Zalghout v Insurance Australia Limited t/as NRMA Insurance
[2025] NSWPICMP 831
•28 October 2025
| DETERMINATION OF REVIEW PANEL | |
CITATION: | Zalghout v Insurance Australia Limited t/as NRMA Insurance [2025] NSWPICMP 831 |
CLAIMANT: | Ali Zalghout |
INSURER: | Insurance Australia Limited t/as NRMA |
REVIEW PANEL | |
MEMBER: | Hugh Macken |
MEDICAL ASSESSOR: | Christopher Canaris |
MEDICAL ASSESSOR: | Surabhi Verma |
DATE OF DECISION: | 28 October 2025 |
CATCHWORDS: | MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; review of medical assessment; somatic symptom disorder with predominant pain and persistent depressive disorder; assessment of whole person impairment (WPI); front seat passenger; physical symptoms post-accident; current functioning impairment; examination as to consistency; long-standing history of anxiety; pre-accident mental health plan; deterioration with recurring suicidal thoughts; criteria for DSM-5; exacerbation of somatic symptom disorder; exacerbation of persistent depressive disorder with an anxious distress; pre-existing impairment; Held – 6% WPI found; certificate revoked. |
DETERMINATIONS MADE: | CERTIFICATE OF DETERMINATION Assessment of threshold injury and degree of permanent impairment Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017 1. The Panel revokes the certificate of Medical Assessor Alexey Sidorov dated 2. The following is a non-threshold injury for the purposes of the Act: · somatic symptom disorder with predominant pain and persistent depressive disorder (dysthymia) with anxious distress. 3. The following injury was caused by the motor vehicle accident and give rise to a whole person impairment of 6% which is not greater than 10%: somatic symptom disorder with predominant pain and persistent depressive disorder (dysthymia) with anxious distress. |
·
STATEMENT OF REASONS
INTRODUCTION
Ali Zalghout (the claimant) is a 28-year-old man who was injured in a motor vehicle accident on 21 January 2023. Following the accident, he lodged an application for personal injury benefits and thereafter sought a concession from the insurer that his injuries ought to be considered non-threshold injuries. Following a review, the insured declined to make this concession and consequently the applicant filed an application for assessment of threshold injury and whole person impairment (WPI). The claimant was examined by Medical Assessor Alexey Sidorov on 1 October 2024 who, in a certificate dated 13 October 2024 determined that the claimant had sustained a threshold injury. He did not go on to determine WPI.
The claimant sought review of this determination and in a decision dated 9 December 2024 President’s delegate Ratula Gupta decided that there is a reasonable cause to suspect that the medical assessment was incorrect in a material respect. The matter was referred to this Medical Review Panel.
The Panel issued directions to the parties to upload the Application and Reply for assessment and this material has now been uploaded and considered by the panel. The panel has determined that it was appropriate that the claimant be re-examined and thereafter the Panel reconvene to formalise its certificate and reasons.
Clause 14F of Schedule 1 of the Personal Injury Commission Act 2020 (the PIC Act) provides that the new review provisions apply in relation to a decision of a new decision-maker. A “new decision maker” is defined in cl 14A(1) of the Schedule 1 of the PIC Act. As the medical assessment, the subject of the review, was made on or after 1 March 2021, the new review provisions apply.
The new review provision provides that a Review Panel consists of two Medical Assessors and a Member assigned by the Motor Accidents Division of the Personal Injury Commission (Commission).
Part 5 of the PIC Act enables the Commission to make rules with respect to its practice and procedure including proceedings before a panel reviewing a decision of a Medical Assessor.
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 matter solely based on the written application.
The review of the medical assessment is by way of a new assessment of all the matters with which the medical assessment is concerned.
The claimant was examined by Medical Assessors Christopher Canaris and Surabhi Verma on 8 October 2025 by Teams audiovisual conference.
Psychosocial history and pre-accident history
The claimant is a 28-year-old former landscaper who has not worked since his motor vehicle accident in January 2023. He denied any history of psychiatric illness. (“Never like this… why would I have mental health issues – I was working – I had a life”). He said he had been previously medically well. He said he had injuries before “but I went back to work after 3 weeks – 4 weeks – nothing serious – I went back to work immediately”. He does not drink alcohol. He smokes “at least 30 cigarettes a day” which he pays for by “borrowing money – I buy tobacco and roll it to make it last as long as I can”. He does not use drugs. He does not gamble. He denied any history of problems with the law. He denied any other claims history.
He was born in Lebanon and came here when he was “at least 1 year old”. He has a 13-year-old brother for whom he is the carer and another brother who has two younger children and another brother who stays with his brother. He is the eldest of his siblings. His mother does not speak English despite being here 25 years. His brother also gets Centrelink. His parents divorced “a long time ago… I can’t remember when”. He was old enough to support himself when his parents divorced.
He completed his schooling at the age of 13 years at the end of year 9 starting an apprenticeship in landscaping and paving. He has had an active ABN since 2013. He never married but had a girlfriend for around five to six years before the accident who stayed at his place “half the time”. Before his accident, he was “just working – looking after my family – quoting on the weekend because I had to provide – all my hobbies stopped when I left school”.
History of the motor accident
On the day in question, he was a front-seat passenger in a vehicle driven by his brother-in-law. A car suddenly reversed out of a driveway, resulting in a collision. Airbags deployed. He,
“just got my brother to take me home and slept it off and went back to work the next day for a couple of days – I had unbearable pain… I thought it would be better, but everything got worse. I followed the directions of my doctor, and I did exactly what they wanted me to do…”
History of symptoms and treatment following the motor accident
He injured his “back and neck – I had numbness in my hands and my feet – severe pain every single day, every single hour, every single second”.
He saw a physiotherapist until the insurer cut off all payments.
He complains of “no sleep – nightmares – I have no sleep because of my pain – I've lost my mind”. He was asked to clarify this. He said, “You try sitting between 4 walls for 3 years and looking after my younger brother… and my mother”.
He attributed the emergence of his mental health symptoms to “sitting behind 4 walls in pain”.
His mood is “not good at all”. He was asked to elaborate and replied, “How can I describe that?” he was asked if he felt sad or anxious. He replied, “Everything”.
He saw a psychologist for “at least a year or over” until the insurer cut off payments. He could not tell us what medication he had been prescribed.
Details of any relevant injuries or conditions sustained since the motor accident
He “did get hit again – I can’t remember exactly but I did get hit again”. He was asked to elaborate and said, “I tell you – I lost my mind – I can’t remember nothing no more”.
Current symptoms
He was asked about his current symptoms. He said, “My psychologist sent letters to you guys – you should know – how come you’re asking me”. However, he said he had “depression and PTSD”.
He “can’t sleep – I can’t go nowhere – I've got nowhere – I'm borrowing money from people to feed my family – what can I tell you”.
He feels as though life was not worth living but has never tried to harm himself as he would not do this to his mother or family.
Current and proposed treatment
He is not having any treatment saying, “They stopped everything”. He said his medication was stopped after he had swollen feet and he was sent to hospital which may have been five or six months ago. He “had a hundred blood tests”. He wants to see Fair Trading and “I want to sue everyone” because “they gave me a sickness – sending me to a specialist and the specialist says, what did your doctor say – how does that make sense”. It seems his foot was swelling up and he had “fungus coming out of it”. He said, “I've lost 30 kilos – I've lost my mind”.
He no longer sees his doctor saying his doctor had told him he couldn't see him anymore because his letters were being investigated and there seems to have been a problem with the case manager querying invoices. He says no one is looking after him now.
Mental state examination
The claimant was interviewed by Microsoft Teams. A good audiovisual connection was established. He was at his home in Casula where he lived with his mother and younger brother. He presented as a gaunt looking man of appearance consistent with the stated age and Middle Eastern ethnicity with a long dark beard. He had short cut hair. He wore a white Calvin Klein tracksuit top which looked clean. He provided the history documented above. His narrative was short on detail with frequent statements to the effect that he could not remember and that he had lost his mind making for a challenging interview. His narrative was strongly dominated by his complaint of severe pain which he imparted in a dramatic manner. His mood was dysphoric and his effect restricted. No evidence of psychosis or cognitive impairment emerged.
Current functioning
He spends his day “every day between 4 walls” and does “nothing” at his home. His mother gives him her Centrelink, and he borrows money saying he has “sold everything I have and she's sold everything she has”.
He was asked what he could not do physically after the accident. He said, “I could not lift – the pain worsened day by day – my back was hurting – getting worse day by day – I couldn't afford to see a specialist”. He had trouble raising his hands and brushing his teeth. He showers “very rarely” saying, “My mum has to grab me literally to bathe me”. He would change his clothes “when she showers me”. She does this “because I don't have the energy and I don’t feel like having showers”. He does not do any cooking or cleaning (“Nothing”) saying he is not up to this physically. His would “barely eat at all – I've lost so much weight – over 25 kilos now” and says he weighs “possibly 48 – 50 kilos”. His mother cooks his meals “here and there because I hardly eat”. His mother goes shopping for him because “I [physically] can't move”.
He does not go out socially. He has not been out of the house at all for about two years. He does not have any visitors. He does not go out “because I've lost my mind”. He did not elaborate on this further beyond multiple references to sitting between four walls all day and being in pain.
He does not drive. He would “hardly get in a car since they refused my claim – I only went to my appointments – that was the only reason I left the house”. He would sometimes be taken by his mother and sometimes catch an uber saying, “I can’t sit very long – I'm in severe pain everyday”.
He alluded to “screaming at my mother” while staying at home. He said that his girlfriend had left him “a couple of months after the accident”. He does not plan to get married saying, “I want to look after my mother and my brother”. He was asked why his girlfriend left him. He said, “Why wouldn’t she – I was losing my mind – I wasn’t supporting her – we stopped going out...”.
He does not read or watch TV (“Nothing at all”). He reiterated, “Try sitting between 4 walls for 3 years – trying to look after my mother and my brother”. He said he looked after his mother and brother “financially – I look after their rent – I pay their bills”. He transfers money online. He is able to do so over the phone. He could tell us his rent was $550 dollars per week, and he gets “about a thousand… to look after the whole family”. He spends money on cigarettes, food, electricity, gas, rent. He spends “at least $100 every second day” on cigarettes. His Centrelink goes straight to rent – he gets $1100 a fortnight”. His mother buys the food out of her Centrelink payment.
He was going home from work at the time of the accident. He has not worked since. He “can’t work because of the pain” but also because of the depression saying, “How can I go back to work the way I am after being T-boned – pain every single day every single second – how can I work”.
Comments on consistency
He was asked about entries in his medical file relating to mental health issues from before the accident. He said, “It was time of Covid”. It was pointed out to him that the dates of these entries preceded COVID-19. He said, “I don’t remember”.
He had no recall of having been on Panadeine Forte or Targin before the accident.
He was asked about entries just prior to the accident referring to low mood and social isolation. He said, “I had no idea what that was about”.
He sold his belongings and his ute and could not specify what he had spent his money on saying he had “lost my mind”.
He was very vague as to the care he gave to his family given that he received a carer payment. He was very vague as to what he did other than to look after the bills or pay the rent. He was unable to state what condition they had to justify a carer payment despite repeated questions.
He was asked about the 2020 motor vehicle accident. He said he went back to work immediately. It was pointed out that he had been off work for three months. He was asked if he could recall a CTP claim. He said he just did what his doctor told him to do and that he went back to work.
He was asked about a Centrelink certificate from 2022. He thought it may have been for “anxiety, depression”. He was asked about September 2022 entries relating to a claim. Again, he said he could not remember.
REVIEW OF DOCUMENTATION
Summary of relevant documentation
The Medical Assessors noted the claimant’s submissions dated 25 August 2025 stating that both threshold injury and WPI should be assessed.
The Medical Assessors noted the claimant’s statement dated 6 June 2023. This relates to a range of injuries including a motor vehicle accident on 29 February 2020 following which he had three months off work with a back injury, a work injury on 5 August 2022, and the subject motor vehicle accident.
The Medical Assessors noted the police report dated 17 February 2023. The subject accident was classified as a Minor Traffic Crash and Tow Away Only.
The Medical Assessors noted the ProCare report dated 21 July 2023.
The Medical Assessors noted the clinical records of Bankstown Family Medical Practice as at 18 May 2020 noting a presentation on 11 February 2019 with depression for which he received supportive counselling, advice in activity scheduling, with a discussion of antidepressants. On 28 February 2019, he was seen by a psychologist and was noted to have a “Long-standing history of anxiety” with “reported symptoms of chest pains, breathing difficulties, psychomotor agitation and anger”. He was noted to be experiencing significant financial distress because of “over $5500 in unpaid fines”. There are ongoing references to therapy sessions with his psychologist and on 27 June 2019 is reported as describing significant chronic pain in his lower back exacerbated by his work as a paver. By
25 July 2019, his anxiety and mood issues were said to have largely resolved but he continued to experience high levels of chronic pain. There are subsequent presentations with pain, eg, on 16 January 2020 with initiation of a trial of Targin (an opioid). On
1 May 2020, there is a reference to the motor vehicle accident on 29 February 2020 in which he was rear-ended on a roundabout. He had worsening pain and was thus prescribed Lyrica as well as Panadeine Forte and Voltaren. There is a mental health care plan dated
26 January 2019 relating to “Depression and Stress”. There is a further mental health plan dated 16 January 2020 which documents DASS 21 results in the moderate range for depression, severe range for anxiety, and moderate range for stress. There are sundry certificates of capacity relating to the February 2020 accident.The Medical Assessors noted the medical records of Australis Group as printed on
30 November 2023. An initial entry on 2 July 2021 notes a history of chronic intermittent lower back pain for three to four years which he rated as 8 or 9/10 in severity at times. His general practitioner (GP) reported the following:“Ali asked me multiple times during the consultation what pain medication I’m going to prescribe him. On multiple occasions he said that when he presents to the hospital, they give him morphine and sent him home. Also mentioned on a few occasions that the hospital has discharged him with endone [sic]. He also told me that Dr Amil Dewan will not prescribe him any pain management anymore.”
His GP “advised Ali that I do not prescribe opioid medications or any drugs of addiction to new patients. Furthermore, I advised Ali I did not initiate opioid medications for chronic pain unless this has been suggested by an appropriate specialist and that they continue to follow-up without specialists for ongoing management reviews”. The next consultation on
5 February 2023 refers to the subject motor vehicle accident. He was noted not to have gone back to work because of pain which was described as “unbelievalbe [sic]” because of which he could not sleep and had been taking Panadeine Forte. There are subsequent presentations with severe pain and requests for stronger analgesia as Panadeine Forte was not working. On 23 February 2023, he reported “symptoms of mental illness with anxiety and depression” wanting to see a counsellor. On 1 March 2023, he is described as “emotionally decompensating with poor sleep, poor pain adjustment, grumpy and arguing with family”. There are further presentations with pain and prescriptions for Panadeine Forte and he is noted to have been referred to a counsellor. There is an email dated 4 May 2023 from his physiotherapist suggesting that he would benefit from psychological intervention “due to his report of ongoing low mood and anxiety, and his pain focused outlook”. There are prescriptions for mirtazapine (an antidepressant) and later Pristiq (desvenlafaxine – another antidepressant) and sundry entries relating to physical issues including an MRI of his spine.There were sundry certificates of capacity finding him to have no capacity for work.
There were sundry referrals to psychology, to a neurosurgeon, and to pain management as well as physiotherapy and sundry correspondence from these.
The Medical Assessors noted the complete record of Issa Medical Centre as at 10 April 2024. An initial visit as recorded on 15 August 2022 and relates to a lifting injury at work on
5 August 2022 giving rise to lower back pain with denial of any prior history of back pain. There are subsequent presentations with pain. On 9 November 2022, he presented as very distressed because he was not receiving help from the insurer and was financially, mentally, and physically exhausted but denied suicidal ideation or plans. On 11 November 2022, he complained of poor sleep and depression and was started on mirtazapine (an antidepressant). On 6 January 2023, he was noted to have low mood, reduced interest in doing things he usually did, disturbed sleep, poor appetite, and insomnia and was offered a referral to a psychologist and psychiatrist. He was also prescribed Lyrica. There were prescriptions for Panadeine Forte. There are later presentations, e.g. 3 May 2023, in which he complains of pain but denied depression and had stopped mirtazapine and Panadeine Forte. Further presentations relate to pain. On 7 August 2023, his GP declined to provide a prescription for Panadeine Forte as he had been getting the same script from another GP and the time interval between prescriptions was too short (40 tablets on 1 August 2023 and 20 tablets on 4 August 2023). Remaining consultations relate to pain and to prescriptions for Panadeine Forte.
The Medical Assessors noted the report of Dr T Mastroianni, IME occupational physician dated 27 July 2023.
The Medical Assessors noted the report of Dr Andrew Keller, IME occupational physician, dated 19 February 2024. Dr Keller noted him to be seeing a psychologist for depression from around May 2023 onwards, and a subsequent motor vehicle accident on 16 June 2023 causing increased neck and back pain. He was noted to have denied prior neck and back problems. He complained of depression and anxiety. Dr Keller noted inconsistencies in his account taking note of documentation of long-standing lower back pain. He considered that he had sustained minor (threshold) physical injuries only.
The Medical Assessors noted the report of Dr Abhishek Nagesh, IME psychiatrist, dated
10 July 2023. Dr Nagesh took a history of the accident noting that the claimant alleged being in shock and pain all the time. One month down the track, he became depressed in the context of his pain, inability to work, and inability to be as active as previously with loss of income. He worried about his future and could not sleep because of pain. He lost appetite and lost 5kg of weight. He lacked energy and motivation and his ability to concentrate diminished. He became socially withdrawn and felt worthless. He also reported nightmares and flashbacks. He also stopped driving for a couple of months. He was started on low dose of amitriptyline for his pain and saw psychologist. Dr Nagesh diagnosed major depressive disorder of moderate degree with anxious distress. He assessed WPI at 24% with no deduction for pre-existing impairment or adjustment for treatment effects. He assessed him as Class 2 for travel, Class 3 for self-care and personal hygiene, social and recreational activities, social relationships (social functioning), and concentration, persistence, and pace, and Class 5 for adaptation.
Comment:
Dr Nagesh’s assessment is problematic in that he made no assessment of pre-existing impairment and recorded him saying that he had no prior history of mental illness. That said, Dr Nagesh only had the records of Australis Group although the initial presentation on
2 July 2021 in which he made multiple requests for opioid analgesia may have served as reason for concern.The Medical Assessors noted the report of Dr Inglis Howe Synnott, IME psychiatrist, dated 23 May 2024. Dr Synnott diagnosed major depressive disorder with prominent anxiety. He noted significant discrepancies between the claimant’s account and the medical documentation which undermine confidence in determining the impact of the subject motor vehicle accident. He consequently declined to assess WPI because of this.
The Medical Assessors noted the reports of Dr Shiva Moshir, treating clinical psychologist, dated 6 November 2023, 8 March 2024, and 22 March 2024. Symptoms reported comprised severe pain, extremely depressed mood, ongoing severe anxiety, sleep issues due to pain and anxiety, sweating, heart palpitations, loss of motivation, poor concentration, inability to control worry and over thinking, irritability, and loss of appetite. The 6 November 2023 report suggests that consideration of medication to reduce his severe pain, anxiety, and depression was likely to be helpful. The 8 March 2024 report notes a deterioration with recurring suicidal thoughts as well as frequent thoughts of death and hopelessness in the setting of excessive worry, extremely depressed mood, angry outbursts expressed multiple times over sessions, severe stress, feeling desperate, being unable to regulate emotions, and restrictions because of lack of support and ongoing pain. He is described as withdrawn from family and friends with no social interactions making him isolated. He is said to be unmotivated and feeling trapped and is thus unable to follow routines through the day because of “multiple issues such as severe pain, extremely low mood, lack of energy, intrusive thoughts, flashbacks and financial difficulties”. The last report reiterates the persistence of these symptoms “despite practising psychological strategies” and again suggests consideration of medication to reduce his problems.
The Medical Assessors noted the certificate of Medical Assessor Alexey Sidorov dated
13 October 2024. Medical Assessor Sidorov diagnosed the claimant with an adjustment disorder with mixed anxiety and depressed mood which was a threshold injury for the purpose of the act and concluded that an assessment of the degree of permanent impairment of these injuries was therefore not required. Medical Assessor Sidorov noted him to have provided an account that was “overall fake” and that “his description of symptoms was somewhat embellished” while noting him to have a dysphoric effect.The Medical Assessors noted the claimant’s and insurer’s submissions in relation to assessment of WPI. The Medical Assessors also noted the insurer’s submissions in relation to the WPI disputes asserting that the claimant’s psychiatric injuries were not related to the subject accident as they appeared to be a continuation of pre-existing depression and anxiety thus not exceeding 10% threshold.
DETERMINATIONS
Diagnosis and reasons
The claimant is diagnostically challenging due to multiple inconsistencies between the history provided and the contents of his medical file. Due to these inconsistencies and his dramatic manner throughout the interview, the Medical Assessors considered the diagnosis of factitious disorder. However, they determined that there was insufficient evidence to warrant this diagnosis.
His most consistent complaint is one of severe pain, which dominates his life, coming on against a background of presentations prior to the subject accident with pain. In the circumstances, a diagnosis of somatic symptom disorder with predominant pain is unavoidable.
In terms of DSM-5-TR criteria, further Medical Assessors noted the presence of severe pain which is distressing and which has given rise to significant disruption of his daily life (Criterion A). The dramatic manner in which he speaks of his pain and its severity together with the restrictions he attributes to his pain leads to the conclusion that he displays excessive thoughts, feelings, and behaviours manifest in disproportionate thoughts about the seriousness of his symptoms, persistently high levels of anxiety about his symptoms, and excessive time and energy devoted to his symptoms (Criterion B). His symptoms have been continuously present for two years and nine months (Criterion C). Additionally, the long duration of his symptoms coupled with the presence of three of the symptoms specified in Criterion B indicates that his somatic symptom disorder with predominant pain is persistent and severe.
The Medical Assessors observed evidence of drug-seeking behaviour both before and after the accident, as well as the claimant’s report that his doctors were refusing to prescribe medications for him. There was evidence suggesting an opioid use disorder, but it was impossible to determine how active it was or its severity. The Medical Assessors could only rely on the limited history provided by the claimant and the documentation available. They found evidence of 28 attendances leading to a prescription for Panadeine Forte over 60 weeks, which equated to a prescription for 30 tablets every fortnight or about two tablets per day, not clearly excessive. They noted a single occasion in August 2023 when his GP declined to prescribe Panadeine Forte because the interval between prescriptions was too short, and he had obtained a prescription from another GP. They also could not access services such as SafeScript NSW, which could reveal problematic prescription patterns, as access for non-clinical purposes is prohibited. Consequently, they refrained from making a diagnosis of opioid use disorder.
The Medical Assessors observed his mood symptoms and his repeated claim that he had lost his mind, couldn't sleep, experienced nightmares, and was losing weight. They noted his reluctance or inability to fully describe the symptoms. However, they observed his dysphoric mood, restricted affect, reported weight loss, and the fact that he had consistently attracted diagnoses of major depressive disorder during presentations where he variously complained of depressed mood, anxiety, low energy, insomnia, suicidal ideation, poor concentration, and weight loss. Due to the chronic nature of his mood disturbance, the Medical Assessors concluded that he met the criteria for a diagnosis of persistent depressive disorder (dysthymia) with anxious distress.
In relation to DSM-5-TR criteria, they noted the presence of depressed mood for most of the day, more days than not, over the past two years and nine months (Criterion A), accompanied by poor appetite with weight loss, insomnia, low energy, and feelings of hopelessness, as evidenced by intermittent suicidal ideation (Criterion B). These symptoms have never been absent for any significant period (Criterion C). He may have met the criteria for major depressive disorder at times, though it was unclear whether these symptoms were continuously present – nonetheless, this was not essential for the diagnosis (Criterion D). He had never experienced a manic, hypomanic, or cyclothymic episode (Criterion E). There was no evidence of schizoaffective disorder, schizophrenia, schizophrenia spectrum disorder, delusional disorder, or other psychotic disorders (Criterion F). His symptoms were not attributable to the effects of substances or another medical condition (Criterion G), and they caused clinically significant distress and psychosocial impairment, as demonstrated by his social withdrawal, inability to work, and neglect of self-care H).
Causation and reasons
There is evidence suggesting he may have had a somatic symptom disorder with predominant pain prior to the accident, as he had a history of presentations related to pain that appeared excessive. However, it is unclear whether he would have met the formal criteria for this condition. Since the accident, he has consistently complained of severe pain, and there is clear evidence that his pain-related condition has significantly worsened following that event.
His previous complaints of pain may have reflected a vulnerability to a somatic symptom disorder. Still, the increased severity of his symptoms indicates that the incident was a substantial cause of his condition. While depression and anxiety were evident before the accident, a definitive diagnosis remains difficult due to the claimant’s inability to provide detailed information.
Nonetheless, the recurring presentations dating back as far as 2019 suggest either a major depressive disorder with anxious distress or an anxiety disorder. The available documentation indicates that his current symptoms are markedly more severe and cause greater impairment after the accident, with his depressive and anxious symptoms being driven by his pain. The worsening of his symptoms within the context of chronic pain suggests that the accident has substantially contributed to the development of his persistent depressive disorder.
Threshold injury
Somatic symptom disorder with predominant pain and persistent depressive disorder (dysthymia) with anxious distress are recognised psychiatric illnesses and as such not threshold injuries. Both have been exacerbated by the subject accident.
Permanency of impairment
He appears to have been continuously unwell over the preceding two years and nine months despite seeing a psychologist and as is evident from the documentation on hand taking an antidepressant. His condition has stabilised and his level of impairment is unlikely to change substantially or by more than 3% over the ensuing year.
Degree Of Permanent Impairment Psychiatric Impairment Rating Scale
| Psychiatric diagnoses | 1. Persistent depressive disorder (dysthymia) with anxious distress | 2. Somatic symptom disorder with predominant pain (not assessable for whole person impairment) |
| 3. | 4. | |
| Psychiatric treatment description | He sees a psychologist and has been on an antidepressant. | |
| Category | Class | Reason for Decision |
| 1. Self-Care and Personal Hygiene | 2 | He was asked what he could not do physically after the accident. He said, “I could not lift – the pain worsened day by day – my back was hurting – getting worse day by day – I couldn't afford to see a specialist”. He had trouble raising his hands and brushing his teeth. He showers “very rarely” saying, “My mum has to grab me literally to bathe me”. He would change his clothes “when she showers me”. She does this “because I don't have the energy and I don’t feel like having showers”. He does not do any cooking or cleaning (“Nothing”) saying he is not up to this physically. His would “barely eat at all – I've lost so much weight – over 25 kilos now” and says he weighs “possibly 48 – 50 kilos”. His mother cooks his meals “here and there because I hardly eat”. His mother goes shopping for him because “I [physically] can't move”. Comment: The Medical Assessors noted the considerable contribution of physical symptoms to his limitations which cannot be assessed for whole person impairment. Using clinical judgement, they rated him as Class 2 in this category. |
| 2. Social and Recreational Activities | 2 | He does not go out socially. He has not been out of the house at all for about 2 years. He does not have any visitors. He does not go out “because I've lost my mind”. He did not elaborate on this further beyond multiple references to sitting between 4 walls all day and being in pain. Comment: The Medical Assessors noted the significant contribution of physical symptoms to his limitations which cannot be assessed for whole person impairment. Using clinical judgement, they rated him as Class 2 in this category. |
| 3. Travel | 2 | He does not drive. He would “hardly get in a car since they refused my claim – I only went to my appointments – that was the only reason I left the house”. He would sometimes go taken by his mother and sometimes catch an uber saying, “I can’t sit very long – I'm in severe pain everyday”. Comment: Despite the significant contribution of pain which is not assessable for whole person impairment to his loss of functioning in this regard, there was evidence of a psychological contribution to his loss of functioning. Using clinical judgement, the Medical Assessors rated him as Class 2. |
| 4. Social Functioning | 3 | He alluded to “screaming at my mother” while staying at home. He said that his girlfriend had left him “a couple of months after the accident”. He does not plan to get married saying, “I want to look after my mother and my brother”. He was asked why his girlfriend left him. He said, “Why wouldn’t she – I was losing my mind – I wasn’t supporting her – we stopped going out...”. |
| 5. Concentration, Persistence and Pace | 3 | He does not read or watch TV (“Nothing at all”). He reiterated, “Try sitting between 4 walls for 3 years – trying to look after my mother and my brother”. He said he looked after his mother and brother “financially – I look after their rent – I pay their bills”. He transfers money online. He is able to do so over the phone. He could tell us his rent was $550 dollars per week, and he gets “about a thousand… to look after the whole family”. He spends money on cigarettes, food, electricity, gas, rent”. He spends “at least $100 every second day” on cigarettes. His Centrelink goes straight to rent – he gets $1100 a fortnight”. His mother buys the food out of her Centrelink payment. Comment: The Medical Assessors noted his repeated assertions that he had “lost my mind” because of which he was unable to provide information in a range of areas. This was in contrast to his capacity to provide information relating to disposal of his income and to transfer money online using his phone. Using clinical judgement, they determined his impairment in this category to be Class 3. |
| 6. Adaptation | 2 | He was going home from work at the time of the accident. He has not worked since. He “can’t work because of the pain” but also because of the depression saying, “How can I go back to work the way I am after being T-boned – pain every single day every single second – how can I work”. Comment: The Medical Assessors noted the considerable contribution of physical symptoms to his impairment which cannot be assessed for whole person impairment. Using clinical judgement, they rated him as Class 2 in this category. |
| List classes in ascending order: 2, 2, 2, 2, 3, 3 | ||
| Median Class Value: 2 | ||
| Aggregate Score: 14 | ||
| % Whole Person Impairment: 7% | ||
*%WPI = Percentage Whole Person Impairment
Psychiatric Impairment Rating Scale – Pre-existing/subsequent impairment
Assessment of pre-existing WPI was problematic. The Medical Assessors while noting his contention to be working and functioning well considered the claimant not to be a reliable reporter of his functioning before the accident. They considered the documentation on hand but found little information relating to functioning.
| Psychiatric diagnoses | 1. Major depressive disorder and/or anxiety disorder | 2. Somatic symptom disorder with predominant pain (not assessable for whole person impairment) |
| 3. | 4. | |
| Psychiatric treatment description | He had been referred to a counsellor. | |
| Category | Class | Reason for Decision |
| 1. Self-Care and Personal Hygiene | 2 | In an entry on 16 January 2023 of the Issa Medical Centre, there was a report of reduced appetite. There was no other documented evidence of impairment in this category. |
| 2. Social and Recreational Activities | 2 | In an entry on 6 January 2023 of the Issa Medical Centre, there was a report reduced interest in his usual activities. |
| 3. Travel | 1 | There was no documented evidence of impairment in this category. |
| 4. Social Functioning | 1 | There was no documented evidence of impairment in this category. |
| 5. Concentration, Persistence and Pace | 1 | In an entry on 6 January 2023 of the Issa Medical Centre, there was a report of insomnia but it was not clear whether this was associated with any impairment in concentration, persistence, and pace. |
| 6. Adaptation | 1 | He was working full-time at the time of the accident. |
| List classes in ascending order: 1, 1, 1, 1, 2, 2, | ||
| Median Class Value: 1 | ||
| Aggregate Score: 8 | ||
| Pre-existing % Whole Person Impairment: 1% | ||
*%WPI
Apportionment – pre-existing/subsequent impairment
Of his total WPI of 7%, 6% is attributable to the subject motor vehicle accident and 1% to pre-existing impairment.
Effects of treatment
There was no adjustment for treatment effect as he was not having treatment.
Degree of permanent impairment caused by the motor accident
6%
Conclusion
The Panel certifies that the claimant has sustained a degree of permanent impairment caused by the motor accident of 6%.
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