Morphet v. Pafco Insurance Company, 2020 CanLII 94808

Citation: Morphet vs. Pafco Insurance Company, 2020 ONLAT 19-005942/AABS

Released Date: 11/12/2020

In the matter of an Application pursuant to subsection 280(2) of the Insurance Act, RSO 1990, c I.8., in relation to statutory accident benefits.

Between:

Meghan Morphet

Applicant

and

Pafco Insurance Company

Respondent

DECISION

PANEL:

Kimberly Parish, Adjudicator

APPEARANCES:

For the Applicant:

Frank Van Dyke

For the Respondent:

Crystal A. Schulz

HEARD:

By way of written submissions

OVERVIEW

1The applicant was injured in an automobile accident on April 19, 2016 (the “accident”) and sought benefits from the respondent pursuant to Ontario Regulation 34/10, known as the Statutory Accident Benefits Schedule - Effective September 1, 2010 (the “Schedule”). The respondent, Pafco Insurance Company, refused to pay for a medical benefit and the applicant applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of this dispute.

2A case conference was held on January 27, 2020. The parties were unable to resolve their dispute and have proceeded to a written hearing.

ISSUES

3The disputed claims in this hearing are:

i. Is the applicant entitled to a medical benefit in the amount of $7,901.50 for occupational therapy services, recommended by Swanson Occupational Therapists in a treatment plan (OCF-18) dated March 1, 2019?

ii. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

4Based on the evidence before me, I find the applicant is entitled to the OCF-18 for occupational therapy in the amount of $7,091.50 and interest pursuant to s. 51 of the Schedule.

ANALYSIS

Is the treatment plan (OCF-18) in the amount of $7,091.50 reasonable and necessary?

5I find the occupational therapy treatment plan is reasonable and necessary and the applicant is entitled to this OCF-18. The applicant has a significant pre-existing condition of chronic back pain that I find was exacerbated by the accident. Further, her current level of impairment and psychological symptoms, which are a result of the accident, support the treatment proposed within this OCF-18 for the reasons I address below.

6The applicant submitted that she sustained serious injuries to her back, neck, right hand, and head as a result of the accident. The emergency room hospital record dated April 20, 2016 noted she has chronic lower back pain. Tenderness was noted in the cervical and thoracic spine and it was noted she complained her neck was stiff/sore. She was diagnosed with a whiplash type injury.¹ She further submitted her pre-existing back injury from a 2006 workplace injury was exacerbated by the accident. The applicant’s position is the proposed OCF-18 is reasonable and necessary to assist her with performing the activities of daily living (“ADLs”) and her employment tasks which she was able to perform prior to the accident. The applicant submitted that the OCF-18 addresses her physical impairments and post-accident issues with memory, concentration, and attention. It was also noted within the OCF-18 that she presented many symptoms consistent with severe depression.

7The respondent concedes the applicant’s prior medical history, which includes chronic low back pain, is relevant, but the respondent maintains the OCF-18 is not reasonable and necessary. The respondent submitted there has been no medical evidence put forth by the applicant to support that she suffers from severe depression or cognitive impairment as a result of the accident. The respondent further submitted that the applicant’s complaints of headaches, hip pain, right knee pain, right wrist pain, and balance issues are not a result of the accident.

8The OCF-18 was prepared by Ms. Brooke Alexander (“Ms. Alexander”), occupational therapist at Swanson Occupational Therapists. The OCF-18 proposed 12 sessions of occupational therapy and noted the applicant’s impairments from her injuries affect her ability to carry out the tasks of her employment and ADLs. The goals of the OCF-18 included occupational therapy treatment to address impairments through education and practice of strategies and environmental adaptation to facilitate increased participation in her ADLs. Further goals were noted as follows: facilitate the purchase and installation of recommended equipment and ensure she can safely use it, facilitate referrals for pool therapy, physiotherapy, psychology, a gait analysis, investigation into her sleep difficulties, engagement in activity-based intervention to facilitate re-involvement in life roles, and to explore emotional self-regulation strategies to address low mood and encourage her to pursue psychological intervention.

9The imaging results obtained shortly after the accident of the applicant’s cervical and thoracic spine noted no fractures or abnormal findings. The applicant attempted to undergo an MRI in June 2016 but was not able to complete it due to reported anxiety, so the imaging results were incomplete². A CT scan of the lumbar spine in June 2019 noted no abnormal findings³.

10The applicant concedes that she suffers from chronic low back pain since 2006 and was receiving ongoing treatments for her pain at the Kingston Orthopedic Pain Institute (“KOPI”) pain clinic since 2009⁴. However, the applicant submitted she had limitations with standing, sitting, and walking prior to the accident due to her chronic low back pain. She submitted she was still able to work and perform her ADLs, but since the accident, she is no longer able to work, nor perform many of her ADLs. In May 2016, Dr. G. Murphy⁵, her treating physician at KOPI, noted her complaints as low back pain radiating to her right and left legs. He noted she previously had similar symptoms but was able to tolerate work and her ADLs. I accept that this statement references the time period following the accident as she was working at the time of the subject motor vehicle accident and has not returned to work since the accident. Dr. Murphy noted that she was struggling with her ADLs and that she was unable to tolerate any walking, sitting, or standing. He further noted that she had limited response to date from medication or physiotherapy and that she was not ready to discuss a return to work.⁶ Dr. Murphy issued a letter dated July 27, 2018,⁷ which noted she was still unable to return to work as she was still recovering from the motor vehicle accident.

11I find the information above from Dr. Murphy in combination with his KOPI clinical notes and records (CNRs) supports there has been an increase in the applicant’s reported level of pain complaints which has adversely affected her level of functioning since the accident. I rely on the Basic Pain Inventory/Functional Interference (“BPI”) Scores noted within the KOPI CNRs from April 1, 2014 - December 19, 2017, which is the last CNR entry that noted these scores.⁸ For example, the CNR entry for April 1, 2014 rated her walking ability at 2/10, normal work at 5/10, relations with people at 5/10, sleep at 7/10, enjoyment of life at 4/10, and provided an overall BPI score of 35/70. The CNR dated May 20, 2015 noted her BPI score increased to 42/70. The BPI score noted in the CNR dated March 2, 2016 was 42/70. Following the accident, the KOPI CNRs support that her BPI scores had increased.⁹ The increase in BPI scores supports that the applicant’s reported pain levels had increased post-accident. I accept this evidence supports that the applicant was in a worse position with respect to her reported pain levels following the accident.

12I find this evidence supports there was an exacerbation in her reported chronic low back pain following the accident. Dr. Murphy has treated her for back pain since 2009 and while he noted she was limited with walking, sitting, and standing prior to the accident, he noted in May 2016 that she is no longer able to do these things. I accept that this period is about a month following the accident, but the July 2018 note from Dr. Murphy indicates she is still recovering from the accident. Further, she was working at the time of the accident at a job she had held since 2011 but she has not returned to work since the accident. I find this evidence supports there has been an exacerbation to her chronic low back pain since the accident.

13I find the orthopedic assessment report of Dr. J. Townley, orthopedic surgeon, dated October 2, 2018¹⁰ is persuasive in finding that the accident exacerbated the applicant’s pre-existing condition. Dr. Townley noted that he reviewed the hospital records from two hospitals spanning from December 2006 - December 2016, and the medical records from KOPI from June 2016 - June 11, 2018. His report noted he conducted a clinical interview and performed a physical examination. Dr. Townley concluded the applicant sustained soft tissue injuries to her neck and lower back from the motor vehicle accident. He further opined that the injuries to her lower back were an exacerbation of her pre-existing condition.

14His report further noted that she had received timely physiotherapy and treatment by a chronic pain specialist and neither intervention had an impact on her pain or function, and she remains severely disabled. Dr. Townley diagnosed her neck and low back pain as myofascial pain and he noted she has likely developed chronic pain syndrome with an extremely poor prognosis for improvement. He noted that a multidisciplinary management team assessment would be in her best interest and a referral to a psychologist to assist with the development of coping strategies. I find Dr. Townley’s opinion persuasive as he noted reviewing her hospital records from 2006 – 2016 and the CNRs from KOPI post-accident to June 2018. Therefore, I accept he reviewed her medical history for a significant time prior to the accident and was able to opine on changes to her condition post-accident, which are supported by the clinical interview and the physical examination performed at the time of the assessment.

15The respondent submitted the applicant sustained a workplace injury in 2006, which resulted in the Workplace Safety and Insurance Board (“WSIB”) making a decision that found she had a permanent injury, which required her to be off work for four years. The diagnosis which stemmed from that injury was Myofascial Pain Syndrome secondary to lumbar facet syndrome and right SI joint pathology.¹¹ At the time of the accident, the applicant had been attending the KOPI clinic for seven years. Six weeks prior to the accident, the applicant received nerve block injections to address the chronic pain to the area of her lumbar spine.¹²

16The respondent submitted that the applicant failed to pursue psychological treatment despite Dr. Murphy’s recommendation she might benefit from seeing a psychologist in 2009, 2011, and 2012.¹³ The respondent further submitted that, prior to the accident, the applicant suffered from undiagnosed abdominal pain, nausea, vomiting, and one episode of umbilical discharge. This is noted in the hospital records for the period spanning from October 2012 - June 2015, which affected the applicant’s ability to work.¹⁴ While prior to the accident Dr. Murphy recommended she receive psychological treatment and there is no evidence that she received any psychological treatment, the applicant was able to work prior to the accident except for the periods she was off from work as noted above which appears unrelated to her low back pain.

17The respondent submitted the applicant’s attendance for physiotherapy treatment between April - October 2016 was inconsistent and she was discharged from the Canadian Back Institute (“CBI”) due to poor attendance. However, the orthopedic report of Dr. Townley noted that she reported attending physiotherapy 2-3 times per week for six months following the accident but reported to Dr. Townley that it did not make a difference for her back pain or function.¹⁵ She also reported this same information at an insurance examination (“IE”) vocational assessment conducted by Ms. Maja Wojcik-Marano, vocational evaluator, which formed part of a multi-disciplinary assessment. A report was issued January 28, 2019.¹⁶ Ms. Wojcik-Marano further noted the applicant reported having difficulty driving home following physiotherapy as her pain levels increased during treatment. I find this evidence provides an explanation which supports why the applicant did not attend physiotherapy treatment on a consistent basis. I am persuaded by the evidence that she shared with two assessors that this treatment modality was not helpful in reducing her pain level.

18The respondent submitted the first time the applicant reported right hip and bilateral leg pain was during a WorkWell Functional Abilities IE Evaluation (“FAE”) with Ms. K. Freeman Dunikowski (“Ms. Freeman Dunikowski”), physiotherapist, who issued a report forming part of a multidisciplinary IE assessment report dated December 21, 2017¹⁷ (“December 2017 report”). In her report, Ms. Freeman Dunikowski noted the applicant sprained her right wrist a few weeks prior to the assessment, which contributed to the loss of functioning at the time of the assessment. While the CNRs produced for the hearing did not note the applicant should utilize a cane to ambulate, Ms. Freeman Dunikowski noted that the applicant could not attempt all tasks for safety reasons. Ms. Freeman Dunikowski also noted the applicant had poor balance and was deemed unsafe to perform walking tasks without the use of her cane. I find this evidence persuasive that she had difficulty walking and maintaining her balance without the use of a cane, which she did not utilize prior to the accident. Ms. Freeman Dunikowski further noted that she walked with an “antalgic” (way to avoid pain) gait and decreased weight bearing through her right lower extremity. It was noted she frequently would walk into walls when not using a cane. Further, that neck flexion caused pain in her neck down to her right shoulder blade, and all other movements increased neck stiffness. It was also noted by Ms. Freeman Dunikowski that right shoulder movement caused pain in the upper back and shoulder blade, she was unable to independently move her right leg, and strength testing was attempted but was too painful. I find this information persuasive and supports that the applicant required a cane to assist her with balance, ambulation, and for safety reasons, despite the applicant’s CNRs not referencing the recommendation for a cane.

19Dr. D. Scott, psychiatrist, issued an IE report¹⁸ as part of the same multidisciplinary assessment. Dr. Scott diagnosed her with somatic symptom disorder with predominate pain which is moderate. He noted her prognosis remains guarded against a psychiatric point of view as long as she remains in pain. I find it noteworthy and persuasive that Dr. Scott noted that she had no prior psychiatric difficulties prior to the accident and, as a result, concluded her psychological condition has been exacerbated by the accident.

20The applicant underwent an occupational therapy in-home functional assessment and a report dated December 11, 2018¹⁹ was issued by Ms. Alexander, occupational therapist. The report noted she was able to ambulate within her home without a mobility aid but used a cane when she was out in the community and for longer distances. Ms. Alexander concluded that the applicant suffers from significant impairments impacting her ability to engage in her ADLs. Impairments and pain to the following areas were noted as follows: mid/low back, coccygeal, hip, right knee, right wrist, headaches, limited mobility/range of motion in lower extremities, impaired balance and limited ability to sit, crouch, bend, walk, reach, lift, and stand. Ms. Alexander noted testing revealed cognitive impairments. On page 14 of her report, Ms. Alexander noted that her impairments in physical, cognitive, and emotional functioning impact her ability to participate in self-care, productive, and leisure activities in which she actively engaged in pre-accident.

21An IE paper review report of Dr. M. Fox, physiatrist, dated January 28, 2019²⁰ formed part of a multidisciplinary IE report (“2019 multidisciplinary IE report) to assess the applicant’s entitlement to post 104-week income replacement benefits. Dr. Fox had previously performed an in-person assessment as part of the December 2017 report relating to entitlement to income replacements. He noted details within the 2019 multidisciplinary IE report, which outlined his findings previously noted within his December 2017 report. These previous findings noted that it is possible she is symptomatic from lumbosacral radiculopathy; in particular affecting the right L5 and/or S1 nerve roots. Dr. Fox opined in his December 2017 report that the applicant sustained a whiplash injury as a result of the accident and thinks she has chronic myofascial pain in her cervical spine as a result of this injury. He opined she had chronic pain prior to the accident but noted he was unable to provide a precise diagnosis of her back pain as he did not have her medical records prior to the accident. His opinion did not change in his 2019 IE paper review report and he again noted he was unable to provide a diagnosis for the cause of her back pain, or a prognosis as he did not have a complete MRI to review, or a CT scan. While the applicant did sustain a whiplash injury from the accident, she was assessed by Dr. Fox in 2017 and he noted he thought chronic myofascial pain in her neck developed as a result of the accident. I find this evidence supports the injuries to her neck had not resolved and as a result I accept this would have been contributing to her ongoing pain.

22While the KOPI CNRs noted she received nerve block injections for pain to the L5 and S1 areas of her lumbar spine²¹, I accept that this was a pre-existing condition which she was receiving treatment for prior to the accident. However, post-accident, I find the applicant continued to receive injections for pain and was also prescribed additional medications post-accident which I will address below.

23The applicant also underwent a further psychiatric IE assessment in December 2019 with Dr. D. Oliver, psychiatrist, as part of the 2019 Multidisciplinary IE report²². Dr. Oliver noted it was confusing that there are no physical findings to account for the drastic change in her physical condition, nor were they any changes to her pre-existing treatment. It was noted that she reported that over the past two years she has limited her daily function to staying in bed, or on the couch and that she only slept about 2 hours/night. She reported receiving a temporary maximum benefit from her chronic pain treatment, about 30%. I disagree with Dr. Oliver that there were no changes to her pre-existing treatment and rely on the KOPI CNRs. While the applicant received nerve block injections to address her chronic back pain prior to the accident, the KOPI CNRs note an increase in the number of prescribed medications to address her pain following the accident and also noted she received lidocaine infusions.²³ While the applicant reported receiving a 30% benefit from her chronic pain treatment, and the KOPI records noted she received a 70% benefit from treatment both pre- and post-accident, I do not afford much weight to this discrepancy. This is because Dr. Oliver noted having reviewed medical documentation found in appendix A of the 2019 Multidisciplinary IE report. It noted she reviewed the CNRs of KOPI from 2017-18 and Dr. Murphy from 2009 - 2018. Dr. Oliver noted there are no new physical findings to account for the reported progressive physical deterioration warranting the use of a cane for mobility. Dr. Oliver could not determine any psychiatric symptoms that warrant a DSM major psychiatric diagnosis and noted the DSM V diagnosis 294.8; mood disorder due to another medical condition.

24Dr. Oliver recommended focusing and clarifying the reported physical symptoms and once they are removed, any psychological symptoms should resolve. From this evidence, I find that the applicant’s chronic pain was significantly limiting her functioning and her ability to complete her ADLs as well as carry out activities which she participated in and enjoyed prior to the accident. These activities included: walking her dog a few times a day, engaging in activities with her nieces such as organizing sleepovers and taking them to the park, reduced housekeeping tasks, playing guitar, and camping. The applicant was also consistent in reporting this information. The information was noted within the reports to Dr. Fox, Dr. Scott, Dr. Townley, and Ms. Alexander. I already accepted the applicant needed a cane to safely ambulate and I rely on what was noted in the December 21, 2017 IE report of Ms. Freeman Dunikowski.

25An IE Functional Abilities Evaluation (“second FAE”) also formed part of this 2019 Multidisciplinary IE report. The report was issued by S. Vats, physiotherapist, and J. Gingrich, kinesiologist²⁴. She reported to these assessors that taking the dog outside to go to the washroom requires her to significantly rest afterwards and that she is unable to do the dishes, vacuum, or cook. She further reported when going out to get groceries, she is able to lean/push a cart and weight bear for approximately 40 minutes if she takes breaks and goes at her own pace. She reported grocery shopping takes all her energy and she requires most of the day afterwards to rest. She further reported she can walk with a cane for 5-10 minutes without requiring a break and without the use of a cane she can walk for 4-6 minutes without requiring a break. She also reported low back/right leg pain, intermittent but daily neck pain, intermittent coccyx pain, constant mouth pain, and intermittent pain in her right knee and wrist. The second FAE test findings and clinical observations results combined noted the applicant’s abilities fell within the limited strength range. The report further noted low levels of physical effort and she reported pain in her back and neck globally when performing the assessment tasks. She was observed to be in a significant amount of discomfort, was constantly shifting/changing her position, and displayed significant muscle guarding.

26As a result, there was a lack of quantitative data to obtain an accurate representation of her current lifting capabilities. It is worth noting that the report noted that her activity is impacted by her symptom level and that she may be able to do more physically at times than what was demonstrated during the assessment. From this evidence, I am not persuaded that the applicant’s reported pain in the areas of her mouth or her right wrist are linked to the accident. The applicant produced a copy of a Plan Member Statement, dated April 26, 2016²⁵ which noted she will be seeing a dentist for her mouth pain. However, I am not persuaded by this evidence that her mouth pain is a result of the accident as the document does not reference the accident in relation to her mouth pain. Prior to the 2019 Multidisciplinary IE report, there has been no further medical evidence to support the pain in her mouth is a result of the accident. The prior FAE IE assessment report of Ms. Freeman Dunikowski which formed part of the 2017 December report confirms the applicant reported she sprained her right wrist a few weeks before that assessment. Therefore, I find the mouth and right wrist pain are unrelated to the accident. However, I find the second FAE does confirm the applicant has limitations with walking, sitting, standing/weightbearing due to pain which would limit her ability to carry out many of her ADLs and I find the limitations which she reported to be consistent with what was previously reported to the other assessors.

27The applicant underwent a Neurocognitive IE assessment with Dr. C. Hope, neuropsychologist, to assess the OCF-18 in dispute and he issued a report dated June 26, 2019²⁶. The applicant reported continued pain in the areas of her neck, head, shoulder, jaw, mid to lower back, legs, and right wrist. The respondent submitted this was the first time the applicant reported shoulder pain. I disagree as I had noted in paragraph 18 that within the IE FAE report of December 21, 2017 it was noted the applicant reported the pain in her neck radiated to her right shoulder blade. Dr. Hope noted the applicant reported she is sleeping 3-4 hours/night and has anxiety about everything. Dr. Hope could not provide a diagnosis, nor opine if she reached maximum medical recovery (“MMR”.) This was because he found validity issues with the test results because of symptom over-reporting and negative response bias on cognitive testing. Dr. Hope further opined that as a result it is not reasonable to accept her self-report of her impairments as valid. Dr. Hope further noted: “Over-reporting and invalid assessment results, however, do not rule out the possibility that Ms. Morphet is experiencing genuine symptoms of distress. She has a long pre-accident history of difficulties with pain, which could reflect a tendency to somatize her distress. Thus, the presence of a somatic symptom disorder cannot be ruled out. Unfortunately, in the context of the current assessment results, this diagnosis is not supported.” Dr. Hope determined that as a result of no valid evidence to support a valid neuropsychological impairment, the OCF-18 was not reasonable and necessary.

28From the list of documents reviewed, it appears Dr. Hope reviewed pertinent medical documents including the records of Dr. Murphy from 2009 to 2018, the prior IE multidisciplinary IE assessment reports, the 2018 addendum report of Dr. Fox, Quinte medical records, imaging results, and the disputed OCF-18. From this evidence, I find Dr. Hope would have been able to understand the applicant suffered from chronic back pain prior to the accident, and that she still continued to receive ongoing treatment from Dr. Murphy post-accident to help with managing her ongoing pain. While I accept that Dr. Hope was unable to provide a diagnosis that she suffered from a neuropsychological impairment, nor was he able to determine if she reached MMR due to issues with validity on the test results, I do not accept that his report is definitive in determining whether this OCF-18 is reasonable and necessary for reasons I will address below.

29I find the OCF-18 to be reasonable and necessary for the following reasons. The applicant was diagnosed with chronic pain prior to the accident. I find the accident has exacerbated the chronic pain in her low back and that she has developed pain in her neck and coccyx region since the accident. I accept she experiences pain in her legs since the accident and rely on what has been noted by Dr. Murphy in May 2016, which I referenced within paragraph 10. I find the IE FAE report, second FAE report, and Ms. Alexander’s occupational therapy assessment report all provide support that the applicant required the use of a cane to assist her with balance and walking. While I accept that there is no evidence to support the applicant suffers from a cognitive impairment as a result of the accident, I am persuaded her anxiety levels have increased post-accident. The increase in her anxiety levels has impacted the increase in her BPI scores post-accident and I rely on Dr. Murphy’s CNR dated June 11, 2018²⁷ which supports this finding. From the results noted on the FAE and second FAE, I accept that the applicant’s pain severely limits her ability to perform her ADLs which is a result of the accident. Prior to the accident she was receiving nerve block injections and was prescribed pain medication by Dr. Murphy, but she also was working at a job which she had for 5 years and ambulated without the use of a cane. The previous activities she enjoyed prior to the accident which she is limited, or unable to currently perform were consistently described and reported to a number of assessors. I find the applicant had issues with poor sleep quality both prior and post accident, but I find her level of reported pain has significantly increased post-accident which is supported by Dr. Murphy performing lidocaine infusions and increasing the number of prescribed pain medications post-accident.

30While the respondent submitted she already attended occupational therapy sessions in August - November 2016 and learned strategies to address her chronic pain through the use of mindfulness which she found useful, I find the proposed goals within the disputed OCF-18 are supported. I find the applicant’s pre-existing condition was exacerbated by the accident, the pain in her neck has not resolved and has contributed to her impaired level of functioning post-accident as I referenced within the paragraph above. I am persuaded by the recommendation made by Ms. Alexander for a referral for pool therapy but not for physiotherapy. This is because the applicant had reported physiotherapy had not worked to manage her pain post-accident. Further, she reported to Ms. Maja Wojcik-Marano, vocational evaluator, in January 2019 that her pain was aggravated following physiotherapy treatment. In addition to the applicant’s chronic pain, it was also noted that she suffers from low mood and increased reliance on her husband to assist her due to her functional limitations and inability to carry out her ADLs, which I accept have been impacted by her impairments post-accident.

31I am also persuaded by Dr. Oliver’s finding that focusing on clarifying and resolving her reported physical symptoms should resolve the psychological symptoms. The evidence for the hearing supports there has been no psychiatric or psychological treatment received by the applicant since the accident. However, I accept the recommendations made by Ms. Alexander are reasonable and necessary to address the applicant’s psychological symptoms which neither Dr. Oliver, nor Dr. Hope could diagnose, but neither ruled out that she is experiencing psychological symptoms. I accept that the deterioration in the applicant’s level of functioning both physically and psychologically since the accident have been supported in the numerous assessment reports and the CNRs of Dr. Murphy. I find the recommendations made by Ms. Alexander are reasonable and necessary to achieve the proposed goals outlined within the OCF-18.

CONCLUSION

32For the reasons I outlined above, I find the applicant is entitled to the OCF-18 for occupational therapy in the amount of $7,091.50 and interest pursuant to s. 51 of the Schedule.

Footnotes

1. 1Tab 5 of applicant’s submissions – Emergency room record of Quinte Health Care, dated April 20, 2016.
2. 2Tabs 22, 23, and 25 of the applicant’s submissions – X-ray of thoracic spine dated April 21, 2016. X-ray of cervical spine dated April 20, 2016. Incomplete MRI of the lumbar spine dated June 7, 2016.
3. 3Tab 24 of the applicant’s submissions - CT scan of lumbar spine dated June 4, 2019.
4. 4Tab 1 of the respondent’s submissions – Clinical notes and records of Dr. Murphy/KOPI.
5. 5Tab 19 of applicant’s submissions – Musculoskeletal Questionnaire Attending Physician’s Statement of Dr. Murphy, dated May 17, 2016.
6. 6Ibid, at pages 3-5.
7. 7Tab 20 of the applicant’s submissions – Letter from Dr. Murphy, dated July 27, 2018.
8. 8Supra, note 4 – CNRs of Dr. Murphy/KOPI for entries dated April 1, 2014 – December 19, 2017, at 13-37.
9. 9Ibid, CNR entry June 14, 2016 noted BPI score 46/70, at 27. CNR entry August 9, 2016 noted BPI score 54/70, at 25-26. CNR entry October 18, 2016 noted BPI score 52/70, at 23-24. CNR entry November 17, 2014 noted BPI score 52/70, at 22-23. CNR entry February 14, 2017 noted BPI score 51/70, at 19, 20. CNR entry May 16, 2017 noted BPI score 51/70, at 18. CNR entry July 4, 2017 noted BPI score 52/70, at 17. CNR entry October 31, 2017 noted BPI score 53/70, at 14, 15. CNR entry December 19, 2017 noted BPI score 56/70, at 13.
10. 10Tab 12 of the applicant’s submissions – Orthopedic Assessment Report of Dr. Townley, dated October 2, 2018.
11. 11Supra, note 4 - CNR dated February 24, 2009, at 68 -69.
12. 12Ibid, CNR dated March 2, 2016, at 28-29.
13. 13Ibid, CNR entries dated March 31, 2009, January 18, 2011, and May 28, 2012, at 47, 55, and 56.
14. 14Tab 2 of the respondent’s evidence – Hospital records from Quinte Health Care Trenton Memorial Hospital, at 1-12.
15. 15Supra, note 10, at page 5 of report.
16. 16Tab 4 of respondent’s submissions – Vocational Assessment Report of Maja Wojcik-Marano contained within Multidisciplinary Assessment dated January 28, 2019, at page 15 of report.
17. 17Tab 3 of the respondent’s submissions – WorkWell Functional Capacity Evaluation IE assessment report of K. Freeman Dunikowski, dated December 21, 2017 at 26, 32, 34, 35, 37
18. 18Ibid, Psychiatric IE assessment report of Dr. Scott which formed part of multidisciplinary assessment, dated December 21, 2017, at 13.
19. 19Tab 13 of the applicant’s submissions - occupational therapy in-home functional assessment report of Brooke Alexander, dated December 11, 2018, at 8.
20. 20Tab 4 of the respondent’s submissions – Physiatry IE report of Dr. Fox, dated January 28, 2019 contained within multidisciplinary report for assessing post 104-week income replacement benefits, at 2, 4, 7, 9, 10.
21. 21Supra, note 4. KOPI CNR entry dated September 6, 2011, at 52.
22. 22Supra, note 20, at 6-11.
23. 23Supra, note 4, at 12-22.
24. 24Supra, note 20, at 38, 47.
25. 25Tab 7 of the applicant’s submissions – Plan Member’s Statement for Sunlife Assurance Company of Canada, dated April 26, 2016 at section 3 (page 2 of 4) of Plan Member’s Statement
26. 26Tab 5 of the respondent’s submissions – IE neuropsychology assessment report of Dr. Hope, dated June 13, 2019, at 9, 10
27. 27Supra, note 4, at 12.