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Case study 7 - an insurer correctly assesses minor injury

The Assessor found the claimant’s injuries being the right shoulder, neck, scalp, right side of chest, right hip and the related symptoms meet the criteria of a minor injury as defined by the Motor Accidents Injury Act 2017.

Introduction

The claimant was involved in a T-bone collision, their vehicle was struck on the left-hand side. An ambulance was called and they were taken to hospital for investigation due to reported dizziness.

The claimant has attended their GP on many occasions and has taken to wearing a neck brace to assist in pain management despite not being referred to do so by a medical professional.

The assessment

There is a dispute about whether the injury is a minor injury under Schedule 2 section 2(e) of the Motor Accident Injuries Act 2017 (the Act).

Clinical examination

Cervical Spine

  • Neck posture, alignment and contour were normally maintained.
  • Reported tenderness to the slightest touch.
  • No noted muscle spasm, or guarding, no dysmetria/asymmetry of neck movements.
  • Observed half normal range of rotation left and right, and half normal range of lateral bending to the right and left.

Thoracic Spine

  • No pain or other complaints in the thoracic region.
  • Examination was unremarkable.

Lumbar Spine

  • Pain in the right flank was unremarkable, was not tender.
  • No muscle spasm, guarding, nor asymmetry.

Upper extremity

  • No wasting or deformity noted.
  • Arthritic changes in the hands, fingers and thumbs observed.
  • Moderate range of motion reduced in the right side: flexion reduced 30°, 30° abduction, and 10° adduction.
  • There were no neurological abnormalities detected in the upper limbs, with normal power, tone, deep tendon reflexes and no sensory deficits detected.

Lower extremity

  • Examination of the right hip and legs was unremarkable.

The examination was consistent with “whiplash injury to the neck and right shoulder” as diagnosed in the hospital discharge report.

Review of Documentation

Discharge summary from St George Hospital: indicates MVA occurred and no diagnostic entities identified. These findings are indicative of a minor injury.

Motor Accident Medical Certificate: confirmed the diagnosis of a whiplash injury, Hyperextension injury of the neck involving the trapezius muscles.

Diagnosis

Neck – soft tissue injury

Right Shoulder – pain referred from the soft tissue injury to the neck.

Injuries to the scalp, right side of chest and right hip are considered to have resolved.

Minor Injury

Section 1.6(2) of the Act

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

Schedule 1 [2] clause 4 of the Motor Accident Injuries Regulation 2017:

  1. An injury to a spinal nerve root that manifests in neurological signs (other than radiculopathy) is included as a soft tissue injury for the purposes of the Act.

The following injury is a minor injury

  • Neck – Soft tissue injury
  • Right shoulder – pain referred from the soft tissue injury to the neck.
  • (Resolved) Scalp injury
  • (Resolved) Right side of the chest
  • (Resolved) Right hip