Villanueva v Lifetime Care and Support Authority of New South Wales

DETERMINATION OF REVIEW PANEL
CITATION:	Villanueva v Lifetime Care and Support Authority of New South Wales [2025] NSWPICMP 855
CLAIMANT:	Mauricia Villanueva
INSURER:	Lifetime Care and Support Authority (CTP Care)
REVIEW PANEL
SENIOR MEMBER:	Susan McTegg
MEDICAL ASSESSOR:	Margaret Gibson
MEDICAL ASSESSOR:	Dawn Piebenga
DATE OF DECISION:	5 November 2025
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accidents Compensation Act 1999; treatment and care dispute; domestic assistance; claimant sustained injury in a motor vehicle accident arising out of a carjacking; injury to hip, shoulders, arms, elbows, hands, neck, L4 compression fracture with kyphotic deformity, chest, pelvis, lower limbs, and psychological injury; domestic assistance provided by sister and paid by claimant; Review Panel certified domestic assistance of eight hours per week was reasonable and necessary and related to the injury caused by the accident; application by claimant for increase in care from 8 hours per week to 12 hours per week; review of certificate of Medical Assessor (MA) who certified an increase in hours of domestic assistance from 8 hours to 12 hours per week related to the injury caused by the accident but was not reasonable and necessary in the circumstances; Held – notwithstanding structural progression in vertebral pathology no evidence of functional deterioration; certificate of MA confirmed.
DETERMINATIONS MADE:	ASSESSMENT OF TREATMENT AND CARE Certificate issued under s 7.23(1) of the MotorAccident Injuries Act 2017 1. The Review Panel affirms the certificate of Medical Assessor Castle-Burton dated 13 March 2025.

STATEMENT OF REASONS

BACKGROUND

Ms Mauricia Villanueva (the claimant) was injured in a horrific carjacking on
6 November 2018.
Ms Villanueva sustained multiple injuries including to her head, shoulders, arms, elbows, hands, neck, back, chest, hips, pelvis and lower limbs. She also sustained psychological injury.
At the date of the accident Ms Villanueva was 65 years of age. She is now 71 years of age.
On 4 September 2019 Ms Villanueva lodged an Application for personal injury benefits seeking statutory benefits in respect of injury sustained in the accident.
Until 6 November 2023 Insurance Australia Limited trading as NRMA Insurance (the insurer) was the relevant insurer with liability to pay statutory benefits to Ms Villanueva under the Motor Accident Injuries Act 2017 (the MAI Act). However, in accordance with s 3.2(3) of the MAI Act the relevant insurer is now the Lifetime Care and Support Authority through CTP Care.
On 12 March 2020 the insurer accepted liability for statutory benefits after 26 weeks.
On 31 May 2022 the insurer declined the claimant’s request for reimbursement for domestic services provided by Concepcion Villanueva and Lourdes Tibig, the claimant’s sisters. On
8 June 2022 the claimant requested an internal review of that decision.
On 23 June 2022 the insurer issued a Certificate of Determination – Internal Review affirming the decision dated 31 May 2022 to decline the request for reimbursement of domestic services from Concepcion Villanueva and Lourdes Tibig.[1]
On 27 July 2022 the claimant filed an application with the Personal Injury Commission (Commission) seeking a medical assessment to resolve the treatment and care dispute between the parties. That dispute was referred to Medical Assessor Farhan Shahzad.
Pursuant to Schedule 2, cl 2 of the MAI Act, various matters are declared to be medical assessment matters, including (b) “whether any treatment and care provided or to be provided to the injured person is reasonable and necessary in the circumstances or related to the injury caused by the motor accident for the purposes of section 3.24”.
A medical assessment matter is determined in accordance with Division 7.5 of the MAI Act by a Medical Assessor.[2]

TREATMENT AND CARE – STATUTORY PROVISIONS

[1] Insurer’s documents p 20.

[2] Section 7.20 of the MAI Act.

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.
(d) there will be a need for the services to be provided for those hours per week and that consecutive period of time and that need is reasonable in all the circumstances.”

DOCUMENTS BEFORE THE REVIEW PANEL

The Review Panel (the Panel) issued a Direction to the parties on 26 May 2025. The Panel noted on 18 April 2025 the claimant uploaded to the portal a bundle of documents paginated from page 1 to 72 (claimant’s documents).
The insurer was directed to upload a bundle of all documents relied upon by the insurer in the review by 16 June 2025. On 16 June 2025 the insurer uploaded a bundle of documents paginated from page 1 to 227 (insurer’s documents).
On 14 July 2025 the claimant uploaded to the portal an Application to Lodge Additional Documents (ALAD) with the following additional documents:
·        statement from the claimant dated 20 May 2025;
·        statement from the claimant dated 13 July 2025;
·        statement from the claimant dated 14 July 2025, and
·        certificate from Dr Nathan Hartin dated 17 May 2025.
Noting the claimant is self-represented and where the documents sought to be relied upon are relevant to the issues in dispute between the parties the Panel has admitted these documents into evidence.
On 17 October 2025 the claimant uploaded a letter seeking to rely upon further information she forgot to mention at the time of the assessment by Medical Assessor Piebenga on 22 September 2025. The Panel refuses the claimant leave to rely upon this letter where it would be procedurally unfair to CTP Care and where it was not served more than 14 days before the medical assessment in accordance with Rule 67C of the Personal Injury Commission Rules 2021.

DISPUTE WITH INSURANCE AUSTRALIA LIMITED TRADING AS NRMA INSURANCE

Certificate of Medical Assessor Shahzad

On 27 July 2022 the claimant filed an application with the Commission seeking a medical assessment to resolve the treatment and care dispute between the parties.
That dispute was referred to Medical Assessor Farhan Shahzad.
In a certificate dated 18 July 2023 Medical Assessor Shahzad certified the request for payment or reimbursement for domestic services relates to the injury caused by the accident and is reasonable and necessary in the circumstances.

Certificate of the First Review Panel dated 7 February 2024

The insurer lodged an application for review of the certificate of Medical Assessor Shahzad which was referred to a Review Panel comprised of Member Susan McTegg, Medical Assessor Dawn Piebenga and Medical Assessor Margaret Gibson (the First Review Panel).[3]
[3] Insurer’s documents p 120.
The First Review Panel was of the view Medical Assessor Shahzad conflated the medical assessment dispute and a merit review dispute. Under Schedule 2, cl 1 of the MAI Act a dispute about whether the cost of treatment and care provided or to be provided to the claimant is reasonable for the purposes of s 3.24(1) of the MAI Act is a merit review matter.
The dispute about the cost of the treatment and care was referred to Merit Reviewer Cassidy who issued a certificate dated 8 May 2024.
In a certificate dated 7 February 2024 the First Review Panel revoked the certificate of Medical Assessor Farhan Shahzad dated 18 July 2023 and issued a new certificate certifying as follows:
· the need for domestic assistance for eight hours per week from the date of accident to 6 November 2023 is reasonable and necessary in the circumstances, and
· the need for domestic assistance for eight hours per week from the date of accident to 6 November 2023 is caused by the accident.
The First Review Panel limited the dispute for treatment, namely domestic assistance to
6 November 2023 where it would be procedurally unfair to CTP Care to make a determination after that date where CTP Care was not on notice of the dispute, had not been joined to the proceedings or given the opportunity to be heard.
The First Review Panel reported pre-accident the claimant and her sister completed some domestic tasks independently such as shopping, laundry, cooking, bed making and cleaning their own bathrooms/bedrooms. They also shared responsibility for cleaning communal areas for example, vacuuming and mopping.
The First Review Panel concluded as follows:
“137. The medical evidence concludes that Ms Villanueva has marked osteoporosis in the lumbar spine and that the healed crush fracture of the L4 vertebra caused by the accident has resulted in a kyphosis deformity. Whilst it is likely the pre-existing osteoporosis contributed to the fracture and the degree of collapse and compression Ms Villanueva claims she could stand straight and that she was able to self-care and attend to domestic tasks independently prior to the accident. Her ability to perform tasks that involve prolonged standing, walking unaided, unilateral and bilateral lifting and carrying, reaching above shoulder height and reaching below knee height are all limited. She has not returned to driving and therefore community access is also limited.
138. Ms Villanueva continues to undertake self-care activities independently, albeit at a reduced frequency and providing she can pace herself.
139. She relies on her sister(s) to perform all the cooking and domestic duties including but not limited to, cleaning, laundry, and shopping.”
The First Review Panel found that the following domestic assistance was reasonable and necessary in the circumstances:
(a)     meal preparation 20 minutes per day or 2.3 hours per week;
(b)     dishes 10 mins per day or 1.17 hours per week;
(c)     stripping and changing bedding 20 mins fortnight = 10 mins per week or 0.17 hours per week;
(d)     laundry 2 loads at 20 mins per load = 40 mins/week or 0.67 hours per week;
(e)     vacuuming 30 mins/week or 0.5 hours per week;
(f)      sweeping and mopping 40 mins/week or 0.67 hours per week;
(g)     heavy cleaning bathrooms - 30 mins/week or 0.5 hours per week;
(h)     rubbish management 10 mins/week or 0.17 hours per week, and
(i)     shopping 45 mins/week or 0.75 hours per week.
The First Review Panel also considered one hour per week (on average) for community access was reasonable and necessary.

DISPUTE WITH CTP CARE

On 17 May 2024 CTP Care approved domestic assistance for eight hours per week at $35 per hour from 22 March 2024 to 21 March 2025.[4]
[4] Insurer’s documents p 29.
On 31 May 2024 CTP Care refused to approve domestic assistance at a rate of $60 per hour. A dispute concerning the cost of care was referred to Merit Reviewer Cassidy and is not a dispute for consideration by this Panel.
On 5 June 2024 Ms Villanueva sought an internal review. She requested an increase in domestic assistance from 8 to 12 hours per week.
CTP Care issued an Internal Review Certificate dated 19 June 2024 declining to approve an increase from 8 hours to 12 hours per week of domestic assistance.[5]
Ms Villanueva filed an application in the Commission for determination of that dispute. The dispute was referred to Medical Assessor Kenna.

Certificate of Medical Assessor Kenna

Medical Assessor Kenna issued a certificate dated 5 December 2024 in which he certified that he was unsure if the request for an increase in hours from 8 hours per week to 12 hours per week related to the injury and whether it was reasonable and necessary in the circumstances.[6] Medical Assessor Kenna recommended that the claimant be independently assessed by an occupational therapist.
Thereafter, the dispute was referred to Medical Assessor Castle-Burton.
[5] Insurer’s documents p 37.
[6] Insurer’s documents p 184.

CERTIFICATE UNDER REVIEW OF MEDICAL ASSESSOR CASTLE-BURTON

In a certificate dated 13 March 2025 Medical Assessor Castle-Burton certified as follows,
The following treatment and care:
· the request for total hours of domestic care (provided by Concepcion Villanueva) to be increased from 8 hours per week to 12 hours per week is not reasonable and necessary under the circumstances, and
· the request for total hours of domestic care (provided by Concepcion Villanueva) relates to the injury caused.[7]

[7] Insurer’s documents p 196.

The following treatment disputes were referred to Medical Assessor Castle-Burton for assessment:
· whether the request for total hours of domestic care (provided by Concepcion Villanueva) to be increased from 8 hours per week to 12 hours per week is reasonable and necessary under the circumstances, and
· whether the request for total hours of domestic care (provided by Concepcion Villanueva) to be increased from 8 hours per week to 12 hours per week relates to the injury caused by the accident.
Medical Assessor Castle-Burton reported Ms Villanueva submitted she experienced chronic excruciating back pain which was worsening and deteriorating. She relied upon a report of
Dr Hartin dated 23 May 2023 and an MRI report of 13 June 2023 which stated the L4 vertebral fracture with compression is greater than 70%, where it was only said to be 50% at the time of scans on 6 November 2018.
Medical Assessor Castle-Burton assessed Ms Villanueva in the home she now shares with her sister Concepcion at Westmead on 27 February 2025 whilst the assessment undertaken by Medical Assessor Piebenga and the occupational therapy assessment undertaken on
21 August 2023 took place in the claimant’s previous home in Woodcroft.
Medical Assessor Castle-Burton reported the claimant’s functional presentation was essentially the same as that described in the Panel’s certificate of 7 February 2024, and in the report of the occupational therapist in the Initial Needs Assessment of the
24 August 2023. She concluded there was no physical change representing functional deterioration to warrant an increase from 8 to 12 hour per week. Her assessment of the claimant’s reasonable and necessary care was eight hours per week for meal preparation, cleaning bathroom, vacuuming, cleaning of common areas, mopping floors, laundry, sheet changes, shopping and community access/transportation.

REVIEW PROCEDURE

The claimant lodged an application for review of the medical assessment of Medical Assessor Castle-Burton on 22 April 2025 within 30 days of the date on which the certificate of Medical Assessor Castle-Burton was made available to the parties.
On 20 May 2025 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).
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.[8]
[8] Rule 128 of the PIC Rules.
The review is by way of a new assessment of all matters with which the medical assessment is concerned. However, the insurer having conceded that the treatment and care did relate to the injury resulting from the accident the Panel is only required to determine if the treatment and care was reasonable and necessary in the circumstances.

THE EVIDENCE CONSIDERED BY THE PANEL

Statement of Ms Villanueva

Ms Villanueva provided a statement dated 27 March 2025 in support of the application for review. She also provided letters dated 20 May 2025 and 13 July 2025 which incorporates both evidence and submissions.
She stated objective evidence of her deteriorating condition is provided by the MRI of her lumbar spine dated 13 June 2023 which shows > 70% compression at L4 whereas the MRI of 6 November 2018 only showed > 50% compression at L4.
Ms Villanueva stated the MRI of 15 March 2025 shows that the L4 vertebra is now contacting the L4/L5 nerve root which is causing her non-stop excruciating pain which is making moving very hard.
She reports experiencing more severe and intense excruciating pain which has meant not only could she not sleep but she could not get up from bed. Ms Villanueva states her medication namely Pregabalin has increased from 25mg to 75mg twice a day.
Ms Villanueva states before the injury she cooked her own Filipino meals, she cleaned her own home, she washed her dishes, she washed her clothes and did her laundry, she did her own grocery shopping and she watered her plants. She states before the accident her sister Concepcion did not perform domestic duties for her. In particular Ms Villanueva stresses
Medical Assessor Castle-Burton did not take into account the time required to cook Filipino hot meals, which Ms Villanueva states is one hour per meal or a total of three hours per day.
Ms Villanueva states the intense and chronic excruciating pain she experiences means she is unable to perform even the most basic personal care without assistance, for example getting dressed, taking off clothes, putting on and taking off shoes and socks, toileting, showering, washing her back and lower extremities. She states she cannot bend, stretch out or twist her body, pick up things accidentally dropped on the floor, take her BP, prepare a hot milk drink, a hot water drink, or a hot water bottle for constipation and other basic domestic care.
Ms Villanueva states she cannot sleep because of the intensity of the pain and nor can she get up from her bed because of the pain. As a result Dr Ong, the claimant’s general practitioner prescribed an additional pain killer Lyrica Pregabalin 25mg which has since been increased to 75mg.
Ms Villanueva describes pre-injury recreational and social activities she enjoyed and participated in and which she can no longer enjoy.

Statement of Concepcion Villanueva

Ms Concepcion Villanueva provided a statement dated 19 March 2025 in which she describes providing physical and psychological care to the claimant in addition to care and domestic services. She states she gives the claimant fluids to help combat constipation, she listens to the claimant’s stories to fulfil her psychological needs, she consoles and comforts the claimant and provides her with a warm milk drink. She reported providing the claimant with personal hygiene including washing, brushing and cleaning the claimant’s back and lower extremities. She helps the claimant put on her panties, pants and socks. She also described assisting the claimant when she feels heart burn, shortness of breath, difficulty in breathing, dizziness and fatigue.
Ms Concepcion Villanueva states she provides domestic assistance of 23 hours per week for the following:
·        cooking – 1.5 hours per day or 10.5 hours per week;
·        washing up dishes and pots - 3.5 hours per week;
·        washing utensils – 1.75 hours per week;
·        vacuuming/dusting - .5 hours per week;
·        mopping - .5 hours per week;
·        laundry – 1.5 hours per week;
·        bed making/changing - .5 hours per week;
·        bins and rubbish management - .25 hours per week;
·        grocery shopping – 1 hour per week;
·        bathroom cleaning - .5 hours per week;
·        GP waiting time and travel – 1 hour per week;
·        taking BP (blood pressure) - .5 hours per week;
·        support and listening during panic attacks or nightmares - .5 hours per week, and
·        personal care - .5 hours per week.

A daily diary has been provided showing the meals cooked each day and domestic services rendered for the period 7 November 2024 to 21 March 2025.
Whilst it is asserted domestic assistance and care has been provided for 23 hours per week the claim made is for 12 hours per week.

Treating medical evidence

On 18 February 2025 Dr Ong issued a certificate in which she reported the main complaints were:
·        chronic excruciating back pain;
·        unable to get up from bed due to intense/or severe back pain, and
·        her back pain injury is worsening and or deteriorating.[9]
[9] Claimant’s documents p 69.
Dr Ong stated the claimant required 12 hours per week of domestic and nursing care assistance.

Dr Sean Suttor, orthopaedic specialist

On 18 December 2019 Dr Suttor reported Ms Villanueva had marked osteoporosis in the lumbar spine.[10] He also noted the trauma caused a fracture which resulted in her coronal and sagittal imbalance. He concluded given the marked osteoporosis he did not think any surgical intervention was likely to succeed in correcting her deformity.
[10] Insurer’s documents p 51.
In a report dated 3 February 2020 Dr Suttor stated the healed crush fracture of the L4 vertebra with resulting kyphosis deformity and positive sagittal balance was related to the accident.[11] He also concluded the pre-existing osteoporosis contributed to the fracture and the degree of collapse and compression. Dr Suttor reported Ms Villanueva was able to self-care but would have limitation of domestic duties as they relate to physical activities due to her lower back pain and inability to stand for extended periods.
[11] Insurer’s documents p 52.

Dr Nathan Hartin, orthopaedic specialist

On 17 November 2020 Dr Nathan Hartin reported spinal deformity radiographs performed on 16 September 2020 demonstrated compression fracture at L4 where there is significant local kyphotic deformity creating a trajectory to significant positive sagittal balance. He agreed with Dr Suttor that surgery would be inadvisable given the claimant’s significant osteoporosis. He stated surgical correction would require a spinal osteotomy through the L4 level and instrumentation extending from L2 to the pelvis. He considered the high risk of instrumentation failure and the risk of the surgery itself meant the risks of surgery would outweigh any potential benefits. He described her injury as disabling.[12]
[12] Insurer’s documents p 85.
On 4 March 2025 Dr Hartin reported Ms Villanueva’s low back pain had deteriorated and was accompanied by paraesthesia extending down the lower extremities in a non-dermatomal distribution.[13] He noted generalised deconditioning about the lower extremities. He noted knee reflexes were symmetric and ankle reflexes absent.
[13] Claimant’s documents p 67.
On 25 March 2025 Dr Hartin reported the dominant symptoms are those of axial back pain.[14] He considered fusion contra-indicated given severe osteoporosis. He stated the low back pain relating to the kyphotic deformity and spinal imbalance was not easily remediable.
[14] Claimant’s documents p 68.
On 23 May 2023 Dr Hartin reported Ms Villanueva felt her lumbosacral kyphotic deformity had been deteriorating over time.[15] He reported there was no radicular pain into the lower extremities and no neurologic features. He reported Ms Villanueva had difficulty standing erect and had a fixed kyphosis at the thoracolumbar junction. Dr Hartin ordered updated investigations.
[15] Claimant’s documents p 65.
On 12 June 2023 Dr Hartin reviewed the updated imaging.[16] He noted Ms Villanueva had severe lumbar kyphosis relating to an L4 fracture affecting her ability to stand erect and her daily activity tolerance. He encouraged Ms Villanueva to remain active within the limitations of her symptoms. He noted her persistent symptoms related to the lumbar deformity, positive sagittal balance, the inability to stand erect and impaired activity tolerance.
[16] Claimant’s documents p 66.
Dr Hartin provided a certificate dated 17 May 2025 in which he stated:
“Ms Villanueva has an L4 malunion and significant kyphotic deformity. This causes severe back pain and severe activity limitation. It would be reasonable for Ms Villanueva to be provided with 12 hours per week of domestic and personal care assistance.”[17]
[17] ALAD p 24.

Rehabilitation Services assessment of Patrick Callaghan, 24 August 2023

Mr Callaghan undertook an activity of daily living assessment on 11 August 2023 at the claimant’s then home at Woodcroft.[18]
[18] Insurer’s documents p 91.
Ms Villanueva reported experiencing a mild worsening in symptoms over the last 12-month period noting an MRI scan in June 2023 indicated a worsening in wedge compression. She also reported ongoing psychological symptoms including low mood, anxiety and reduced volition for self-care, productivity and leisure tasks. She was engaged in fortnightly psychology treatment via telehealth.
Ms Villanueva lived with her retired sister Concepcion who is her primary caregiver. He reported she was living in a two-storey home with three bedrooms upstairs, a study/bathroom downstairs, two bathrooms, and tile flooring.
Mr Callaghan reported Ms Villanueva had some limitations but was independent in dressing, grooming, bathing/showering and toileting. Again, subject to limitations he reported she was independent in toilet transfer and chair/bed transfers. He reported Ms Villanueva mobilised using two walking sticks although she reported her mobility tolerance had worsened over the preceding 12 months due to an increase in pain in her lower back and lower limbs. She could walk approximately 50m in total but had difficulty ascending or descending stairs, stating she only utilised the internal staircase approximately twice a year.
It was noted Ms Villanueva did not have the functional capacity and relied on her sister for the preparation of all meals, for cleaning of the bathrooms and kitchen on a weekly basis, for vacuuming and mopping, for laundry and shopping.
Mr Callaghan recommended the continuation of domestic assistance currently provided by Concepcion. He anticipated she provided a minimum of eight hours of care per week for
Ms Villanueva.

Imaging

MRI lumbosacral spine, 21 November 2019 – the reported concludes:
“1. Wedge compression fracture L4 – no acute signs.
2. Right L45 paracentral herniation contracting right L5 nerve root and associated severe right foraminal stenosis.
3. Central L1/2 herniation with annular tear, no stenosis.”[19]
[19] Claimant’s documents p 53.
X-ray lumbosacral spine, 13 December 2019 – the report concludes:
“There is an L4 crush fracture associated with severe loss of anterior vertebral body height. There is grade 1 anterolistheses of L3 on L4 by approximately 5 mm. There is focal lumbar kyphosis centred at L4, as well as a lumbar curvature convex to the left.”[20]
[20] Claimant’s documents p 55.
MRI lumbar spine, 13 June 2023 – the report concludes:
“There is a chronic L4 vertebral crush fracture associated with up to 70 % of anterior loss of vertebral body height with an associated vertebral kyphotic deformity, without evidence of associated cauda equina compression. Multilevel spondylotic changes are as described.”[21]
[21] Claimant’s documents p 56.
EOS – low dose X-ray spine, 13 June 2023 – the report concludes:[22]
[22] Claimant’s documents p 58.
“Findings – The vertebral bodies have been numbered using the standard of nomenclature of seven cervical, twelve thoracic and five lumbar type vertebrae.
Mild broad thoraco-lumbar kyphosis convex to the right. Using the references of the superior endplate of T4 and the inferior end plate of L4, the Cobb angle measures 20 degrees.
Straightening of the normal cervical lordosis and thoracic kyphosis.
Straightening of the normal lumbar lordosis with a focal kyphotic deformity centred on L4.
Superior endplate fracture of the L4 vertebral body with up to 65% loss of vertebral body height anteriorly.
Grade 1 retrolisthesis/retropulsion of the posterosuperior aspect of the L4 vertebral body relative to L3 measuring 3mm.
Vertebral body heights within the remainder of the spine maintained.
Intervertebral disc heights within the cervical spine are maintained.
There is pelvic retroversion:
·Pelvic incidence – 61 degrees.
·Sacral slope – 27 degrees.
·Pelvic tilt – 34 degrees.
Kyphosis L1/S1 – 10 degrees.
Marked positive sagittal balance: SVA measures 182mm.
Positive coronal balance: C7-CSL lies 81 mm to the right of the midline at level of S1.
Overall sagittal spine-pelvic alignment is imbalanced with compensatory mechanisms by pelvic retroversion and knee flexion (13 degrees).
With the patient standing, the right acetabulum lies 3 mm superior relative to the left.”
MRI Whole spine, 17 March 2025 – the report concludes:[23]
·        C6/7 spondylosis and mild to moderate posterior disc bulge;
·        Moderate left C7/T1 foraminal narrowing with possible left C8 nerve root compression;
·        Mild T11/12 and very mild T12/L1 posterior disc bulges. No nerve root contact in the thoracic spine;
·        Multilevel lumbar spondylosis, and
·        L1/2 moderate central posterior disc protrusion and mild spinal canal stenosis, mild L2/3 posterior disc protrusion, marked L4 anterior wedging and possible compression of the right descending L5 nerve root are similar to MRI
10 June 2023.

[23] Claimant’s documents p 62.

X-ray whole spine – EOS, 20 March 2025 – the findings were recorded as follows:
“Longstanding wedging of the body of L4 is again noted with 60 percent loss in height anteriorly, unchanged from previous. As a consequence there is a prominent lower thoracic kyphosis with the spinal column and upper body angled anteriorly by approximately 32 degrees. There is an associated thoracolumbar scoliosis to the left. The Cobb angle measurement of this, measured on the frontal view, is likely to be exaggerated, given the upper body flexion.”[24]

Medico-legal assessments

[24] Claimant’s documents p 63.

Dr Uthum Dias, occupational physician

Dr Dias assessed the claimant and provided a report dated 16 October 2020.[25] He reported she has continued to suffer from debilitating symptoms of lower back pain, stiffness and discomfort and associated pins and needles radiating down both legs. She also suffered from tension headaches, fatigue and psychological comorbidity because of the accident.
[25] Insurer’s documents p 53.
Dr Dias reported Ms Villanueva can undertake self-care activities but has to pace herself.
He reported Ms Villanueva lived with her two older sisters and relies on them to perform all the cooking and domestic cleaning duties at their home. She is also unable to do grocery shopping.
Dr Dias reported Ms Villanueva walked with a stiff antalgic gait pattern relying on a four pronged walking stick. He described “a bent kyphotic posture” and noted she sat throughout the history taking component of the assessment leaning forward indicating significant discomfort in her lumbar spine.
Dr Dias diagnosed an acute closed head injury and soft tissue injuries to the left shoulder, left elbow, right and left hips, both legs and both feet and toes. He also reported:
“Ms Villanueva suffers from chronic severe lower back pain, stiffness and discomfort with an associated chronic right L5 radiculopathy and an associated L3/L4 anterolisthesis (grade 1 – 5mm) secondary to an acute severe L4 crush fracture with a (52% loss of vertebral body height) and secondary significant focal lumbar kyphoscoliosis.”
He reported as a result of her lower back pain Ms Villanueva:
“had to rely on her sisters to perform all the cooking and domestic cleaning duties at their home. … She has also not been able to perform grocery shopping duties on a consistent basis since the subject incident and relies upon her older sisters to perform grocery shopping tasks.”
Dr Dias concluded Ms Villanueva had required approximately eight hours of domestic assistance per week on a regular basis over the previous 23 months and was likely to continue to require approximately seven hours of domestic assistance per week on an indefinite basis.

Dr John Bosanquet, orthopaedic surgeon

Dr Bosanquet assessed the claimant and provided a report dated 29 October 2020.[26] He reported Ms Villanueva lived with her two sisters and was not doing any cooking or cleaning. He reported prior to the accident Ms Villanueva provided her share of domestic duties.
[26] Insurer’s documents p 75.
On examination he reported:
“This revealed a very wasted and frail woman, measuring approximately 150cm and weighing around 45kg. She was flexed to at least 45º and walked slowly. She had a marked kyphosis and a scoliosis to the right. Thus, her lumbar spine movements were restricted. Lying on the couch, her straight leg raise on both sides was to 60º. There was no deficit in her lower limbs and her reflexes were present. She was tender over the L4 spinous process where there was a kyphotic prominence.”
Dr Bosanquet concluded Ms Villanueva’s restrictions were difficulty with prolonged sitting or standing and driving distances. He reported she required assistance with activities of cleaning, shopping, cooking, and washing and would require assistance in the future. He specifically stated she would require assistance with vacuuming, dusting, cleaning the bathroom, washing, and hanging out the washing and noted the assistance would be required for the long term.

Medical Assessments
Medical Assessor Ian Cameron, 3 July 2021

Medical Assessor Cameron assessed the claimant on 22 June 2021 and provided a certificate dated 3 July 2021.[27]
[27] Insurer’s documents p 102.
He concluded soft tissue injury to the toes, feet, legs, left elbow, left shoulder, hips, head, cervical spine, and thoracic spine had resolved.
He assessed 20% whole person impairment (WPI) in respect of the L4 compression fracture of the lumbar spine caused by the accident. He assessed 0% WPI in respect of scarring.

Medical Assessor Doron Samuell, 31 August 2021

Medical Assessor Samuell assessed the claimant on 19 August 2021 and provided a certificate dated 31 August 2021.[28] He certified the claimant had sustained post-traumatic stress disorder caused by the accident resulting in a WPI of 26%.

SUBMISSIONS

[28] Insurer’s documents p 112.

Claimant’s submissions

The claimant provided submission in support of the Application for review.
The claimant submits the Medical Assessment Certificate of Medical Assessor Castle-Burton dated 13 March 2025, is incorrect on the basis of the Medical Assessor’s alleged assertion that the applicant has “no evidence of weakening and deterioration”. Ms Villanueva submits on the contrary, she has objective evidence of weakening and deterioration of her condition, including:
(a)     a comparison of the radiological evidence taken on 6 November 2018, when compared with that of 13 June 2023, demonstrates an increase in the compression of her L4 fracture from 50% to 70%;
(b)     an MRI taken of the applicant’s lumbar spine on 15 March 2025 demonstrates that while there has been a reduction of the compression of the fracture, the fracture is impacting her L4/5 nerve root;
(c)     reports of Dr Nathan Hartin dated 4 March 2025 and 25 March 2025 indicated the applicant has an absence of reflexes of her ankles and toes which she submits are evidence of weaking and deterioration, and
(d)     the applicant’s general practitioner, Dr Julie Ong, has increased her medication to compensate for an increase in pain and therefore further weakening and deterioration.
Ms Villanueva relies upon the certification provided by Dr Ong that she requires 12 hours of domestic assistance and care. Ms Villanueva states the opinion of Dr Ong should be given significant weight where she has been treating the claimant for over three decades, has seen the claimant multiples times and is aware of the claimant’s limitations and impairments.
Ms Villanueva provided further submissions by letter dated 20 May 2025.[29]
[29] ALAD p 2.
She stated objective evidence of her deteriorating condition is provided by the MRI of her lumbar spine dated 13 June 2023 which shows > 70% compression at L4 whereas the MRI of 6 November 2018 only showed > 50% compression at L4.
Ms Villanueva stated the MRI of 15 March 2025 shows that the L4 vertebra is now contacting the L4/5 nerve root which is causing her non-stop excruciating pain which is making moving very hard.
Further submissions dated 14 July 2025 refer not only to the certificate of Dr Ong but also the certificate of Dr Hartin who states it would be reasonable for Ms Villanueva to be provided with 12 hours per week or domestic and personal care assistance. [30]
[30] ALAD p 21.

Insurer’s submissions

CTP Care provided submissions dated 12 July 2024.[31]
[31] Insurer’s documents p 1.
CTP Care notes, in accordance with the prior decision of the Commission, that it does not dispute that the applicant is entitled to the provision of/and reimbursement for attendant care services in accordance with s 3.24(2) of the MAI Act.
CTP Care submits the claimant has failed to provide persuasive evidence which supports a deviation from the determination of the Commission that eight hours of attendance care services was reasonable and necessary.
It is noted that Dr Dias, occupational physician in his report dated 16 October 2020 recommended the claimant would require approximately seven hours of domestic assistance per week on an indefinite basis.
Reference is made to paragraph 106 of the certificate of Merit Reviewer Cassidy where she stated:
“the Review Panel’s examination findings, the documents from the applicant’s sisters and the applicant’s own evidence is that assistance is being provided with cooking, cleaning, laundry, shopping and bedmaking. The applicant was said to be independent in toileting and grooming. The type of care being provided is not nursing care but domestic services.”
CTP Care provided submission dated 9 August 2024.[32] The claimant asserted the deterioration in her condition as evidenced by the MRI scan of 10 June 2023 which demonstrated >70% compression at L4 led to a requirement for assistance with showering, toileting, dressing, picking things up from the floor, heavy lifting and medication management. However, CTP Care notes the Activities of Daily Living Assessment Report dated 24 August 2023 reported she was independent with limitations with respect to dressing, grooming, bathing/showering and toileting.
[32] Insurer’s documents p 7.
Further, CTP Care notes at the time of her assessment by the Review Panel the claimant reported she could shower herself, but she didn’t want to shower. It was also reported the claimant demonstrated independent transfers on and off her couch and mobilising to the toilet. She was also observed to independently transfer on and off the toilet slowly and carefully. The Medical Assessor also reported Ms Villanueva remained independent with personal care.
With respect to meal preparation CTP Care notes Ms Villanueva has submitted that due to the compression fracture of her L4 vertebra her body does not function as well causing her to lose her appetite. To combat this, she only wants to eat freshly cooked hot Filipino meals cooked by her sister and as a result her meal preparation requirements are approximately 10.5 hours per day. However, at the time of the assessment by the Medical Assessor as part of the review it was reported:
“Concepcion has prepared enough food for two people. Ms Villanueva noted that it does not take her sister a lot of extra time as she was preparing her own meals previously. She added ‘we eat the same food’.”
CTP Care disputes there is sufficient evidence to support an increase in domestic care to 12 hours per week.

THE ASSESSMENT

Review of imaging

Medical Assessor Gibson reviewed the imaging and noted some progression in the severity of the spinal condition over time, although she also noted this would be expected in any case as the claimant ages.
On reviewing the reports of the MRI scan of 17 March 2025 in comparison to the
13 June 2023 study, the radiologist comments that the L5 nerve root compression is similar, however there does appear to be a new annular tear at L1/2, as this was not noted on the previous imaging. Comparing the X-rays whole spine 20 June 2023 and 20 March 2025, the radiologist comments that the L4 compression is unchanged, however it has increased in comparison with earlier reports.

The Panel notes both her treating doctors, namely her general practitioner and orthopaedic surgeon have concluded her symptoms and restrictions are increasing over time. Dr Hartin in his statement dated 4 May 2025 states Ms Villanueva’s low back pain had deteriorated and there were absent ankle reflexes. Dr Ong appears also to be of the same view, and
Ms Villanueva’s medication for pain has been increased over time. These practitioners who have consulted the claimant over time have been seeing her over time, were of the view her situation is worsening, and she requires more support.
Medical Assessor Kenna had recommended an occupational therapy report, as the actual number of hours required cannot be assessed based only on medical evidence and whilst the imaging studies and examination findings assist with establishing impairment, the need for domestic assistance is a disability question.

Assessment by Medical Assessor Piebenga

Medical Assessor Piebenga conducted her assessment of Ms Villanueva on 22 September 2025 to determine whether her domestic care needs should be increased from 8 hours to 12 hours per week.
The assessment took place at her residence with her sister Ms Concepcion Villanueva present throughout.

General presentation and home environment

Ms Villanueva presented as a petite 71-year-old woman with chronic pain, evidenced by careful, guarded movements and visible discomfort during positional changes. She was cooperative and provided detailed responses, although she was somewhat repetitive in emphasizing the impact of her injuries.
The current two-storey home is significantly more suitable for her needs than her previous Woodcroft residence. The main level contains her bedroom with ensuite (equipped with shower chair and over-toilet aid), an open-plan kitchen/dining area, and wide tiled corridors. This layout improvement has eliminated the need to climb 15 stairs to access a bathroom, directly improving her showering frequency from "every three months" to one to two times weekly.

Physical presentation and functional capacity

Ms Villanueva demonstrates significant postural abnormalities consistent with her L4 compression fracture: fixed forward flexion of 45°, inability to achieve upright posture, marked thoracolumbar kyphosis, and slight scoliosis.
She ambulates using two walking sticks with slow, deliberate gait, reduced step length, and visible pain behaviours. These findings are identical to observations by Mr Callaghan in August 2023 and Medical Assessor Castle-Burton in March 2025.
Pain assessment revealed severe constant pain (9/10 at rest, 10/10 with movement) at the L4 level, managed with Osteomol 665mg TDS, Pregabalin 25mg BD, and monthly Actonel. Standing tolerance is limited to two to three minutes with support. She cannot bend to pick up items from the floor, carry objects while walking, lift more than 1-2 kg, or reach low cabinets or overhead shelves.
The following photographs show a comparison between Ms Villanueva’s earlier presentation on 9 January 2024 and her recent presentation on 22 September 2025:
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Photos 1 and 2: Photos taken on 9 January 2024 (previous assessment)
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Photos 3 and 4: Photos taken on 22 September 2025 (current assessment)

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Photos 5 and 6: Mobilising with two walking sticks (9 January 2024)

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Photos 7 and 8: Mobilising with two walking sticks (22 September 2025)

Personal care

Ms Villanueva is essentially independent with personal care tasks when using adaptive equipment, though tasks are performed slowly with discomfort. She showers one to two times weekly with occasional assistance from her sister for washing her back and lower legs (cannot reach due to restricted range of motion). She independently manages toileting, dressing (in seated position), and grooming. This represents notable improvement from 2022 when she accessed bathroom "only twice per year" at her previous residence, directly attributable to environmental modifications and appropriate equipment.
[IMAGE UNABLE TO RENDER]
Photos 9 and 10: Independent with toilet transfer using Over Toilet Aid (OTA) on
9 January 2024 and 22 September 2025
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Photos 11 to 13: Independent with seated transfer from couch 9 January 2024 and
22 September 2025 and shower stool on 22 September 2025
Medical Assessor Piebenga considered Ms Villanueva's independence could be further enhanced through provision of a long-handled sponge (for washing back and lower extremities), dressing stick/reacher, and sock aid with long-handled shoehorn. Strategic reorganization of her wardrobe combined with training in compensatory techniques would significantly reduce reliance on caregiver assistance.
While Ms Villanueva demonstrates capacity for independent personal care with adaptive equipment, Medical Assessor Piebenga recognized that incidental assistance may occasionally be required. This includes assistance with occasional transfers when pain levels are elevated, retrieving clothing items from areas outside her accessible range despite wardrobe reorganization, assistance during showering when balance or pain is compromised, and other brief personal care supports that arise intermittently. Such assistance is typically brief (one to two minutes per instance) but occurs sporadically throughout the week. Medical Assessor Piebenga therefore recommended an allocation of 15 minutes per week for incidental personal care assistance, acknowledging that while
Ms Villanueva has established capacity for independence in these areas, the unpredictable nature of chronic pain and her functional limitations may necessitate occasional support.

Domestic tasks

Ms Villanueva's functional limitations have remained remarkably consistent across assessments from June 2022 through September 2025, despite moving to a more accessible home and the passage of nearly three years. While imaging shows progression of vertebral compression (50% in 2019 to 70% in 2023), this structural deterioration has not translated into functional regression. She presents with the same mobility limitations, standing/walking tolerance, and inability to perform domestic tasks as documented since her accident.

Meal preparation, cooking and washing dishes

Pre-accident, Ms Villanueva prepared traditional Filipino meals using fresh ingredients, estimating two hours per day initially, though at reassessment she claimed 21 hours weekly (1 hour × 3 meals × 7 days) and "sometimes up to 5 hours for one meal." Her sister Concepcion separately prepared her own meals while working full-time as a registered nurse.
Currently, Ms Villanueva is completely reliant on her sister for meal preparation. Concepcion stated: "before Mauricia's accident, I would spend 15 to 20 minutes making breakfast and 45 minutes for lunch and dinner, approximately 2 hours a day. Now I cook for both of us but there has been no increase in the time it takes me to cook for one person or two." Medical Assessor Piebenga observed Concepcion preparing a traditional Filipino lunch with fresh protein and vegetables. Regarding dishes, Ms Villanueva claimed it takes 45 minutes per meal, though Concepcion acknowledged being "a clean freak" who can take "over an hour to wash a small number of dishes."
While Ms Villanueva can access the kitchen and refrigerator using walking sticks, she cannot remove items safely or carry anything back to her seat. Her functional limitations (inability to stand >2-3 minutes, carry objects while using sticks, reach low/high shelves) create genuine barriers to meal preparation.
Medical Assessor Piebenga concurred with Medical Assessor Castle-Burton's allocation of 30 minutes daily (3.5 hours weekly) for meal preparation and dishes. The critical principle is that reasonable and necessary care refers to additional time taken, not total time spent. Concepcion was cooking her own Filipino meals pre-accident and continues to do so. The additional time of approximately 10 minutes per meal appropriately captures incremental time to prepare one extra portion (particularly when using rice cooker and slow cooker allowing task co-mingling), plate and deliver meals, complete additional washing up, and provide fetch/carry assistance throughout the day.

Shopping

Pre-accident, Ms Villanueva drove independently to West Point Shopping Centre weekly, managing all physical aspects independently. Concepcion shopped for herself four times weekly (twice to fruit shop in Wentworthville, twice to Westmead Woolworths/Coles), spending 15-20 minutes in store plus driving time.
Ms Villanueva is now completely reliant on her sister for shopping. However, Concepcion continues shopping four times weekly as she did pre-accident. The frequency and duration remain unchanged.
Medical Assessor Piebenga agreed with Medical Assessor Castle-Burton's allocation of 45 minutes weekly. The critical factor is identifying incremental additional time directly attributable to Ms Villanueva's injury, not total shopping time. Concepcion's shopping frequency is unchanged. There is no extra travel time, parking, or trolley management time. Based on Concepcion's own estimate of 15-20 minutes per shop, the incremental time to select items for a second person is realistically less than 10 minutes per trip. Across four shopping trips weekly, this represents approximately 30-40 minutes additional time. The allocation of 45 minutes weekly generously captures the reasonable additional time to shop for two rather than one, accounting for item selection, checkout processing, and unpacking.

Cleaning tasks

Pre-accident, Ms Villanueva and Concepcion shared cleaning responsibilities equally.
Ms Villanueva claimed she completed: light cleaning 10 minutes daily (70 minutes weekly), vacuuming weekly (30 minutes), sweeping/mopping weekly (40 minutes), her own bathroom cleaning weekly (20 minutes each), alternating shared bathroom fortnightly (20 minutes).
Ms Villanueva now relies entirely on her sister for all cleaning. However, Concepcion described herself as "a clean freak" who chooses to clean frequently and meticulously, admitting to cleaning two unused upstairs bathrooms and vacuuming unused upstairs areas twice weekly, "to keep busy." Medical Assessor Piebenga’s observations confirmed the home was immaculately clean and well organized, consistent with the observations of both
Mr Callaghan in 2023 and Medical Assessor Castle-Burton in 2025.
Medical Assessor Piebenga concurred with Medical Assessor Castle-Burton's allocation of 70 minutes weekly (20 minutes vacuuming/general tidying, 20 minutes bathroom cleaning, 30 minutes mopping), recognizing the need to differentiate between reasonable and necessary care and tasks undertaken by choice. It is not reasonable to fund cleaning of unused bathrooms or areas not accessed by either resident. The care reasonably required relates to Ms Villanueva's bedroom/ensuite, shared common areas downstairs, and routine kitchen/laundry tidying - tasks previously shared that are now completed solely by Concepcion.

Laundry and bed linen changes

Pre-accident, Ms Villanueva completed three loads weekly (lights, darks, linens). She is now entirely dependent on her sister for laundry and bed linen changes, as she cannot carry laundry from her bedroom, bend to load/unload the top-loading machine, hang items outside, or manage the physical demands of changing bed linen. She noted: "I can fold it when I am sitting on the couch. I try to do this on days when I am feeling good. I know this is one thing I can do," demonstrating insight and willingness to contribute where able.
Concepcion currently completes approximately three loads weekly for Ms Villanueva plus weekly bed linen changes. Ms Villanueva noted increased night perspiration requiring more frequent changes of nightwear and sheets.
Medical Assessor Piebenga supported the allocation of three loads weekly: sorting/loading (5 minutes), hanging (10 minutes), folding (5 minutes) = 20 minutes per load (1 hour total), plus weekly bed linen change (20 minutes), totalling 1 hour 20 minutes weekly. This fairly reflects additional support required while recognizing Ms Villanueva's capacity to contribute with folding when able.

Community access and transportation

Ms Villanueva has not driven since her injury and has surrendered her driver's license. She experiences significant anxiety with car travel and exacerbation of back pain with sitting. She relies entirely on Concepcion for transport, primarily limited to monthly GP visits at Rooty Hill (1.5 hours round-trip plus 0.5 hour waiting time) and occasional specialist appointments.
Pre-accident, Ms Villanueva was highly active as a parish catechist coordinator, teaching scripture full-time voluntarily, and managing her own travel including international trips. She no longer attends church, social functions, or group gatherings, attributing this to anxiety, low mood, self-consciousness regarding her posture, and social withdrawal.
Medical Assessor Piebenga found there was a need for the allocation of one hour weekly for community access support. This captures average additional time for medical appointment travel, recognizing variation between weeks while representing a practical estimate of time reasonably required for her current level of community access, without extending to social transport she is not presently engaging in.

Comparison with previous assessments

A key observation is the remarkable consistency in Ms Villanueva's reported functional abilities across occupational therapy assessments over nearly three years. Despite the passage of time and change to a more accessible home, her functional limitations have remained essentially stable. While she has demonstrated improvement in personal care (particularly showering frequency) due to environmental modifications, her capacity to engage in domestic tasks requiring standing, walking, bending, lifting, and carrying has not meaningfully changed.
Medical imaging demonstrates progression of L4 vertebral compression from 50% (November 2019) to 70% (June 2023) - documented structural deterioration of approximately 20 percentage points over 3.5 years. However, this structural change has not been accompanied by corresponding functional deterioration. Ms Villanueva presents with the same mobility limitations, standing/walking tolerance, and inability to perform domestic tasks as consistently documented since her accident.
Medical Assessor Castle-Burton's assessment of 27 February 2025 provides valuable corroborating evidence. Medical Assessor Piebenga noted her findings aligned closely with the findings of Medical Assessor Castle-Burton; identical postural abnormalities (fixed 45° flexion, marked kyphosis), identical mobility patterns (slow, pain-producing, reliant on two sticks), identical transfer observations (extremely slow with significant discomfort), and identical functional limitations. Both assessments found Ms Villanueva essentially independent with personal care when using equipment but unable to participate meaningfully in domestic tasks.
The concordance between two independent occupational therapy assessments conducted one year apart in different home environments provides strong evidence regarding
Ms Villanueva's actual functional capacity and care needs. Both assessments concluded eight hours per week is reasonable and necessary.

PANEL DETERMINATION

Alleged deterioration in function

Ms Villanueva's submission emphasized deterioration citing progression of vertebral compression (50% to 70%), worsening "chronic excruciating" back pain, and increased pain medication (Pregabalin addition). The key question in determining care is not whether she experienced progression of vertebral pathology (imaging clearly demonstrates this), but whether structural progression resulted in functional regression from her established baseline disability level.
Evidence indicates Ms Villanueva reached a functional plateau following her injury, documented by multiple medical specialists: Dr Suttor in February 2020 concluded her condition had "stabilised" and in October 2020 Dr Dias concluded her "physical injuries have stabilised and she has reached maximum medical improvement." The assessment of Medical Assessor Piebenga demonstrated her functional abilities remain at this established plateau level. There is no evidence of functional regression despite structural progression.
Regarding increased pain medication, Pregabalin addition represents a modification to pain management but does not objectively demonstrate functional deterioration. Ms Villanueva’s self-reported pain levels (9/10) are consistent with previous assessments.

Hours of care

Ms Villanueva's submission included diaries documenting her sister providing approximately 23 hours weekly of domestic care, which is presented as evidence that eight hours weekly is inadequate. The Panel notes several issues arise with relying on self-reported diaries:
(a)    concurrent activities - many activities recorded occur simultaneously with tasks Concepcion would perform regardless of Ms Villanueva's presence including preparing household meals, cleaning common areas, and shopping for groceries;
(b)    reasonable efficiency - diary entries suggest time allocations exceeding reasonable expectations, with meal preparation time substantially exceeding
Ms Villanueva's own pre-accident time and shopping time exceeding reasonable duration given proximity to shops, and
(c)    distinction between care provided and care required - family members may choose to provide assistance beyond what is objectively necessary due to affection or desire for comfort, but the test is what objectively needs to be provided, not what is actually being provided.
Concepcion has ceased working as a registered nurse and is available at home full-time. She may naturally provide companionship, prepare elaborate meals, maintain the home to exceptionally high standards, and anticipate needs before assistance must be requested. While these caring behaviours are admirable, they exceed the threshold of reasonable and necessary care for compensation purposes.
The appropriate comparison is between Ms Villanueva's pre-accident contribution to household tasks (approximately 50% share as both sisters maintained the home together), her current inability to contribute due to injuries, and the time reasonably required to complete her share of tasks. On this basis, the Panel considers eight hours weekly represents reasonable and necessary allocation to replace Ms Villanueva's lost contribution.
Insurers are required to pay reasonable cost of treatment and care needs. In determining whether treatment and care is reasonable and necessary in the circumstances, the Panel has considered:
·        Ms Villanueva's genuine functional limitations caused by accident injuries;
·        the extent to which these limitations prevent her from completing pre-accident domestic tasks;
·        the time reasonably required to complete these tasks on her behalf;
·        consistency of findings across multiple independent assessments;
·        the absence of functional deterioration despite structural progression, and
·        the need to distinguish between care actually provided versus care objectively necessary.
The currently approved eight hours weekly:
·        has been consistently recommended across multiple occupational therapy assessments, namely the assessment of Mr Callaghan in August 2023, the first assessment by Medical Assessor Piebenga in 2024, the assessment of Medical Assessor Castle-Burton in February 2025 and the assessment of Medical Assessor Piebenga of 22 September 2025;
·        represents substantial support for Ms Villanueva's domestic care needs;
·        acknowledges her genuine functional limitations caused by the accident-related injuries, and
·        provides appropriate compensation for care provided by her sister.

CONCLUSION

The Panel affirms the certificate of Medical Assessor Castle-Burton dated 13 March 2025.

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Citations

Villanueva v Lifetime Care and Support Authority of New South Wales [2025] NSWPICMP 855

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[2025] NSWPICMP 855

5 November 2025