, confirm Mr Toor sustained radicular lumbosacral back pain as a result of the accident, with bilateral radiculopathy;

   ·        an MRI of the lumbar spine dated 14 April 2021 demonstrated L4/L5 mild disc bulging causing nerve root impingement;

   ·        Allied Health Recovery Reports dated 23 March 2021 and 26 April 2021 confirm Mr Toor had back pain radiating down bilateral legs;

   ·        Mr Toor was referred to Dr Andrew Kam, neurosurgeon on 14 March 2021 for lumbosacral pain and radiculopathy. In his report dated 27 April 2021 Dr Kam noted pain symptoms in the low back and lower extremity had increased and any laughing, coughing or sneezing aggravated the pain. Dr Kam referred Mr Toor for steroid injections and recommended L4 laminectomy surgery;

   ·        Mr Toor was referred for a KUB ultrasound and MRI of the left hip and pelvis for ongoing pain in the left flank and worsening left sided posterior hip pain, and

   ·        an ultrasound of the right shoulder of 12 May 2021 demonstrated a “small partial thickness intrasubstance tear of subscapularis”. Dr Moses accepted the right shoulder injury was related to the accident and due to altered sleeping position due to low back pain.

   [31] A1 p 22.

3. The claimant provided undated submissions in respect of the review application. The claimant submitted Medical Assessor Woo erred in determining the injury to the right shoulder was minor having regard to the following:

   ·the history that the claimant experienced a “little bit of pain” in his right shoulder at the time of the accident;

   ·the claimant reported complaints of right shoulder pain to Dr Moses on 17 May 2021;

   ·Medical Assessor Woo accepted that the right shoulder pain reported to Dr Moses on 17 May 2021 “could have gradually increased over the following two months”;

   ·an ultrasound of the right shoulder of 12 May 2021 demonstrated “small partial thickness or intrasubstance tear of subscapularis”, and

   ·on examination Medical Assessor Woo noted minimal restriction of movement in the right shoulder and complaints of mild right shoulder pain.

Insurer’s submissions

1. The insurer provided submissions dated 9 September 2021 in respect of the minor injury dispute and the treatment dispute.[32]

   [32] AD1 p 11.

2. The insurer noted that whilst the claimant complained of lumbar pain there is no evidence that two or more of the clinical signs mentioned in cl 5.9 of the Guidelines existed to satisfy the diagnosis of radiculopathy. Whilst Dr Farhan diagnosed the claimant with bilateral radiculopathy the insurer submits the diagnosis is not supported by a clinical examination providing evidence of spinal root dysfunction which satisfies the criteria of radiculopathy. The insurer submits the claimant sustained a soft tissue injury to his back on a background of pre-existing lower back pain requiring treatment.

3. In relation to the treatment dispute the insurer submits there are no records available to substantiate an injury to the KUB sufficient to validate investigation to those regions.  The insurer argues the treatment sought is not reasonable and necessary.

4. The insurer submits there is no evidence suggesting the claimant has been diagnosed with any left hip pathology and neither of the two specialists, Dr Moses or Dr Kam, sought fit to request imaging of the left hip to assist with the claimant’s rehabilitation.  The insurer submits the request for an MRI of the left hip/pelvis is not reasonable and necessary.

1. Further submissions, which are undated, address the question to be determined by the delegate of the President.[33]

   [33] AD1 p 6.

2. In relation to the partial thickness tear or intrasubstance tear of the subscapularis the insurer submits the subscapularis is a muscle and that a tear of a muscle is not a “complete or partial rupture of tendons, ligaments, menisci or cartilage”.

3. The insurer provided supplementary submissions on 17 November 2022.[34]

   [34] AD7 p 1.

4. The insurer highlights the following from the insured’s statement:

   “40.I was travelling very slowly and had only just accelerated after being stationary. I looked to my right to check for traffic and as a I turned back the Camry had stopped in front of me.

   43.           It was a very low speed subtle impact, I would describe as a tap.

   47.The driver never suggested he had any injury or showed any sign of injury. He told me he was fine and it was only a little tap.

   48.           The damage to my car was to the front plastic grill which was broken.

   49.The damage to the rear of the Camry was to the plastic bumper which had a dent.”

5. The insurer highlights the claim form dated 22 March 2021 refers to injury to the back.

6. The insurer notes the records from NAS Advanced Medical Centre[35] and that entries of
   7 March 2021, 14 March 2021, 20 March 2021, 24 March 2021 (physiotherapy),
   24 March 2021, 27 March 2021, 31 March 2021 (physiotherapy), 31 March 2021,
   7 April 2021 (physiotherapy), 8 April 2021, 14 April 2021 (physiotherapy), 19 April 2021,
   

   [35] AD2.

   19 April 2021 (physiotherapy), 21 April 2021, 22 April 2021, 22 April 2021 (physiotherapy), and 26 April 2021 (physiotherapy), do not mention any right shoulder complaints.

7. On 1 April 2021 Dr Moses only reported complaints of ongoing lower back pain with radicular features.

8. On 27 April 2021 Dr Kam only referred to back issues. 

9. The insurer submits the first complaint about the right shoulder occurred on 30 April 2021, nearly two months after the accident despite 17 consultations with medical practitioners in that period, the claim form, the specialist report and the rehabilitation initial assessment.

10. The insurer submits the pathology reported on 12 May 2021 ultrasound is an incidental finding consistent with the claimant’s age. The insurer submits the tears evidenced are consistent with an underlying pathology rather than traumatic in origin. 

11. Further, the insurer submits that tears to muscle fibres are minor injuries under the MAI Act and the ultrasound report of 12 May 2021 does not identify the types of fibres torn.

THE MEDICAL EXAMINATION

1. Mr Toor was examined by Medical Assessor Gibson on 14 April 2023. He attended unaccompanied.

Pre-accident medical history and relevant personal details

1. Mr Toor was born in Pakistan where he finished high school and then obtained qualifications in accounting. He worked as an accountant for several years. 

2. He arrived in Australia in 2016. He completed a two-year college degree in accounting; however, he was then unable to find an accounting role. 

3. He commenced full-time employment in a warehouse. He was working in that position by the time of the accident.

4. In October 2021, he commenced work as a call centre operator with insurer, IAG. In this position he works from home taking client calls regarding motor vehicle accidents. He works 9-hour to 10-hour shifts on four days a week, Sunday to Wednesday.

5. Mr Toor lives with his wife. They moved to Adelaide in September 2021. They currently live in a two-bedroom one-bathroom house, without any significant yard to maintain. He said he and his wife share all the chores.  She is currently studying.

6. Mr Toor had a prior history of low back pain.  He said this related to his work in the warehouse, particularly as he was unaccustomed to manual labour prior to arriving in Australia.  He said he had experienced occasional referral of the low back pain to his left leg.  He had imaging performed of his lumbar spine and he had taken medication for pain. 

7. On specific questioning, he advised that in the period leading up to the accident, he would intermittently experience some low back pain, but there had been no ongoing referral of pain to the left leg.

8. There was no additional injury, medical or surgical history of relevance.

History of the accident

1. Mr Toor had been a seat-belted driver of a Toyota Camry sedan. At the time, he was working as an Uber driver, and he had three passengers in the car. He was waiting to make a left-hand turn at an intersection and had stopped to give way to a bus when his vehicle was hit from behind by another car. 

2. Following the accident, his car was driveable, however it required some repair, but this had been managed by the owner given it was a hire car. There was no airbag deployment. Police and ambulance did not attend the accident. 

3. In contrast to the history obtained by the original assessor, Mr Toor indicated there had been no immediate pain although it "felt like a big hit." He said that although he had been pushed forward with the impact, he had his seatbelt on, so he had not struck anything inside the vehicle. However, by the following morning, there was low back pain and a numb sensation in the low back. He said since then, the pain had been "moving around" in the low back area, sometimes referring into his left leg, but never into the right leg.

4. He consulted GP, Dr Farhan the day after the accident, and was referred to Dr Bassam Moses, Sports Physician, who then recommended physiotherapy treatment.
   Mr Toor had multiple physiotherapy sessions at the NAS Medical Centre.

5. On 1 April 2021 he was referred to Dr Andrew Kam, neurosurgeon, whom he visited on
   27 April 2021. Dr Kam recommended L4/L5 epidural block. The first procedure was performed 5 May 2021 and the second, 30 July 2021. Unfortunately, the pain relief provided by the steroid injection only lasted several weeks. 

6. On specific questioning, Mr Toor maintained that the right shoulder symptoms commenced a few days after the accident, and he indicated the anterior aspect of his right shoulder as the area where the pain was first felt. He said he was unsure as to the reason for the pain, although he felt it might have related to the fact that he had to sleep on his right side as he was having trouble lying flat or lying prone due to his back pain. I questioned whether perhaps the seatbelt may have been a cause, but he was not sure.

7. Mr Toor has persisting pain and stiffness in his lower back and intermittent left leg pain. There is anterior right shoulder discomfort. He complaints of stiffness in the middle of his back.

Current treatment

1. Mr Toor takes Lyrica 150 mg twice daily and Diclofenac or Naproxen as required. He takes Telmisartan for hypertension.  He applies heat packs as required.  There was no other current treatment. 

2. When asked specifically about the recommended ultrasound kidneys, ureters, and bladder recommended by his GP, he said he had not had the investigations done. He thought the request had come about as he had pain in his left loin region for several days, but this has since totally resolved.

3. Since his arrival in Adelaide, he has received no other treatment for his injuries.

Physical examination

1. Mr Toor was right-handed.  He was 180 cm tall and weighed 101 kg.  He had a normal gait.  He could walk on heels and toes.

2. On examination of the cervical spine, there was full normal range of movements in all planes. There was no asymmetry, muscle spasm or guarding.

3. On examination of the upper limbs, there was normal power, sensation, and reflexes.  On examination of both shoulders, there was tenderness over the anterior aspect of the right shoulder. 

4. Shoulder movements were as follows:

Shoulder Movements	Active ROM Measured RIGHT	Active ROM Measured LEFT
Flexion	150 °/130 °	180 °
Extension	60 °/ 50 °	50 °
Internal Rotation	40 °/ 80 °	80 °
External Rotation	80 °	80 °
Abduction	120 °/ 115 °	180 °
Adduction	50 °	50 °

1. On examination of the lower back, there was tenderness over the lower lumbar vertebrae centrally.  There was also tenderness over the left lateral facets.  Flex/extension was half normal, rotation half normal and lateral flexion one-third normal bilaterally.  He reported some sharp pain when he returned to the erect position after forward flexion. Straight leg raise was 70 degrees bilaterally.  Neural tension signs were negative.  There was normal power, sensation, and reflexes in the lower limbs.  Circumferential measurements were equivalent, therefore, there was no muscle wasting.

2. On examination of the lower limbs, Trendelenburg sign was negative bilaterally. There was tenderness over the left sacroiliac joint. There was no specific tenderness over the hip joints.

3. Hip movements were as follows:

Hip movements	Right	Left
Flexion	130 °	130 °
Internal Rotation	30 °	30 °
External Rotation	40 °	40 °
Abduction	30 °	30 °
Adduction	25 °	25 °

1. Medical Assessor Gibson asked Mr Toor about the comment of the original assessor as to the presence of mild tenderness over the right sacroiliac joint (SIJ), but he maintained that his symptoms had always been on the left.

SUMMARY AND CONCLUSIONS

Threshold injury

1. Mr Toor is a 37 year-old-man, who was involved in the accident on 6 March 2021.

2. There was history of a work-related injury in late October 2017, when Mr Toor had fallen over a box at work. At that stage, his GP, Dr Mohiuddin had recorded left SI joint tenderness and reduced left hip movements. Plain X-ray imaging on 31 October 2017 showed mild L5/S1 degeneration. The back pain had resolved by 5 November 2017.  

3. On 6 February 2018 Dr Virk reported pain over the right gluteal region and tenderness of the hip and thigh although the pain resolved by 1 March 2018. On 5 September 2020 Dr Farhan recorded chronic low back pain radiating to the bilateral hips. Mr Toor had a CT scan of the lumbar spine on 8 September 2020 and on 5 December 2020 Dr Farhan reported worsening back pain. This was consistent with the history provided by Mr Toor of low back pain leading up to the accident, although over time this symptom had been intermittent. 

4. At the time of the clinical examination by Medical Assessor Gibson, there was local tenderness over the lower lumbar levels, both centrally and extending laterally to the left and over the left SI joint.  There was no radiculopathy.  There were no radicular complaints. 

Right shoulder

1. In relation to the right shoulder, the Panel was not convinced Mr Toor had sustained a non-threshold injury to his right shoulder as a result of the accident. Had there been an acute tendon injury to the right shoulder, symptoms would have been apparent much sooner after the accident. The history provided by Mr Toor was of a gradual onset of symptoms, which he himself attributed to his altered sleep pattern, and there was an absence of any immediate or specific right shoulder symptoms.

2. The Panel notes Dr Farhan saw Mr Toor on several occasions after the accident with no mention of any specific right shoulder condition until right scapular pain was recorded on
   30 April 2021. Furthermore, the pain recorded by Dr Farhan was in an entirely different distribution to the pain described at the time of the examination by Medical Assessor Gibson.

3. The Step-by-step physiotherapist, Mr Zhuang treated Mr Toor on a number of occasions but the first complaint relating to the development of right shoulder pain was not recorded until 20 May 2021.

4. Mr Toor consulted Dr Moses on 1 April 2021 when he only reported complaints of ongoing lower back pain with radicular features and on 27 April 2021 Dr Kam only referred to back issues. On 17 May 2021 Dr Moses recorded a three week history of right shoulder pain, but was of the opinion that the pain and imaging finds were “difficult to relate back to the accident”.

5. The imaging of the right shoulder was performed two months after the accident on
   12 May 2021.  The Panel were of the opinion that the “small partial thickness intrasubstance tear of subscapularis” disclosed on the ultrasound was an incidental finding. The Panel is not satisfied the tear is traumatic in origin or causally related to the accident.

6. There is no evidence of bruising or complaint to substantiate a seat belt injury as causative of the small partial thickness intrasubstance tear of the subscapularis and notwithstanding the opinion of Dr Moses the Panel is not satisfied the tear could have resulted from the claimant’s altered sleeping position.

7. The Panel finds the claimant did not sustain injury to the right shoulder caused by the accident. Had there been an acute (sudden and severe) injury to the shoulder causing a tear to the subscapularis, the symptoms would have been present soon after the traumatic event.

Lumbar spine

1. The CT scan of the lumbar spine of 11 March 2021 concluded there was no significant interval change since the earlier CT scan on 8 September 2020.

2. Whilst the Panel notes the pre-accident history of low back pain including tenderness of the left SIJ in October 2017 and pain radiating to both hips in September 2020 the Panel notes the consistency of complaint following the accident. Whilst there is no evidence of a direct injury to the SIJ, the Panel accepts the claimant sustained a soft tissue injury to the lumbar spine aggravating pre-existing pathology with pain radiating to the SIJ.

3. Whilst the Panel notes Mr Toor complained of lumbar pain there is no evidence that two or more of the clinical signs of radiculopathy as required by cl 5.9 of the Guidelines existed to satisfy the diagnosis of radiculopathy of Dr Farhan or at the time of examination by Medical Assessor Gibson. 

4. In relation to the lumbar spine, there was no imaging evidence that would suggest there had been a non-threshold injury to the lumbar spine and there was no radiculopathy on physical examination. 

5. In the absence of two signs of radiculopathy the Panel finds the claimant sustained a soft tissue injury to the lumbar spine with pain radiating to the SIJ caused by the accident which is a threshold injury.

Left hip/pelvis

1. Medical Assessor Gibson reported the left hip and pelvis were normal to examination. Whilst there was tenderness over the left SIJ joint there was no specific tenderness over the hip joint.  Medical Assessor Gibson reported Mr Toor walked normally, did not complain of flank pain but of slightly left sided lumbar spine pain.

2. There is no imaging to support injury to the left hip or pelvis.

3. The Panel does not find any evidence of injury to the left hip or pelvis but accepts the claimant may experience SIJ joint symptoms secondary to his lumbar spine condition.

Right hip/pelvis

1. Medical Assessor Gibson reported the right hip and pelvis were normal to examination with no specific tenderness over the hip joint.

2. There is little complaint by Mr Toor since the accident pertaining to the right hip or pelvis and no imaging to support injury to the right hip or pelvis.

3. The Panel finds the claimant did not sustain injury to the right hip or pelvis caused by the accident.  

Treatment dispute

1. In dispute is a proposed KUB ultrasound. There was no evidence of any injury to the kidneys, ureter or bladder.

2. Mr Toor had explained he understood these investigations were suggested by GP due to the presence of a temporary loin pain, which subsequently resolved over several days.

3. The Panel is not satisfied Mr Toor sustained injury to the kidney, ureter or bladder caused by the accident and finds that the proposed KUB ultrasound is neither reasonable nor necessary and did not relate to injury resulting from the accident.

4. There is also a treatment dispute in respect of an MRI of the left hip/pelvis.

5. Notwithstanding some tenderness over the left SIJ joint there was no tenderness over the left hip joint, and it was otherwise normal on clinical examination.

6. The Panel also notes neither Dr Moses nor Dr Kam recommended Mr Toor undergo imaging of his left hip or pelvis.

7. The Panel does not consider the MRI investigation of the left hip/pelvis to be reasonable and necessary in the circumstances, noting the normal examination and the full active range of movement displayed on examination.

8. Where the Panel concludes the claimant did not sustain injury to the left hip/pelvis in the accident the Panel finds the proposed MRI does not relate to the injury caused by the accident. 

PANEL FINDINGS

1. The Panel determines the following injury caused by the accident is a threshold injury:

   ·        lumbar spine – soft tissue injury with pain radiating to the sacroiliac joint.

2. The Panel determines the following injuries were not caused by the accident:

   ·        right shoulder – small partial thickness intrasubstance tear of subscapularis;

   ·        left hip/pelvis – soft tissue injury, and

   ·        right hip/pelvis – soft tissue injury.

3. The following treatment and care does not relate to the injury caused by the motor accident:

   ·        the proposed KUB ultrasound, and

   ·        the proposed MRI of the left hip/pelvis.

4. The following treatment and care is not reasonable and necessary in the circumstances:

   ·        the proposed KUB ultrasound, and

   ·        the proposed MRI of the left hip/pelvis.