A NSW review panel has sided with a claimant over QBE Insurance after finding the insurer's radiologist appears not to have been given critical pre-accident imaging.
The Personal Injury Commission Review Panel handed down its decision on March 31, 2026, revoking an earlier medical assessment that had classified all of the claimant's injuries as threshold under the Motor Accident Injuries Act 2017 - a classification that would have limited her entitlements.
The claimant, Siu Ching Maggie Lam, was a 64-year-old casual support worker and passenger in a vehicle struck on the passenger side on November 25, 2023. The collision forced the car into a second impact with an oncoming vehicle. She reported neck pain, headaches, and chest soreness in the aftermath, with shoulder symptoms building over the following months.
The wrinkle in this case was a documented history of right shoulder trouble. A 2014 ultrasound had picked up a partial thickness supraspinatus tendon tear, which settled with physiotherapy. But imaging taken after the accident — an ultrasound in March 2024 and an MRI in May 2024 — revealed the tear had progressed to full thickness. The claimant's treating orthopaedic surgeon, Dr Tack Shin Lee, recommended surgery and stated the tear was "either an acute injury or an acute injury on chronic injury" contributed to by the accident. QBE declined the surgery. Ms Lam paid for it herself in July 2024.
The original medical assessor, Senior Medical Assessor Ian Cameron, had found all injuries were threshold and that the surgery, while related to the accident, was not reasonable and necessary. He reasoned there was no evidence the pre-existing tear had been aggravated.
The Review Panel disagreed. After reviewing dashcam footage of the collision and conducting a fresh physical examination, the panel found the double-impact mechanism was capable of worsening a rotator cuff tear. It noted that the claimant's shoulders were asymptomatic before the accident and that her complaints became significant and consistent from March 2024 onward.
Importantly, the panel found that the insurer's radiologist, Dr Dugal, did not appear to have been provided with the 2014 ultrasound — the baseline imaging that showed only a partial tear. Without it, he had not commented on the progression. He also lacked clinical history and had not examined the claimant. The panel agreed with Dr Lee that causation "cannot be determined by imaging alone without a review of the clinical history and examination."
The panel reclassified both shoulder injuries as non-threshold, approved the rotator cuff surgery and post-operative physiotherapy as reasonable and necessary, but declined domestic assistance — finding the claimant had not been responsible for yard maintenance before the accident and was independent with meal preparation.
For claims teams, the practical message is pointed: an expert opinion is only as strong as the material behind it. Incomplete briefing of medico-legal experts can unravel an insurer's position on review.
