Does merely “broad” reasoning amount to “inadequate” reasoning?

Key principles

• In assessing causation, all an Assessor is required to determine is whether a Claimant’s injury was caused by the accident. The mere fact an Assessor concludes an injury was not caused by the accident but identifies an alternative cause for that injury, which is not supported by the medical documentation, is irrelevant and does not, of itself, constitute an error.
• A party is not denied procedural fairness in circumstances where the issues in dispute should have been obvious from the medical documentation and there was an opportunity to address these issues, prior to assessment.
• It is sufficient for an Assessor to provide reasons that are broad if the path of reasoning can be logically deduced from the reasons and the Assessor’s clinical findings.

Background

The Supreme Court handed down its decision in Puga v Allianz Australia Insurance Limited [2024] NSWSC 1235 on 2 October 2024.

The Claimant sought judicial review of an Assessor’s finding of 9% whole person impairment (WPI) and a President’s Delegate’s dismissal of the Claimant’s review application.

On 1 September 2023, the Claimant’s orthopaedic injuries were assessed by a PIC Medical Assessor at 9%. On 1 December 2023, the Claimant’s brain injury was assessed by another PIC Medical Assessor at 1%. On 4 December 2023, a Combined PIC Certificate was issued assessing the Claimant’s physical injuries at 10% WPI, below the threshold.

On 15 December 2023, the Claimant lodged an application for review of the Assessor’s Certificate dated 1 September 2023 and the Combined Certificate dated 4 December 2023. The Claimant did not dispute the Certificate dated 1 December 2023.

On 25 January 2024, a PIC President’s Delegate dismissed the Claimant’s review application on the basis the Delegate was not satisfied there was reasonable cause to suspect that the medical assessment was incorrect in a material respect.

The Claimant sought judicial review of the Assessor’s and Delegate’s Certificates on the following grounds:

1. The Assessor erred in their conclusion that the Claimant’s right shoulder condition likely developed after the accident and during the course of his work performing car radio installations when there was no evidence the Claimant had injured his right shoulder at work.
2. The Assessor did not afford the Claimant procedural fairness before reaching their conclusion regarding causation of the Claimant’s right shoulder injury.
3. The Assessor erred by finding the Claimant recalled ‘first noticing right shoulder pain whilst installing car radios in early 2020’, when this was not the evidence before the Assessor.
4. The reasons given by the Assessor, in respect of their assessment of WPI for the right knee, were inadequate.
5. The decision of the Delegate was so unreasonable that no decision maker could have made that decision.

Supreme Court reasons

Associate Justice Harrison rejected all the Claimant’s grounds for review.

Ground one

Her Honour observed, at the time of the accident, and in the period immediately following it, the Claimant never complained about pain in or an injury to his right shoulder and this injury was not recorded by the Claimant in his Application for Personal Injury Benefits. The only evidence before the Assessor, relating to a right shoulder injury, was a medicolegal report by the Insurer’s expert who concluded the Claimant’s right shoulder pain was not caused by the accident.

Her Honour accepted the Assessor considered all the documents before them and had regard to a range of radiological and medical imaging, none of which related to the right shoulder, in coming to their conclusion regarding causation. The Claimant also did not deny telling the Assessor that his right shoulder symptoms developed in mid-2020 or coincided with his return to car installation work. On this basis, her Honour concluded there was sufficient evidence before the Assessor to find the Claimant’s right shoulder injury was not caused by the accident.

Ground two

Her Honour accepted, based on the medical documentation and the reports obtained by the parties, the Claimant was put on notice that the Insurer was going to argue his right shoulder injury was not caused by the accident. The Claimant had the opportunity to prepare an initial statement to expressly state his right shoulder injury did not result from his work assembling car radios and his reasoning why this alternate view was incorrect but did not do so. In these circumstances, Her Honour concluded the Claimant was not denied procedural fairness.

Ground three

Her Honour highlighted the Assessor’s findings on causation must be read as a whole, with the earlier sentences before it. The Assessor notes there was ‘no record of a right shoulder injury in the Claimant’s file’ and that the Claimant recalled first noticing shoulder pain whilst installing car radios in early 2020, approximately 12 months post-accident. The Assessor ultimately concluded it was not plausible ‘the Claimant could injure his right shoulder and be unaware of this for 12 months’. In these circumstances, her Honour was satisfied there was no error.

Ground four

Her Honour acknowledged the Assessor’s mere reference to ‘sections 6.68 to 6.110 of the SIRA Guidelines’, to support the finding of 0% WPI for the right knee, can be considered broad reasoning because some of these sections refer to tests the Assessor did not use in coming to their conclusion. However, her Honour observed the sections of the SIRA Guidelines which the Assessor did use were fewer than three pages. It was not difficult to follow the Assessor’s reasoning when cross referencing those pages with the Assessor’s decision itself, which referred to the Claimant’s range of motion. Her Honour commented that, whilst more precise reasoning could have been provided, the Assessor did not need to provide ‘textbook references’ to justify their decision. All that was required was that the Assessor’s reasoning could be logically deduced.

Ground five

In accordance with the reasons outlined above for ground four, her Honour concluded the Delegate’s finding that there was ‘no requirement for the Assessor to explain the type of testing undertaken’ was not so unreasonable that no decision maker could have made that decision.

Why this case is important

The decision in Puga highlights that just because the reasons provided by an Assessor are ‘broad’, it does not mean the Assessor’s reasoning is illogical. The test is whether the reasoning can be logically deduced from the reasons provided by the Assessor, along with the Assessor’s clinical findings and observations.

Further, this case underscores the importance of identifying the issues which are in dispute before any assessment is conducted. An unfavourable decision will not amount to a denial of procedural fairness if there was an opportunity, prior to the decision being made, for a party to address the issues in dispute but the party chose not to do so.

Additional McCabes Resources

• MC PIC Decision of the Week
• MC MAIA Toolkit
• The Proper Lookout Podcast
• MC Ready Reckoner