DETERMINATION OF REVIEW PANEL	
	
CITATION:	Ahmadi v Insurance Australia Limited t/as NRMA Insurance [2023] NSWPICMP 321	
		
CLAIMANT:	Maryam Ahmadi	
		
INSURER:	Insurance Australia Limited trading as NRMA Insurance	
		
REVIEW Panel	 	
		
MEMBER:	Susan McTegg	
		
MEDICAL ASSESSOR:	Wayne Mason	
		
MEDICAL ASSESSOR:	Doron Samuell	
		
DATE OF DECISION:	28 June 2023	
		
CATCHWORDS:	MOTOR ACCIDENTS –   Motor Accident Injuries Act 2017; assessment of threshold injury under section 1.6(3); the claimant suffered psychological injury in the motor vehicle accident on 7 July 2020; Medical Assessor (MA) Fukui certified adjustment disorder with anxiety; a threshold injury; Held – pre-existing psychiatric state; accident more than negligible contribution; diagnostic criteria for post-traumatic stress disorder not met; diagnosis of adjustment disorder with anxiety; certificate of MA confirmed.

DETERMINATIONS MADE:  	CERTIFICATE OF DETERMINATION
Assessment of Threshold Injury
Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017

The Review Panel affirms the certificate of Medical Assessor Atsumi Fukui dated 31 January 2022.	

STATEMENT OF REASONS
introduction
1.	On 7 July 2020 Ms Maryam Ahmadi (the claimant) was driving her vehicle when a vehicle which had been parked pulled out from the left colliding with the left front passenger side of her vehicle (the accident). Ms Ahmadi asserts she sustained the following injuries in the accident:
•	neck injury;
•	injury to the left shoulder;
•	injury to the back, and
•	psychological sequalae.
2.	Insurance Australia Limited trading as NRMA Insurance (the insurer) is the relevant insurer with liability to pay any damages to Ms Ahmadi under the Motor Accident Injuries Act 2017 (the MAI Act).
3.	Ms Ahmadi’s claim is governed by the provisions of the MAI Act. At the time of the accident statutory benefits for treatment and care under the MAI Act cease after 26 weeks if the person’s only injuries resulting from the motor accident were threshold injuries.
4.	Medical Assessor Fukui issued a certificate dated 31 January 2022 in which she certified that the psychological injury sustained by Ms Ahmadi caused by the accident was a minor (threshold) injury. 
5.	As a result, Ms Ahmadi has no ongoing entitlement to ongoing statutory payments under the MAI Act. 
6.	Ms Ahmadi has sought a review of the certificate of Medical Assessor Fukui. 
BACKGROUND
7.	Ms Ahmadi is 57 years of age. 
8.	On 25 August 2020 Ms Ahmadi lodged an Application for personal injury benefits under the name of Maryam Ahmadi.  The Application shows the claimant has also been known by the family name of Sultani Madadghar.   Medical records appear under the names Maryam Ahmadi, Madaghar Marry Sultani, Marry Sultani or Mary Sultana all bearing an identical date of birth.
9.	On 16 September 2020 the insurer issued a liability notice accepting liability for the first 26 weeks following the accident.
10.	On 30 November 2020 the insurer issued a liability notice declining liability for benefits beyond 26 weeks on the basis the injury sustained by the claimant was a minor (threshold) injury for the purposes of the MAI Act. 
11.	On 17 December 2020 the claimant sought an internal review of the insurer’s decision declining liability.
12.	On 7 January 2021 the insurer issued a Certificate of Determination – Internal Review where the decision to decline liability beyond 26 weeks was affirmed.         
13.	The claimant filed an application with the Personal Injury Commission (Commission) seeking a medical assessment to resolve the minor (threshold) injury dispute between the parties. 
14.	Pursuant to Schedule 2, cl 2 of the MAI Act, various matters are declared to be a medical assessment matter, including “whether the injury caused by the motor accident is a threshold injury for the purposes of the Act”. 
15.	A medical assessment matter is determined in accordance with Division 7.5 of the MAI Act by a Medical Assessor.
THRESHOLD INJURY- STATUTORY PROVISIONS
16.	The Motor Accident Injuries Amendment Act 2022 (the MAI Amendment Act) was assented on 28 November 2022 with various amendments commencing on 1 April 2023. From 1 April 2023 the MAI Amendment Act provides that a “minor injury” is known as a “threshold injury” and “minor injuries” are known as “threshold injuries”. 
17.	The definition of what constitutes a minor injury has not been amended and continues to apply to a threshold injury.
18.	Any reference in these reasons to “minor injury” is a reference to a “threshold injury” and any reference to the word “minor” referring to the injury alleged to have occurred in the accident is a reference to “threshold”. 
19.	A threshold injury is defined in s 1.6 of the MAI Act. Section 1.6(1)(a) of the MAI Act defines a “threshold psychological injury” as:
“A psychological or psychiatric injury that is not a recognised psychiatric illness.” 
20.	Section 1.6 provides that regulations may be made to exclude or include a specified injury from being a threshold psychological or psychiatric injury. 
21.	Part 1, cl 4(2) of the Motor Accident Injuries Regulation 2017 (the MAI Regulation) provides the following:
“Each of the following injuries is included as a threshold injury for the purposes of the Act:
(a)	acute stress disorder,
(b)	adjustment disorder.” 
22.	Part 5 of the Motor Accidents Guidelines (the Guidelines) are made pursuant to s 10.2 of the MAI Act. The Guidelines contain the procedure for assessing whether an injury caused by the motor accident is a threshold injury for the purposes of the MAI Act. Version 9.1 of the Guidelines commenced on 1 April 2023 and applies to motor accidents occurring on or after 1 December 2017. In respect of the medical assessment of whether an injury is a threshold injury, the Guidelines relevantly provide:
“5.3	The assessment will determine whether the injury related to the claim is a soft tissue injury or a threshold psychological or psychiatric injury caused by the motor accident. 
5.4	Insurers should not require injured persons to undergo diagnostic imaging for the purpose of the insurer determining whether the injury related to the claim is a threshold injury. Diagnostic imaging is not considered necessary to assess threshold injury.
5.5	A diagnosis for the purpose of a threshold injury decision must be based on a clinical assessment by a medical practitioner or other suitably qualified person independent from the insurer.
5.6	The assessment of whether an injury caused by the accident is a threshold injury for the purposes of the Act should be based on the evidence available and include all relevant findings derived from:
	(a) a comprehensive accurate history, including pre-accident history and pre-existing conditions
	(b) a review of all relevant records available at the assessment
(c) a comprehensive description of the injured person’s current symptoms
(d) a careful and thorough physical and/or psychological examination
(e) diagnostic tests available at the assessment. Imaging findings that are used to support the assessment should correspond with symptoms and findings on examination.”
23.	In Briggs v IAG Limited trading as NRMA Insurance his Honour Justice Wright stated at [35]:
“The question of causation of injuries was not dealt with in Part 5 of the Guidelines but causation was addressed in Part 6, which related to assessment of permanent impairment. There is no reason to think that different principles were intended to be applied when a medical assessment was being made in relation to causation of minor injuries. Clauses 6.5 to 6.7 provided:
‘Causation of injury
6.5	An assessment of the degree of permanent impairment is a medical assessment matter under clause 2(a) of Schedule 2 of the Act. The assessment must determine the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident. A determination as to whether the injured person's impairment is related to the accident in question is therefore implied in all such assessments. Medical assessors must be aware of the relevant provisions of the AMA4 Guides, as well as the common law principles that would be applied by a court (or claims assessor) in considering such issues.
6.6	Causation is defined in the Glossary at page 316 of the AMA4 Guides as follows: 
'Causation means that a physical, chemical or biologic factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following: 
1.	The alleged factor could have caused or contributed to worsening of the impairment, which is a medical determination. 
2.	The alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination.'
This, therefore, involves a medical decision and a non-medical informed judgement. 
6.7	There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be a sole cause as long as it is a contributing cause, which is more than negligible. Considering the question 'Would this injury (or impairment) have occurred if not for the accident?' may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes.”
ASSESSMENT UNDER REVIEW
24.	The following injury was referred for assessment:
•	post-traumatic stress disorder and/or depressive disorder and/or anxiety disorder. 
25.	The dispute in relation to the psychiatric injury was referred to Medical Assessor Fukui who assessed the claimant on 18 January 2022 and issued a certificate dated 31 January 2022.
26.	Medical Assessor Fukui recorded Ms Ahmadi complained of feeling weak with low energy and has also been more forgetful. She reported she had “changed” since the accident. She described feeling “scared” about driving or being in a car and ruminates on the accident.  She has had nightmares. She was prescribed Zoloft six months after the accident which had increased from 50mg to 150mg. 
27.	Medical Assessor Fukui reported a pre-accident history of anxiety and stress following her divorce.  She did not attract a psychiatric diagnosis and did not engage in specific treatment. She also noted her traumatic background, being a refugee from Afghanistan and having family killed by the Taliban. She reported Ms Ahmadi was involved in a previous motor accident in 2014 but did not have any psychological sequelae.
28.	Medical Assessor Fukui noted Ms Ahmadi reportedly functioned well prior to the accident and described anxiety symptoms and avoidance related to driving.  She noted she was able to maintain self-care and appropriate social and family relationships. Medical Assessor Fukui certified the following injuries were not caused by the accident:
•	post-traumatic stress disorder;
•	depressive disorder, and
•	anxiety disorder. 
29.	Medical Assessor Fukui concluded the claimant’s symptoms were consistent with a diagnosis of adjustment disorder with anxiety.  She noted under Part 1, cl 4(2) of the MAI Regulation an adjustment disorder is a minor injury and certified the claimant had sustained an adjustment disorder with anxiety, a minor injury. 
REVIEW PROCEDURE
30.	The claimant lodged an application for review of the medical assessment of Medical Assessor Fukui within 28 days of the date on which the certificate of Medical Assessor Fukui was made available to the parties.
31.	On 28 March 2022 the delegate of the President being satisfied there was reasonable cause to suspect that the medical assessment was incorrect in a material respect referred the medical assessment to the Review Panel (the Panel).
32.	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 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. 
33.	The new review provisions provide that a review panel consists of two Medical Assessors and a Member assigned to the Motor Accidents Division of the Commission.  Accordingly, the President’s delegate referred the matter to this Panel to assess. 
34.	Part 5 of the PIC Act enables the Commission to make rules with respect to the practice and procedure before the Commission including proceedings before a panel reviewing a decision of a Medical Assessor.
35.	Rules 127 to 130 of the Personal Injury Commission Rules 2021 (the 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.
36.	The review is by way of a new assessment of all matters with which the medical assessment is concerned. However, s 7.25 of the MAI Act provides that the review of a medical assessment can be made on the basis of any agreement by the parties as to the degree of permanent impairment from a particular injury and whether a particular injury was caused by the accident, without those matters having to be the subject of assessment.
37.	The Panel issued a Direction to the parties on 9 February 2023 (the first Direction) requiring each party to file an indexed, paginated bundle of documents. In response to this Direction the solicitor for the insurer uploaded to the portal documents marked AD1 paginated from pages 1 to 76. The solicitor for the insurer also uploaded to the portal an Application to Admit Late Documents seeking to rely upon documents which were not before Medical Assessor Fukui. These documents are marked AD2 and paginated from pages 1 to 241.  The Panel proposes to admit those documents where they are clearly relevant to the current dispute and show a history of psychological illness not fully disclosed by the claimant at the time of her assessment by Medical Assessor Fukui.  The solicitor for the claimant uploaded to the portal a bundle of documents marked AD3 paginated from pages 1 to 34.
38.	On 27 March 2023 the Panel agreed an examination was required.
EVIDENCE BEFORE THE REVIEW PANEL
Application for personal injury benefits 
39.	In the Application for personal injury benefits dated 15 March 2015 in respect of the 
18 December 2014 accident the claimant listed her injury as both legs and bruising, back, shock, neck and headaches, both shoulders, half of face numb, upper chest pain and lack of sleep.
40.	In relation to the question “Were you suffering an illness or injury affecting the same or similar parts of your body at the time of the accident?” the claimant replied “Yes” and listed “back, left shoulder, right knee”.
Clinical notes of Auburn Medical Centre
41.	Unfortunately, the clinical notes are very brief, and the reason for the consultation is not specified. Records also appear under the name Madaghar Marry Sultani or Marry Sultani.
42.	On 23 December 2006 Dr Nazaran prescribed Zoloft for depression.
43.	On 30 December 2014 Dr Navaratne completed a GP Mental Health Care Plan.
44.	On 15 January 2015 Mr Hugo Rodriguez reported he had seen Ms Sultana for anxiety and depression.  He commenced implementing CBT (Cognitive behavioural therapy). 
45.	On 9 February 2015 Dr Hamid reported the claimant had been hit by a car on 17 December 2014 whilst walking on the footpath (the 2014 accident). The record states:
“…she complains of nightmare, scares sitting in car or driving, she also complains of headache, neck, shoulders, lower back and knee pain. On physical examination she is depressed…”
46.	On 13 March 2015 Mr Rodriguez reported Ms Sultana was suffering from severe depression and anxiety with the condition manifesting with lack of motivation and low moods. In a letter to Centrelink the same date Mr Rodriguez stated:
“Ms Sultana’s symptoms are very debilitating, and they are preventing her from complying with tasks related to job search. Strictly from the psychological point of view he [sic] is at present unable to apply herself to look for work and she would find it extremely difficult to maintain employment.
Ms Sultana informed me that she is applying for Disability Pension. I would like to support her application on the basis that her depressive and anxious condition is chronic and has failed to resolve with the passing of time.”
47.	On 28 August 2015 Mr Rodriguez reported Ms Sultana had continued to attend treatment. He stated she exhibited symptoms of depression and anxiety and suffered persistent pain.
48.	On 19 February 2016 Mr Navaratne completed a GP Mental Health Care Plan. Ms Ahmadi was referred to Mr Hugo Rodriguez for management of depression. On 17 March 2016 
Mr Rodriguez stated Ms Sultana had been referred to him by Dr Malouf on 11 March 2010 and had attended treatment sessions irregularly until the present.  He reported she was subsequently re-referred by Dr Navaratne for treatment of psychological trauma resulting from an accident when she was reportedly hit by a car. He reported she was suffering from severe depression and anxiety. Mr Rodriguez described Ms Sultana’s symptoms as very debilitating. 
49.	On 29 November 2016 Mr Rodriguez reported Ms Sultana had attended six further treatment sessions. He said she continued to exhibit severe symptoms of depression and anxiety. Again, he stated her symptoms were debilitating and hindering her ability to work or study. 
50.	On 5 January 2018 Dr Hamid undertook a mental health review, reporting the claimant suffered from depression and was to continue counselling. On 18 May 2018 Dr Hamid created a Mental Health Plan for the claimant and referred her to Dr Reza Pishyar.
51.	On 4 August 2020 Dr Hamid reported complaints referrable to headache, the neck, shoulders and lower back following the accident on 7 July 2020.  
52.	Dr Hamid issued a Certificate of capacity/certificate of fitness dated 14 August 2020. His diagnosis was “Headache, neck, shoulder and lower back pain post MVA & reactive depression”.  In relation to pre-existing factors he reported, “she was involved in MVA 5 years ago, but she was fully recovered”. 
53.	On 29 September 2020 Dr Hamid completed a Mental Health Plan and referred the claimant to Mr Rodriguez. A Mental Health Plan was created on 16 October 2020. 
Report of Dr Oldtree-Clark, 29 July 2015
54.	Dr Oldtree-Clark assessed the claimant in the context of the claim arising from the 2014 accident. He reported she complained of pain, anxiety and memory loss. She had dreams about the accident, flashbacks, nightmares and suffered from palpitations. 
55.	Dr Oldtree-Clark reported the claimant was tense, sad, had withdrawn socially, had trouble concentrating, her thinking was confused and she often felt jittery. Since the accident 
Ms Ahmadi had forgotten what it was like to feel happy, she had a short temper, and had lost interest in things she used to enjoy. Dr Oldtree-Clark noted Ms Ahmadi was attending a psychologist. He diagnosed post-traumatic stress disorder and assessed a whole person impairment of 18%.
Dr Yuk Kai Lee, 23 October 2015
56.	Dr Lee, orthopaedic surgeon assessed the claimant in respect of physical injures alleged to arise from the 2014 accident.  He reported a loss of memory and a fear of cars. Ms Ahmadi was seeing a psychologist every two or three weeks and was also seeing a psychiatrist on Medicare. 
Certificate of Medical Assessor David Sharpe, 17 February 2016
57.	Medical Assessor Sharpe assessed the claimant and issued a certificate dated 17 February 2016. He was asked to assess whole person impairment in respect of injuries to the chest, the right rib, the cervical spine, the lumbar spine, the left shoulder, the right shoulder and the face arising out of the 2014 accident. 
58.	He reported the claimant had flashbacks to the accident which she described as “a most serious accident as she could have died”. He stated, “she explained that the accident ‘has taken away her life”. He reported major inconsistencies during the examination and stated:
“My overall impression at the moment is of a severe functional disturbance with a pain, and perhaps an abnormal reaction to the incident. 
I am not convinced of any ongoing physical injury that could explaine her widespread symptoms and apparent signs.”
Certificate of Medical Assessor Samson Roberts
59.	Ms Ahmadi was assessed on 29 February 2016 in respect of a dispute as to permanent impairment arising out of the 2014 accident. In relation to her psychological coping Medical Assessor Roberts reported when she remembers the accident she gets cold and she shivers.  She is scared by car noises and is no longer motivated to do things. Previously she was happy and outgoing and she hated the spot where the accident happened.  Medical Assessor Roberts reported her dreams varied but included motor accidents and being assaulted. 
60.	He reported she was a markedly disorganised historian and whilst she presented as an anxious depressed woman he found a clear description of her mood state was elusive. He concluded:
“Having regard to the multiple contradictions contained in her account, the vagaries, the discrepancies between her description of her physical injuries and the information contained in the documents, it would be imprudent to seek to determine which aspects of her account can and cannot be relied upon. On this basis, it is not possible to conclude upon a psychiatric diagnosis.”
61.	In a certificate dated 27 July 2016 Medical Assessor Roberts certified that post-traumatic stress disorder was not caused by the accident (the 2014 accident).
Claimant’s submissions
62.	The claimant provided submissions dated 14 February 2022 in support of the application for review.  The claimant submits she meets the criteria required for a diagnosis of post-traumatic stress disorder pursuant to DSM-5.
63.	Specifically, the claimant submits she meets criteria A by reason of her involvement in the accident. In respect of criteria B the claimant submits the presence of nightmares satisfies the criteria for recurrent, involuntary and intrusive distressing memories of the traumatic event. It is submitted the claimant is anxious about driving and only drives if necessary, thereby satisfying criteria C for persistent avoidance of stimuli associated with the traumatic event. Criteria D is satisfied by the decline in appetite and the loss of about 5 kg in weight, her statement that “I’m changed” since the accident and her references to feeling “so weak” or having “no energy”. Criteria E requiring alterations in arousal and reactivity is satisfied by the claimant’s difficulty sleeping and remembering things. The claimant submits the disturbances have impacted on her social and domestic functioning and having regard to the opinion of Medical Assessor Fukui as to causation it is submitted there can be little doubt the claimant’s disturbance is attributable to the accident and not to another cause, substance abuse or medical condition. 
Insurer’s submissions
64.	The insurer provided submissions dated 29 April 2021 in respect of the minor injury dispute. The insurer submitted that Ms Ahmadi did not have a recognised psychiatric illness as defined by DSM-5 based on the following:
•	in her Application for personal injury benefits Ms Ahmadi only referred to symptoms, namely loss of appetite, nervousness, fear of driving and psychological sequelae;
•	whilst the certificate of capacity/certificate of fitness provided a diagnosis of reactive depression, it had not been clinically verified and was not a recognised psychiatric illness as defined by DSM-5, and
•	the insurer had not received any treatment requests or reports from any treating psychologist or psychiatrist relating to a psychological or psychiatric injury. 
65.	In the alternative the insurer submitted any psychological injury is a minor injury. 
66.	The insurer provided undated submissions addressing the assessment of Medical Assessor Fukui. The insurer submits Medical Assessor Fukui considered the claimant’s history, the medical records and her own examination in concluding the claimant had sustained an adjustment disorder with anxiety. 
67.	The insurer provided submissions dated 10 February 2023 addressing the documents attached to the Application to Admit Late Documents. The insurer submitted care should be had with respect to the claimant’s subjective reporting of symptomology and functioning noting she heavily minimised her condition following the 2014 accident and given the relatively minor nature of the accident.  
THE MEDICAL EXAMINATION
68.	Ms Ahmadi was assessed by Medical Assessors Doron Samuell and Wayne Mason. An initial attempt at interview was made on 9 June 2023 without an interpreter but the attempt had to be abandoned after 30 minutes because it was not possible to understand what 
Ms Ahmadi was saying, partly because of language difficulties and partly because she tended not to answer the questions put.
69.	The Medical Assessors subsequently conducted a further interview with the aid of a Farsi interpreter on 16 June 2023 by video-conference.
History
70.	Ms Ahmadi said she was driving along Steele Street in Parramatta at 20 kmph. A vehicle that was parallel parked on the left side of the street pulled out as she drew level. The front right hand side of that vehicle lightly impacted the left passenger side door of her vehicle and then scraped along the entire left side. Ms Ahmadi said she had been wearing a seatbelt and the airbags did not deploy. She immediately parked her car and the lady said sorry and asked her not to call the police. The lady offered to call an ambulance but Ms Ahmadi said it was not necessary.
71.	When asked about her injuries Ms Ahmadi described being very scared and confused and had difficulty sleeping. She said there was an injury to her left shoulder and she lost her teeth because her face impacted heavily on the steering wheel. She described ongoing fear when cars are next to her and that causes her heart rate to increase. She said she has whole body pain and is more sensitive to the cold weather. She also described being forgetful and gave the example of leaving her mobile phone in a coffee shop.
72.	Ms Ahmadi attended the general practitioner who provided a tablet for the pain. She said she attended four sessions of physiotherapy and massage but after that had to pay out of her own pocket. Steroid injections were recommended for the shoulder pain but she was too scared to proceed. She added she has diabetes which causes vision difficulties and this made her afraid to accept the injection.
73.	When asked about psychological treatment Ms Ahmadi said she had not seen anyone for psychological problems. She then remembered that she had consulted psychologist Mr Hugo Rodriguez of Fairfield. She said she had been prescribed the antidepressant sertraline 
100 mg by her GP Dr Hamidi of Auburn; he also prescribes painkillers and her diabetes medication. She said she had many counselling sessions with Mr Rodriguez but the last time she went to see him three weeks ago he was no longer practising at that address. She said appointments were conducted over the telephone during COVID-19.
74.	Current symptoms consist of difficulty with sleep and fear when other vehicles come close to her while she is driving. Ms Ahmadi continues to have shoulder pain and head pain.
75.	Current treatment consists of seeing GP Dr Mohammed Ayman in Auburn who prescribes analgesics and medications for diabetes. At this point Ms Ahmadi mentioned he had referred her to an optician for glasses and she complained of a headache and nausea. She does not consult a psychologist or a psychiatrist. Current medications consist of Diamicron 100 mg, 
60 mg of another diabetic medication whose name she could not remember, and the antidepressant sertraline 100 mg.
76.	Ms Ahmadi’s past medical history consists of diabetes. She denied surgery. When asked about past psychiatric history she denied any and said she was happy. She was reminded she consulted psychologist Dr Hugo Rodriguez in 2014 and she acknowledged this was the case. She also acknowledged she used psychotropic medication in 2004 because she was upset because of domestic violence by her husband and their eventual separation. 
Ms Ahmadi was asked about consultations with psychologist Dr Reza Pishyar in 2017 and she said her GP forced her to go. In general terms Ms Ahmadi denied or downplayed pre-existing psychological conditions and treatment. She denied any family history of psychiatric illness apart from her oldest son being depressed because his girlfriend left him. She denied the use of cigarettes, alcohol and recreational drugs and said she does not gamble.
Psychosocial history and pre-accident history 
77.	Ms Ahmadi is a 58-year-old woman who lives with her 36-year-old son in Department of Housing accommodation in western Sydney. She stated she is in receipt of a disability support pension following the accident. She has not had a partner for 20 years after being subjected to domestic violence by her husband; she was distressed when he initiated an Islamic divorce.
78.	She was born in Afghanistan and described a normal birth and development. She is the youngest of nine children. Her father died of cancer when she was 13 years of age. Her mother came to Australia and died here at 65 years of age of a lung infection. She said two of her brothers were killed by the Taliban. She stated she had attended school to year 12. At age 15 she stated the Taliban wanted to take her and she ran away to hide in a neighbour's home.
79.	Ms Ahmadi was married at age 16 to a 33-year-old man and her oldest child was born when she was 17 years old. There was then a three year gap and she had two further children with a nine months gap. The family fled to Pakistan in 1990 and arrived in Australia in 1991. 
80.	Ms Ahmadi said she separated from her husband 20 years ago because she was working and he was hitting her. She said he returned to the marriage but the domestic violence continued and they eventually separated through the intervention of the police and an apprehended violence order. He instituted an Islamic divorce which she said she did not find distressing. He has remarried and she has had no other partners. She then corrected herself and said she went back to Afghanistan to marry in 2009 but when they returned to Australia she realised he was using her for migration purposes and she had him deported.
81.	With regard to work Ms Ahmadi said she was employed in sales in a jewellery shop for 9 or 10 years but has not worked for the last 4 or 5 years. She said she had commenced some training to work as an assistant in nursing in nursing homes but her mother became sick and she was unable to proceed. She has not worked since the accident in 2020.
82.	Ms Ahmadi denied any history of problems with the law.
83.	When asked about past insurance claims Ms Ahmadi said she could not remember. She then acknowledged there had been claims in the past which had been settled but she could not provide accurate details. She referred to amounts of $8,000 and $20,000. She was reminded of the motor accident in 2014 when she was almost hit by a vehicle which came onto the foot path. Again she said she had difficulty remembering. She referred to another occasion eight years ago when a Lebanese guy hit her car and was shouting at her so she called the police. 
84.	Ms Ahmadi also referred to another motor accident which occurred one or two years ago when someone came out of a lane and hit her car. She said the vehicle was badly damaged and was not able to be repaired but she was not paid enough to replace it. She said it was a bad hit and she was unconscious for between 30 and 60 minutes and it affected her legs and shoulders. She said she was taken to Blacktown Hospital.
Mental state examination
85.	Ms Ahmadi is a small, 58-year-old right-hand dominant Afghani woman whose appearance was somewhat younger than her stated age. She was neatly and casually dressed and well presented for both interviews, which took place alone in an office at her solicitor's rooms. She was identified from her photograph on her NSW drivers licence. In the second interview Ms Ahmadi was assisted by Farsi interpreter Ms Mahim Markham, NAATI CPN 9UV26V. The interpreter stated she was from Iran while Ms Ahmadi was from Afghanistan, which meant they had a slightly different dialect, but there was no difficulty in understanding her. However, she did note Ms Ahmadi tended not to answer the questions put to her and constantly had to be redirected to do so.
86.	Ms Ahmadi was cooperative with the interview and provided information to the best of her ability. She was neither anxious nor depressed in appearance and she displayed a full range of appropriate affect, including positive affect and humour. She was an extremely poor historian who frequently complained of difficulty with memory in regard to motor accidents in the past. She had extreme difficulty in responding to a direct question. 
87.	Psychiatric symptoms consisted only of anxiety while driving when cars came too close and difficulty sleeping. Specifically, Ms Ahmadi did not describe trauma-related symptoms consistent with post-traumatic stress disorder and that she did not describe symptoms consistent with a depressive mood disorder.
88.	Ms Ahmadi was fully oriented in time, person and place and displayed no evidence of organic or psychotic psychopathology.
Comments on consistency
89.	Multiple inconsistencies in relation to past psychological conditions and other motor accidents were noted throughout the interview.

DETERMINATION 
Causation 
90.	On 7 July 2020 Ms Ahmadi was engaged in a relatively minor accident in which a vehicle pulling out from the kerb came into slight contact with the left hand side of her vehicle while she was travelling at a low speed. Ms Ahmadi described being involved in motor accidents prior to this event. There was also a more serious motor accident one or two years later in which she suffered a sustained loss of consciousness and more serious physical injuries. 
91.	While it is unlikely the accident made a major contribution to her pre-existing psychiatric state, it is not possible to say it was a negligible contribution. Therefore, the accident is regarded as being capable of causing anxiety, but not to an extreme degree.
Diagnosis 
92.	Ms Ahmadi meets DSM-5 criteria for an adjustment disorder with anxiety as follows:
(a)	there was the onset of emotional symptoms within three months of the accident; 
(b)	the distress is out of proportion to the severity of the stressor and it causes impairment;
(c)	criteria for another mental disorder not met; 
(d)	symptoms do not represent normal bereavement, and
(e)	the symptoms have continued after termination of the stressor and should therefore be described as chronic.
CONCLUSION 
93.	Specifically, the panel identified no symptoms consistent with post-traumatic stress disorder.
94.	The panel agrees with the diagnosis of adjustment disorder with anxiety arrived at by Medical Assessor Atsumi Fukui and affirms her certificate. This is classified as a threshold injury.