DETERMINATION OF REVIEW PANEL	
	
CITATION:	Karroum v Allianz Australia Insurance Limited [2024] NSWPICMP 741	
		
CLAIMANT:	Leyal Karroum	
		
INSURER:	Allianz	
		
REVIEW Panel	 	
		
MEMBER:	Hugh Macken	
		
MEDICAL ASSESSOR:	Matthew Jones	
		
MEDICAL ASSESSOR:	Christopher Canaris	
		
DATE OF DECISION:	28 October 2024	
		
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; review of medical assessment; whole person impairment; Schedule 1, clause 14F of the Personal Injury Commission Act 2020; previous mental health problems; physical and psychological symptoms; claimant mildly dysphoric; current and proposed treatment; mental health treatment plan; activities of daily living; persistent depressive disorder; no ongoing psychological treatment; application of DSM-5; Held – Medical Assessment Certificate revoked. 

DETERMINATIONS MADE:  	CERTIFICATE OF DETERMINATION
ASSESSMENT OF DEGREE OF PERMANENT IMPAIRMENT
Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017 (the Act)
1.	The Review Panel revokes the certificate of Medical Assessor Abhishek Nagesh dated 26 July 2023 and issues a new certificate determining that the following injuries were caused by the motor vehicle accident and give rise to a whole person impairment which is not greater than 10% and is 7%.

STATEMENT OF REASONS
introduction
1.	Leyal Karroum (the claimant) is a 43-year-old woman who was injured in a motor vehicle accident on 28 December 2019.
2.	The accident occurred at about midnight when she was returning from a fishing trip with both her young daughters in the car with her. 
3.	Following the accident the claimant lodged an Application for personal injury benefits and, in due course, sought a concession from the insurer that her injuries ought to be considered non-threshold and that her degree of impairment exceeded 10% whole person impairment. The insurer declined to make this concession. Following an application for an internal review the insurer issued a certificate of determination confirming their earlier decision that the injury ought to be considered a threshold injury.
4.	The claimant then filed an Application for assessment of a threshold injury and whole person impairment. On 6 June 2023 the claimant was assessed by Medical Assessor Abhishek Nagesh who in a certificate dated 26 July 2023 determined that the claimant suffers from a post-traumatic stress disorder which gives rise to a permanent impairment of 14%.
5.	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.
6.	The new review provision provide that a review panel consists of two Medical Assessors and a Member assigned by the Motor Accidents Division of the Personal Injury Commission (the Commission).
7.	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.
8.	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.
9.	The review of the medical assessment is by way of a new assessment of all the matters with which the medical assessment is concerned.
STATUTORY PROVISIONS/GUIDELINES
10.	Section 57 of the Motor Accident Injuries Act defines a “medical dispute” as a disagreement or issue to which Part 3.4 of the MAC Act applies.
11.	Section 58 and s 60 of the MAC Act together with clauses 1.5-1.7 of the Guidelines set out the procedures for referral to one or more medical assessors and the principles to be applied at such assessments.
12.	The claimant was assessed by the Medical Assessor Christopher Canaris and Medical Assessor Matthew Jones, via audio-visual link through the MS Teams platform, organised by the Commission.
EXAMINATION INTERVIEW
13.	The limits of confidentiality were discussed with Ms Karroum, including that this was for assessment and not treatment and that the Review Panel (Panel) was writing a certificate that would be read by others. Ms Karroum indicated she understood the limits of confidentiality and consented to the assessment. 
14.	The claimant is a 43-year-old woman currently living in Busby, in Sydney, in rental accommodation. She has lived there for approximately one year. She lives there with her two daughters, aged 15 and 13. They are both well and both attending the local high school. 
15.	The claimant reported that her ex-husband was deported to Lebanon after accusations about his involvement with the Islamic State of Iraq and Syria (ISIS). She reported that he is no longer her husband, and they divorced nearly a year ago. She reported he had been detained in Villawood Detention Centre in January 2017 and was deported approximately six months later. Ms Karroum went to Lebanon to visit him approximately three years ago. 
16.	The Panel asked Ms Karroum why she and her husband had divorced, and she said that she was physically unable to make the time and effort to visit him after her injuries in the accident. She reported she went through a lot of depression and was not able to pick herself up. She also commented that he was not able to support her, either emotionally or physically, given his circumstances. Ms Karroum reported she has not re-partnered since the divorce. 
17.	The claimant was initially significantly affected when her husband was detained in Villawood Detention Centre and then things for her were “bad for a couple of years.” She experienced depression, she felt worthless, and she always felt very drained. She was constantly crying and said the situation was “ugly.” At the time she was living with her mother and father. 
18.	The claimant reported she had no previous mental health problems, prior to her husband being detained in immigration detention. She denied any family history of mental health problems. 
19.	From a drug and alcohol perspective, there is no recreational drug history and no history of ingestion of alcohol. She previously smoked cigarettes but now vapes and was vaping in the assessment. She reported she has three cups of coffee a day. She has no gambling history and has never been addicted to prescription medications. 
20.	From a medical perspective, she denied any history of significant medical diagnoses, including a history of hypertension, diabetes or thyroid disease. She does not take any regular medications for medical purposes, and she had undergone no other surgery prior to the motor vehicle accident. Her children were both normal vaginal deliveries which were uncomplicated. 
21.	With respect to income, Ms Karroum reported she is receiving Centrelink benefits in the form of single parent payments. She is not currently employed. 
22.	The claimant reported that she last worked leading up to the accident. She was a childcare teacher at a childcare centre and would work 40 hours a week. At that time, she was living with her parents who helped out with looking after her children.
23.	As an aside, Ms Karroum reported that her father passed away on 17 November 2022. Her mother is still alive and lives in her own home at Abbotsbury, which is about 10 minutes away from her place. 
24.	The claimant has four sisters, three of whom live locally with their families, less than 10 minutes away. One of her sisters lives with her mother. There are no other close extended family members in Sydney. She reported that the family may gather for a barbeque at her mother’s occasionally, with a total of thirty attendees, including her sisters and their children. 
25.	The Panel asked Ms Karroum if she felt any better after the psychological therapy she received related to her husband’s detention and deportation and she said that she did not think that she “ever got better really.” Ms Karroum however did keep working and described the time in her life as “a very big rollercoaster.” She said that after she had returned from visiting her husband overseas, she then started working at the childcare centre. Prior to that she was a stay-at-home mother and also running a family day-care business, for before and after school care, for up to seven children aged between eight and twelve. She went overseas in about 2017. She had worked in childcare for two years after the accident, after having completed a certificate in childcare. 
PSYCHOSOCIAL HISTORY 
26.	The claimant has received previous psychological treatment. In May 2019 (about seven months before the accident) she was referred to see a psychologist who she saw on a few occasions. She was also prescribed an antidepressant, Escitalopram, however she did not take this. The reason she saw a psychologist around that time was after her husband was deported “things went downhill” for her, not having a companion. She had been relying on him a lot. He used to financially support the family, and he worked in formwork. 
27.	From a personal and developmental perspective, Ms Karroum’s parents were married in Lebanon and her father came out to Australia two years prior to her mother. Ms Karroum was born in Sydney and grew-up in Cabramatta West until 2007, and then moved to Abbotsbury. She is the sixth of seven children born to her parents. In addition to her sister, she has two brothers; one lives on his own in Burwood and the other is married and lives in Gregory Hills, about 30 minutes away. She will not travel to see her brothers; however she will see them at her mother’s, and they sometimes come and visit her. 
28.	The claimant’s mother never worked, and her father had a few jobs including on the railways, as a parking inspector, and working in a petrol station.
29.	As a youngster, Ms Karroum had no major health issues. She spent all of her primary school years at Harrington Street Public School in Cabramatta. She spent all of her high school years at Bonnyrigg High School, which she described as good. She went to high school until the middle of year 11 and after that was married at the age of 18. She had met her husband as a student at Bonnyrigg High School. At the age of 19 she had her first child and at the age of 21 she had her second. Her first employment was in family day-care, which she did for about four years, and her second job was in childcare, which she did for about two years. 
HISTORY OF THE MOTOR VEHICLE ACCIDENT
30.	The claimant confirmed the date of accident as 28 December 2019, a little less than five years before the assessment. Ms Karroum reported that that night there was a family outing to go fishing and, on the way back, around 12 midnight, she was driving with her two daughters in the car. There were a few other family members driving in other cars in front. The other cars crossed an intersection and Ms Karroum stopped at a red light. Seconds later a taxi hit her from behind. She reported the impact was hard and that her car merged into the left lane from the impact and luckily no cars were there. She reported she “went into shock mode.” She remembers screaming, feeling terrified and that her children were crying in the back of the car. She reported she suddenly turned around to make sure her children were okay. She said she froze, she could not move, her body was numb, and she was crying and shaking. The other family members heard the big bang and came back to attend to her.
31.	The claimant then reported that she does not remember anything and that she “blacked out.” She did say that no police or ambulance attended the scene and there were two cars involved in the accident. 
32.	The claimant’s car was driveable, and it made it home, driven by another family member. She went in her parents’ car with her two daughters to travel home. At the time she was living with her parents. 
33.	The claimant reported she was in “so much pain” and had a “massive headache.” Ultimately her car was written-off. The Panel cross checked with Ms Karroum whether she struck her head, and she reported that she did not, however did lay her head on the steering wheel at one point. Her next memory after blacking out was jumping out of the car. 
HISTORY OF SYMPTOMS AND TREATMENT FOLLOWING THE MOTOR VEHICLE ACCIDENT
34.	The claimant remembers that she had a severe headache. She also said her neck was sore and it felt like she had “ripped something.” She had a lot of tension down her shoulders and felt like she had been “hit by a bat.” 
35.	With respect to treatment, Ms Karroum said it was around the Christmas holidays and her normal doctor was away. She visited a medical centre at Green Valley Plaza and asked for a scan. She said the following morning she still had the tension in her neck. She thinks she had an X-ray, but she is not sure what it indicated. She was told that she had whiplash. Not long after, her normal general practitioner, Dr Tan Le Tran, returned and he referred her to do other scans, which she believes were an MRI and an ultrasound. 
36.	The claimant received two Cortisone injections; one in her neck and one in her shoulder. She was also referred for platelet-rich plasma (PRP) injections in her neck, shoulder and lower back. 
37.	The only physical injuries that Ms Karroum noticed were in her neck, her shoulders and her lower back. She did receive two operations on her right shoulder which she believes were rotator cuff repairs. The second operation occurred because the first operation was not fully successful. The last time she had a shoulder operation was in 2021. 
38.	The claimant also underwent physiotherapy and went “heaps of times.” She said it was moderately effective, but only offered temporary relief. She continued to feel pain and some days were worse and some days were better. She said she had significant problems because of her right shoulder and being right-handed. She no longer attends physiotherapy and thinks the last time she went was three or four months before the assessment. She stopped because it was no longer being effective.
39.	With respect to ongoing symptoms, Ms Karroum reported she has significant amounts of tension in her neck and, with respect to her shoulder, there are some positions she cannot hold her arm in, and her functioning is very limited. She cannot hang out washing, do overhead work, and she has problems showering. She reported she washes her hair only once a week because she is physically unable to. When she vacuums, she uses her left hand more than her right hand. She has decreased carrying capacity and is unable to lift heavy things. 
40.	The claimant reported that her lower back pain is still a problem and that some days she finds it hard to stand or walk. She has to be careful bending over and sometimes it hurts when she is sitting. She said overall her pain has gradually become better, but she is not pain-free. 
41.	The claimant has not seen a pain specialist or attended a pain clinic since the accident. She takes painkillers in the form of Celebrex and Panadol Osteo, when her pain is bad. 
42.	The Panel asked Ms Karroum with what her pain interfered, and she said that at night she needs to get up and move her body and stretch out. She feels like she cramps up a lot at night-time. With respect to driving, she is unable to drive far distances but does drive locally to the shops and drops her children off at school. She went on to say that she has not really attempted to drive much after the incident. 
43.	The claimant reported she is taking no other medications currently and is receiving no other treatment. She did trial a number of medications after the accident including Endone which “drove [her] nuts” and did not react well with her. She also may have tried Tramadol but found that this was very strong. 
44.	With respect to psychological treatment, Ms Karroum saw Kim Dang after the accident. She thinks she may have seen her five times, and it was between the accident and her operations. More recently, at the start of 2024, she spoke to another psychologist over the phone. She spoke to her two times. The Panel asked Ms Karroum how the initial five sessions of psychological therapy went, and she said she did not know. She finds it hard to open up to people and she tends to be reserved. She has not seen a psychiatrist for treatment. 
45.	The Panel asked Ms Karroum specifically about any other mental health or emotional symptoms following the motor vehicle accident and she responded that she felt very depressed because her lifestyle had changed in regard to her physical capacity. She said it made her feel useless. She also reported that the pain would always get to her, and she does not feel like she is herself no matter how hard she tries. She said she does not feel the same socially, physically or emotionally. She conceded that she had problems previously and tried to seek help but now she feels worse. 
46.	The claimant reported that childcare was very important to her, and it was her “thing.” She then had this accident and she “tumbled again.” 
47.	The Panel asked Ms Karroum about her symptoms around the time she went to see the psychologist, Kim Dang, following the accident. She said she wanted to talk to someone and found it hard. She had a feeling that no one would ever understand her and even though she was trying to talk to family, friends or the psychologist, there was “no response that helped.” We tried to ascertain what other symptoms she was experiencing, and she said that emotionally and physically she “went down”. She said she still cannot pick herself up and she feels like she is “buried in a hole all the time.” 
48.	The Panel asked Ms Karroum about her return to driving, and she said it took about six months or more, however she still found that she was “in shock.” She was always scared, and she felt that she had to be cautious and felt drained all of the time. 
49.	The claimant also reported that she was experiencing flashbacks, and she would remember the accident and that always contributed to her worry. She said she worries especially when she is around cars and traffic, for example, if she is at a red light she needs to look around a lot. She reported that if she was watching television, she would remember the accident or even if she was in the shower, she would remember the accident. When she was doing the dishes at home she would “zone out.” 
MENTAL STATE EXAMINATION 
50.	The claimant was assessed through audio-visual link. She wore a headscarf, spectacles and a navy hoodie with a Champion motif. She wore no overt make-up but there were no signs of neglect. She was polite, cooperative and attentive and displayed no abnormal movements. Her speech was normal, and her command of English was excellent (she was born in Australia). There was no evidence of formal thought disorder or delusional thought processes. She denied any thoughts of self-harm or thoughts of harm to others. When asked about her mood, she described it as “really down.” She said that she does brighten up when she interacts with her children. She does however feel like she is “hating [her]self.” She reported she finds things hard as she is unable to do activities physically with the children and she finds that she is upsetting them all the time. Her affect (expressed emotion) was reactive, congruent and appropriate. She came across as a genuine historian. She was teary at times. She was mildly dysphoric at times but able to brighten in response to humour. She denied any perceptual abnormalities such as auditory hallucinations or ideas of reference. There was no evidence of psychosis. Her cognition, insight and judgement appeared intact in the context of the interview. Rapport was excellent and Ms Karroum spoke openly and freely. Ms Karroum concentrated well for the assessment, which had a duration of in excess of eighty minutes. 
RECENT FUNCTIONING
51.	With respect to sleep, Ms Karroum reported it is disturbed by pain. She also has dreams which are chaotic and involving a lot of people. She will wake-up with a headache. She has dreams of someone chasing after her and she had one dream when she was falling out of an aeroplane. She described her appetite as normal and that she has “put on heaps of weight.” When she was working, she estimated her weight was 78kg or less, and she is now approximately 90kg. She reported her height as 163cm. 
52.	The claimant reported that she misses taking her children to the pool and jumping in the pool, going for long drives and various outdoor activities. She was unable to do these because of her pain. She also worries that something bad might happen. 
53.	The claimant’s energy levels are low, and she will sometimes have a small nap in the daytime. She described herself as feeling “very lazy.” 
54.	With respect to her general daily routine, Ms Karroum reported she would get up at 7.00am, wake her daughters up and they will get themselves ready for school. She reported they make their own lunch and make their own beds, and even help her make her bed. Ms Karroum will then have a coffee, and by 8.30am she will take her children to school, which is about a two-minute drive. She will then go over to the plaza and obtain groceries, in order to cook dinner. She will then come home and do the chores she is able to do, and her level of domestic activity depends on how she feels that day. She reported there are some days she does not function and simply puts off her chores. 
55.	The claimant reported that sometimes her sisters will drop by in response to her calling them and saying that she needs help with something such as washing or heavy cooking. She said her sisters sometimes just drop around for company. With respect to cooking by herself, she will normally produce something easy.
56.	The claimant reported she will watch television and sometimes she zones out while watching. She said her Arabic is not particularly good. She knows a little Arabic through her father, but otherwise speaks predominantly English. 
57.	The claimant reported she does not have friends. She used to have some friends, including one from going to the gym years ago, however she has drifted away from her since the accident as her friend did not understand her circumstances. She said it turns out that this person is not as good a friend as she thought. Ms Karroum had other friends, including workmates from the childcare centre, however they have all drifted away; one is married, one has a baby and “everybody got busy”. 
58.	The claimant reported she is getting on well with her children and family members. Her children are “doing okay at school.” The claimant reported she will usually shower just before bed, at around 8.30pm. The claimant will drive locally, for example to the local plaza, or to visit her mother who is 10 minutes away, or to drop her children off, and pick them up from school, which is two minutes away. She tends not to use public transport unless she desperately needs to go somewhere.
59.	The claimant reported she does not attend mosque, but previously did. She will pray at home however and will kneel if she is able to, but otherwise will pray in the chair. With respect to work, Ms Karroum reported she would like to go back to childcare. The Panel asked Ms Karroum about her subjective capacity to concentrate, and she reported that it has decreased because her “brain is constantly working.” She reported she always has noise in her head, and she is always thinking. She thinks about where she was and where she is now, and this is what is hurting her the most. She confirmed when asked that she had a sense of loss. 
60.	The claimant also noted that she had some memory loss. She said she will forget a conversation she has had with someone or forget where she has placed items. She reported there are days when she wakes up confused and blank and days when she will tell herself that she is not driving. She reported she feels like she zones out a lot and when she does this, she chooses not to drive for safety reasons. 
61.	The Panel asked Ms Karroum what her circumstance would be if her pain was eradicated, and she referred to the fact that the pain has overcome her wellbeing, and she cannot even think positively anymore. She said the emotional side of things has “done so much damage” to her. 
62.	The Panel asked Ms Karroum what she would enjoy doing if she had no pain, and she said that she would like to go to the gym and go back to work. She reported she loved being at her workplace and loved doing what she was doing. She also reported she would like to stop smoking. She said she would also like to socialise more because pain interferes with her ability to partake of activities, and she feels like an outsider. She also reported she would like to return to swimming in a pool. She said she does go sometimes, but only for a short time. She feels very reserved and snappy and feels “upset”. She reported she does not feel like her friends are understanding where she is coming from. She indicated that if they did understand her, they would show-up more or call her constantly. She said her friends drift off when she is answering questions such as how she feels, and she questions whether they really care. 
CURRENT AND PROPOSED TREATMENT
63.	The claimant is no longer receiving physiotherapy treatment. She said she had tried this, and it was no longer helping. She felt the same way about seeing a psychologist. She said that treatment was not giving her what she needed. When asked what she needed, she said she needs support, including “answers” and reassurance. She felt she never received reassurance from the psychologist, and it turned her off speaking to her. 
64.	The claimant reported she would consider taking antidepressants if they were suggested again. 
SUMMARY OF RELEVANT DOCUMENTATION
65.	The insurer has sought to have the certificate of Medical Assessor Abhishek Nagesh referred to a Review Panel citing what they considered to be his failure to deal with inconsistencies between the claimant’s account of the accident and history in the documentation. Medical Assessor Nagesh reported her as saying that she had gone blank, that her head hit the steering wheel, that her car moved into the next lane, that she could hear people talking but could not respond, and then woke herself up. By contrast, records of the Wilson Road Clinic record a rear end collision with no police or ambulance in attendance and with no reference to a head strike, loss of consciousness, or their vehicle swerving into another lane. Similarly, there was no reference to these events in her application for personal injury benefits or in the history provided to Medical Assessor Sam Perla which recorded that she had denied loss of consciousness, that she had been able to exit the vehicle, and that no police or ambulance attended. The insurer noted similar inconsistencies in the histories obtained by other specialists and then the 13 March 2023 certificate of Medical Assessor Home. The insurer submits that the accuracy of the post-traumatic stress disorder diagnosis is thereby called into question. It further submits that the claimant’s assertion that she had not attempted to return to work because of depressive and anxiety symptoms was not consistent with medical evidence that her capacity for work was significantly limited by physical restrictions. It took issue with the assessment of whole person impairment because it had not taken into account restrictions due to pain.
66.	The Panel noted the claimant’s application for personal injury benefits which refer to her physical injuries but state that the accident was “a big shock for me”. The Panel noted sundry certificates of capacity which refer to physical injuries but also to “Post Traumatic Stress Syndrome” and “Adjustment Disorder Syndrome”. The Panel noted the certificate of Medical Assessor Sam Perla dated 17 August 2021 as cited by the insurer.
67.	The Panel noted the complete record of Wilson Road Clinic as printed on 7 June 2023 will. She was diagnosed with “mixed anxiety/depressive disorder” in 2019 and prescribed Lexapro (escitalopram – an antidepressant) 10mg daily. There is a reference to psychological symptoms such as poor sleep, early morning waking, depressed mood, and low self-esteem in a note on 13 May 2019, which states that her husband had been deported and imprisoned in Lebanon. The Panel noted a GP mental health treatment plan and referral to a psychologist associated with that consultation.
68.	The Panel noted an allied health recovery request for psychology stating a provisional diagnosis of post-traumatic stress disorder while cataloguing symptoms including anxiety while driving, heart palpitations when driving or when alone, general worries, difficulty in relaxing or winding down, loss of motivation, sleep difficulties including wakefulness, flashbacks of the motor vehicle accident including of her children screaming, flashbacks of herself fearing for their lives, intrusive thoughts about the accident, poor concentration with distractibility and zoning out, low mood, irritability, difficulty dealing with stress, increased smoking, loss of interest in previously enjoyed activities, and low energy scores on the depression, anxiety and stress scale (DASS) in the extremely severe range for depression, anxiety and stress and a PCL-5 score of 58 out of a possible 80. 
69.	The Panel noted a psychologist report dated 2 July 2020 reprising the symptoms. The report states that “a speeding motorist hit her car from behind while she was stopped at a traffic light. She reported that her car was a write-off and that she suffered multiple physical injuries during the MVA requiring treatment”. The Panel noted a series of corresponding psychology notes and noted a reference to depression and anxiety over her husband having been deported for which she had seen a psychologist in 2019.
70.	The Panel noted a report of her psychologist, Kim Dang, dated 29 July 2020 which traverses similar territory while noting her understandable distress after her husband had been deported to Lebanon, leaving her with having to raise their two children as a single parent, while stating that her current symptoms “do not align with simply being separated from a husband”.
71.	The Panel noted the report of Dr Inglis (Howe) Synnott, independent medical examiner (IME) psychiatrist, dated 10 May 2023. Dr Synnott noted that she first experienced significant psychiatric difficulties in 2016 when her husband was deported to Lebanon, although she denied seeing a psychiatrist or a psychologist or taking psychotropic medication. Dr Synnott diagnosed major depressive disorder with prominent anxiety and rated her at 6% whole person impairment while deducting 30% (ie, 2%) yielding a final whole person impairment of 4%. He rated her as Class 1 for self-care and personal hygiene, Class 2 for social and recreational activities, Class 2 for travel, Class 2 for social functioning, Class 2 for concentration/memory (concentration, persistence, and pace), and Class 3 for employment (adaptation). He made no adjustment for treatment effect.
72.	The Panel noted the certificate of Medical Assessor Abhishek Nagesh dated 26 July 2023. Dr Nagesh made a diagnosis of post-traumatic stress disorder and assessed the claimant at 15% whole person impairment rating her as Class 2 for self-care and personal hygiene, Class 3 for social and recreational activities, Class 2 for travel, Class 2 for social functioning, Class 3 for concentration, persistence, and pace, and Class 3 for adaptation. He assessed her at 1% whole person impairment for pre-existing major depressive disorder rating her as Class 1 for all categories except for social and recreational activities and concentration, persistence, and pace in which he rated her as Class 2. He made no adjustment for treatment effects and made a final rating of 14%.
73.	The Panel noted the certificate of Medical Assessor Alan Home dated 13 March 2023. Medical Assessor Home certified that the claimant’s injuries comprising a musculoligamentous strain of the cervical and lumbar spines and musculoligamentous strain with aggravation of underlying calcific tendinopathy and post traumatic subacromial bursitis treated with subacromial decompression surgery gave rise to a permanent impairment of 9%. The Panel took note of aspects of the history recorded by Medical Assessor Home referred to by the insurer:
“Her vehicle was stationary when struck from behind by a taxi. There was no secondary forward impact.
Her vehicle was subsequently written off with rear-end damage. She recalls that she sat in the vehicle for a short period. She was attended by family members in a nearby vehicle.”
74.	Medical Assessor Home noted that she was independent with self-care and that she performed the share of domestic chores at home including hanging out washing on a low line while performing heavier chores in a piecemeal fashion, leaving lawnmowing to her brother-in-law.
75.	The Panel noted sundry physical assessments (eg, Dr Jonathan Herald, IME orthopaedic surgeon, dated 11 April 2022) and confirmed that there was no mention of loss of consciousness or head strike although the offending vehicle was said to have hit her car at some speed resulting in “a severe impact”. Dr Herald noted that she had “suffered with PTSD as a result of the accident” in that she had been seeing a psychologist and had been started on Lexapro (escitalopram – an antidepressant).
76.	The Panel noted the Activities of Daily Living Assessment Report dated 6 April 2021 which describes the accident in which the claimant “reported losing control and her car swerved left”. The Panel noted Cervical fusion procedure and right shoulder surgeries times two.
SUMMARY
77.	The claimant was a 43-year-old woman who reported a narrative and presented at assessment as consistent with having a psychiatric diagnosis of Persistent Depressive Disorder under the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). This Persistent Depressive Disorder had been exacerbated by the motor vehicle accident and her subsequent injuries. It had commenced, in the Panel’s opinion, with the difficulties she had experienced with her husband being detained in immigration and detention and deported out of Australia. 
78.	Given the strong pain component in Ms Karroum’s presentation and reported narrative, the Panel considered that there was also likely present a somatic symptom disorder. Notwithstanding this, there was sufficient psychological and emotional symptoms present to diagnose a separate Persistent Depressive Disorder. Ms Karroum’s symptoms have become chronic. In the Panel’s opinion she had not received appropriate treatment for her Persistent Depressive Disorder, however had attempted to speak with a psychologist, with no success. She is not currently receiving any psychological or psychiatric treatment. Her symptoms have stabilised, and the Panel considered that she had a permanent psychiatric impairment. 
79.	The claimant satisfied DSM-5 diagnostic criteria for Persistent Depressive Disorder in the following way. 
80.	The claimant has experienced depressed mood for most of the day, more days than not, for at least two years (criterion A). She has experienced a degree of over-eating, sleep disturbance for a period, low energy levels, low self-esteem, poor concentration at times and feelings of hopelessness (criterion B). 
81.	The claimant has not been without the above symptoms in criteria A and B for more than two months at a time (criterion C).
82.	The claimant may have satisfied criteria for a Major Depressive Disorder for a period of two years (criterion D).
83.	There is no history of any manic or hypomanic episode (criterion E). Ms Karroum’s mental status is not better explained by a schizophrenia spectrum or other psychotic disorder (criterion F). Ms Karroum’s symptoms are not attributable to the physiological effects of a substance or another medical condition (criterion G). Ms Karroum’s symptoms have caused clinically significant distress or impairment in social, occupation and other important areas of functioning (criterion H). 
84.	The claimant’s experience of worry and anxiety would justify a DSM specifier of “with anxious distress.” 
85.	The Panel considered that Ms Karroum had significant mood symptoms prior to the motor vehicle accident that were also present for in excess of two years. As such, we consider it appropriate to assess a pre-accident level of permanent impairment. 

ASSESSED ON HISTORY
Pre-accident degree of permanent impairment
Psychiatric diagnoses	1. Persistent Depressive Disorder	2.	
	3.	4.	
Psychiatric treatment description	Brief psychological therapy	

Category	Class	Reason for Decision	
1. 	Self Care and Personal Hygiene	1	Minor deficit attributable to the normal variation in the general population.
The Panel has no evidence that Ms Karroum had any significant pre-accident impairment in this domain. 	
2. 	Social and Recreational Activities	2	Mild impairment.
The Panel considered that from Ms Karroum’s report, she had global reduction in her enjoyment of any social or recreational activities, “everything had gone downhill” and that, utilising clinical judgement, there was likely a mild impairment in this category. 	
3. 	Travel
	1	Minor deficit attributable to the normal variation in the general population.
The Panel has no evidence that there was any significant impairment in Ms Karroum’s ability to travel (indeed, she travelled to Lebanon to visit her husband). 	
4. 	Social Functioning
	1	Minor deficit attributable to the normal variation in the general population.
The Panel has no evidence before them of any rupture in relationships with her close family or friends. Her husband was separated from her for legal and geographical reasons; however they maintained a relationship at that stage. 	
5.	Concentration, Persistence and Pace	1	Minor deficit attributable to the normal variation in the general population.
Despite Ms Karroum reporting having significant mental health symptoms, she was able to continue to work full-time in her childcare role which demonstrated sufficient concentration, persistent and pace to justify a class 1, minor deficit. 	
6. Adaptation
	1	Minor deficit attributable to the normal variation in the general population.
Again, despite report of significant symptoms, Ms Karroum was able to continue in full-time employment leading up to the accident. 	
List classes in ascending order: 1 1 1 1 1 2 	
Median Class Value: 1	
Aggregate Score: 7	
% Whole Person Impairment: 0%	
*%WPI = Percentage Whole Person Impairment
CURRENT WHOLE PERSON IMPAIRMENT
Psychiatric diagnoses	1. Persistent Depressive Disorder. 	2.	
	3.	4.	
Psychiatric treatment description	Nil treatment.	

Category	Class	Reason for Decision	
1. 	Self Care and Personal Hygiene	1	Minor deficit attributable to the normal variation in the general population.
Ms Karroum is independent with respect to her self-care and personal hygiene such as showering, dressing and grooming. She has some physical difficulties, but these are not taken into account. She partakes of domestic chores and cooking duties to her physical capacity. She still manages her household (however her children are less reliant on her given their age). The Panel’s opinion is that Ms Karroum could live independently, if required, without assistance. 	
2. 	Social and Recreational Activities	3	Mild impairment
Ms Karroum has withdrawn socially and reduced her social and recreational activities. There is some physical component, not taken into account in this assessment. However, the Panel’s opinion was that she has limited social interaction, for example occasional barbeques with close family members, but is no longer partaking of any significant social or recreational activities. Utilising clinical judgement, there is a class 2 mild impairment here. 	
3. 	Travel
	2	Mild impairment
Ms Karroum reported she is still capable of driving, however, will only drive to local and familiar destinations such as her mother’s, the local shops, and the local high school. There are days she does not feel up to driving. She previously would enjoy long drives but no longer does this (partly because of physical reasons, not taken into account in this assessment, but also partly due to anxiety and wariness). Utilising clinical judgement, there is a class 2 mild impairment here. 	
4. 	Social Functioning
	2	Mild impairment
Ms Karroum maintains close supportive relationships with her sisters, her parents and her children. She also maintains contact with her brothers. She has withdrawn from most of her friendships. The Panel does not consider her separation and divorce from her husband to be predominantly caused by her mental health problems emanating from the motor vehicle accident. Utilising clinical judgement, there is a class 2 mild impairment here. 	
5.	Concentration, Persistence and Pace	3	Moderate impairment
Although Ms Karroum concentrated well for the assessment, which had a duration of in excess of eighty minutes, there is little in her reported day-to-day activities that is consistent with having significant capacity in this category. Given the descriptors in the PIRS, the Panel considered it unlikely that she would be able to complete a basic training course, nor concentrate on cognitively demanding tasks for more than thirty minutes. She completes minor domestic tasks within her physical capacity. There are days when she does not have the energy or motivation to properly function in day-to-day tasks. She reported often zoning out doing simple tasks such as watching television or washing dishes. Utilising clinical judgement, the Panel considered there was a class 3 moderate impairment. 	
6. Adaptation
	3	Moderate impairment
Although Ms Karroum reported not being currently capable of her pre-accident employment, this was in part due to physical limitations, not taken into account in this assessment. With respect to her other adaptive roles as daughter, mother and sister, she does function at a moderate level, including in the social context of those family relationships. The Panel took the view that the psychiatric capacity with respect to her pre-accident roles was such that she is able to function, at a reduced level and only up to half her previous capacity, which is, utilising clinical judgement, consistent with a class 3 moderate impairment. 	
List classes in ascending order: 1 2 2 2 3 3	
Median Class Value: 2	
Aggregate Score: 13	
Current % Whole Person Impairment: 7%	
*%WPI = Percentage Whole Person Impairment
Apportionment 
86.	Pre-existing impairment has been apportioned above as being 0%. There is no apportionment for subsequent impairment, in the Panel’s opinion. 
Effects of treatment
87.	The claimant is not receiving any psychological or psychiatric treatment and no adjustment for effects of treatment is warranted. 
88.	Therefore, the final whole person impairment is 7% which is less than 10%.