GIO v Mohammed: the scope of a PIC medical dispute

Mr Mohammed was injured in a motor vehicle accident on 2 May 2022. GIO initially described his neck, upper-back, shoulder and other injuries as threshold injuries and stopped statutory benefits after the relevant period. He sought an internal review and then applied to the PIC for medical assessment of several injuries, including left supraspinatus tendinosis and subacromial bursitis.

An early shoulder ultrasound, performed shortly after the accident, was reported as showing mild supraspinatus tendinosis without a tear and mild bursitis. The first Medical Assessor treated the shoulder injury as soft tissue and threshold. A later further assessment did the same.

During the later Review Panel process, GP records included a further ultrasound report identifying a partial-thickness supraspinatus tear. The Panel directed GIO to address whether that tear was caused by the accident. The Panel ultimately revoked the earlier certificate and certified that the left shoulder injury was not a threshold injury.

GIO argued that the original injury description was limited to tendinosis and bursitis, so the Review Panel had decided an entirely different injury when it considered the tear. The Court rejected that narrow approach. The statutory question is what matters the medical assessment was concerned with, assessed from the application, the insurer’s response, the medical evidence, the certificates, later referrals and the parties’ submissions.

The left shoulder was identified from the start as one of the body regions to be assessed for threshold status. GIO’s own submissions referred to the earlier report saying there was no tear and argued that the evidence did not show a qualifying tendon rupture. That submission made the existence and significance of a tear part of the live dispute, even though the short injury description used the words tendinosis and bursitis.

The Court also considered that the further assessment and referral history continued to include the shoulder. Later medical records supplied during the Review Panel process did not automatically create a new dispute, but they were capable of informing the existing question whether the accident-related shoulder injury was threshold or non-threshold.

The Court accepted the general principle that a Review Panel cannot decide a crucial issue on a basis that neither party had a fair opportunity to address. Procedural fairness is practical: a party must know the important issue and have a meaningful opportunity to provide evidence or submissions about it.

On the facts, the Panel issued a direction identifying the later report and asked GIO to make submissions about whether the tear was caused by the accident. GIO responded with detailed submissions relying on the early ultrasound, the absence of a tear in that report, the time gap and the absence of a clear causal statement in later certificates. The Court considered that response sufficient to reject the procedural-fairness ground.

The Court did not require the Panel to tell GIO in advance that it would find the early ultrasound wrong. The Panel was entitled to use its medical expertise to explain that a negative ultrasound did not conclusively exclude pathology, while also relying on other evidence such as immediate symptoms, continuing problems, examination findings and the absence of another incident.

Mohammed does not make an MRI or ultrasound finding decisive. The Court’s reasoning depended on the full evidence and the way the issue was contested. A later scan may be relevant to causation, but it must be tested against the timing, symptoms, examination findings, earlier imaging, intervening events and competing medical opinions.

It also does not allow a Review Panel to determine an issue that is genuinely outside the referred medical dispute without notice. The Court distinguished decisions such as *Cahill*, where a Review Panel determined a lumbar-spine issue on a basis not put to the parties and procedural fairness was denied. The scope of each dispute must be identified from its own record.

The judgment was judicial review, not a replacement medical opinion. It did not itself decide that Mr Mohammed had a particular WPI percentage or that every shoulder tear is non-threshold. It decided that the Review Panel’s process and legal approach were not shown to contain reviewable error.

A claimant should describe the injury accurately and completely in the claim and PIC material, including the body part, symptoms, clinical findings, imaging and any suspected tendon, ligament, cartilage or nerve injury. An insurer should identify the exact pathology it says is absent or unrelated, rather than relying only on a broad label such as “soft tissue”.

Keep the complete imaging reports and, where possible, the actual images. A report that says “no tear” may be important, but it is not the end of a causation analysis. The chronology should show when symptoms began, what examination found, whether treatment helped, whether there was another incident and when later imaging was obtained.

If a Review Panel raises a new medical issue, respond to the issue rather than only objecting to its existence. If the issue truly falls outside the dispute, identify the missing notice, the evidence or submission that would have been provided and the practical disadvantage caused. That is more useful than a bare procedural objection.

A focused medical-dispute bundle should usually include:

• the original insurer decision, internal-review decision and PIC application or referral
• all early GP, ambulance, hospital and physiotherapy records recording symptoms and mechanism
• the first and later ultrasound, MRI or other imaging reports and the underlying images where available
• clinical findings about active movement, weakness, impingement, tenderness and functional limitation
• certificates of capacity and specialist reports addressing diagnosis, causation and the statutory threshold definition
• the insurer’s submissions, PIC directions, response deadlines and any new material relied upon
• a chronology identifying any prior shoulder problem, later incident, treatment course and change in symptoms