Citation: Palmer v. TD Insurance Meloche Monnex, 2022 ONLAT 20-011080/AABS

Licence Appeal Tribunal File Number: 20-011080/AABS

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:

Patema Palmer

Applicant

and

TD Insurance Meloche Monnex

Respondent

DECISION

ADJUDICATOR:

Taivi Lobu

APPEARANCES:

For the Applicant:

Jaipreet Nanra, Counsel

For the Respondent:

Jamal Rehman, Counsel

HEARD:

Via written submissions

BACKGROUND

1On March 16, 2014, the applicant was a seat belted passenger in a car that was rear-ended at a red light. The applicant attended at hospital emergency where she was prescribed Naprosyn and massage. The diagnosis was “acute back strain/MVC”. She took two to three days off work, and shortly thereafter was seen by her family physician, Dr. Innocent Okafor, who assessed her accident injuries as MVA myalgia and Reactive Mood Disorder.

2The applicant sought benefits pursuant to the Statutory Accident Benefits Schedule Effective September 1, 2010 (including amendments effective June 1, 2016) (“Schedule”)¹. The respondent has paid $3,127.56 for the applicant’s medical and rehabilitation benefits, just short of the $3,500 limit under the Minor Injury Guideline.

3The applicant has been denied certain benefits by the respondent and submitted an application to the Licence Appeal Tribunal - Automobile Accident Benefits Service (“Tribunal”).

ISSUES IN DISPUTE

4The following issues are in dispute:

1. Are the applicant’s injuries predominantly minor as defined in section 3 of the Schedule and therefore subject to treatment within the $3,500.00 limit and in the Minor Injury Guideline?
2. Is the applicant entitled to $2,974.28 for physiotherapy treatment proposed by Focus Physiotherapy in the Treatment Plan (OCF-18) dated February 19, 2019?
3. Is the applicant entitled to $3,162.92 for aqua therapy treatment proposed by Hydroactive Aquatherapy & Rehabilitation in the Treatment Plan (OCF-18) dated February 8, 2020?
4. Is the applicant entitled to $2,254.72 for psychological treatment proposed by Synoptic Medical Assessments Inc. in the Treatment Plan (OCF-18) dated February 8, 2021?
5. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

5I find that:

a. The applicant’s injuries are predominantly minor and therefore subject to treatment within the $3,500 limit of the Minor Injury Guideline;

b. Physiotherapy treatment in the amount of $2,974.28 is not payable as Part 4 of the OCF-18 listed the injury as not predominantly minor and beyond the Minor Injury Guideline;

c. Aqua therapy treatment in the amount of $3,162.92 is not payable as Part 4 of the OCF-18 listed the injury as not predominantly minor and beyond the Minor Injury Guideline;

d. Psychological treatment in the amount of $2,254.72 is not payable as Part 4 of the OCF-18 listed the injury as not predominantly minor and beyond the Minor Injury Guideline;

e. The applicant is not entitled to interest on any overdue payment of benefits pursuant to s. 52 of the Schedule.

ANALYSIS

Applicability of the Minor Injury Guideline

6Under section 3(1) of the Schedule, an “impairment” is defined as “a loss or abnormality of a psychological, physiological or anatomical structure or function.” A “minor injury” is defined as “one or more of a sprain, strain, whiplash associated disorder, contusion, abrasion, laceration or subluxation and includes any clinically associated sequalae to such an injury.”

7Section 18(1) of the Schedule provides that medical and rehabilitation benefits are limited to $3,500.00 if the insured sustains impairments that are predominantly a minor injury in accordance with the Minor Injury Guideline.

8Individuals may be removed from the limits of the Minor Injury Guideline if they can establish that their accident-related injuries fall outside of the Guideline or, under s. 18(2), that they have a documented pre-existing injury or condition combined with compelling medical evidence stating that the condition precludes recovery if they are kept within the confines of the Guideline.

9The Tribunal has also determined that a psychological condition or chronic pain with functional impairment may warrant removal of the Guideline limit. In all cases, the burden of proof lies with the applicant.

10The applicant is submitting that both psychological impairment and chronic pain arising out of the MVA warrant her removal from the Minor Injury Guideline limit.

11I find that the evidence shows that the applicant’s injuries from the 2014 MVA are within the Minor Injury Guideline.

Psychological Impairment

12Psychological impairments, if established, may fall outside the Minor Injury Guideline, because the Guideline only governs “minor injuries” and the prescribed definition does not include psychological impairments.

13The applicant asserts that her psychological impairment justifies removal from the Minor Injury Guideline, submitting that a psychologist, the applicant’s family physician, and a psychotherapist are all of the opinion that the Applicant suffers from psychological injury because of the accident.

14The respondent submits that in three separate psychological examinations, testing and observation demonstrated that the applicant did not meet criteria warranting a diagnosis of a psychological disorder.

15I find that the evidence does not demonstrate an accident-related psychological impairment.

Psychological Impairment – Family Physician

16The applicant relies upon evidence from her family physician, Dr. Okafor, to prove that the applicant suffers accident-caused psychological injury.

17While there has been charting of anxiety, post-accident reactive mood disorder and adjustment disorder by Dr. Okafor, including a November 2014 referral to the Complete Rehab Centre for psychological assessment/counselling, and a referral in December 2020 for psychotherapy, I find that the documentation does not demonstrate an accident-related psychological injury.

18While the applicant stated that Dr. Okafor had referred the applicant to a psychiatrist in 2021, the medical chart relied upon for this submission was for another patient, not the applicant.² The medical chart of another patient was improperly included and not identified as such by either counsel.

19The applicant also relied upon a 2021 medical chart showing reported symptoms of driving phobia, anxiety, apprehension and depressive symptoms, with physician observations of anxiety, and counselling was provided.³ However, again this submission was based on the medical chart of another patient, improperly included in evidence.

20I note that Dr. Okafor’s chart documents an appointment for supportive counselling and medication prescription for the applicant in relation to a personal crisis in June 2019⁴ but I have not been directed to evidence of similar appointment time being devoted to MVA-related psychological issues.

21In a January 2020 appointment which the applicant had requested for the purpose of follow-up on the MVA issues, Dr. Okafor placed a question mark with mood concerns but noted “no acute concerns” from the mental status examination, accompanied by appropriate affect and good mood.⁵ The following appointment in July 2020 did not touch on any psychological issues. Dr. Okafor’s referral of the applicant to a psychotherapist for MVA-related anxiety was made in a December 2020 telephone consultation which the applicant appeared to have initiated for the purpose of referrals for pain and psychotherapy treatments for the accident.⁶

22Prior to 2020, the immediately previous notation by Dr. Okafor for MVA-related psychological concerns was in a June 2015 referral to Dr. Oubada Hawass, physician with the Centre for Pain Management. referencing: “MV low back pain and adjustment disorder.”

23I find that Dr. Okafor’s chart reflects the work of a responsive family physician but does not provide compelling evidence of an ongoing MVA-related psychological condition.

Psychological Impairment – Expert Opinions of Dr. Mills & Dr. Rubenstein

24The applicant asks that I rely upon the April 4, 2016 report of psychologist Jon Mills to find that the applicant’s psychological injuries warrant removal from the Minor Injury Guideline.

25The 2016 report of Dr. Mills appears to be based on a one-time assessment of the applicant. The assessment included an applicant interview with an assessor and the use of five psychological tests (the Brief Pain Inventory (Short Form); Beck Depression Inventory-II, Beck Anxiety Inventory, Impact of Event Scale-Revised, and Accident Fear Questionnaire. The report diagnosed the applicant with:

• Adjustment Disorder with Mixed Anxiety and Depressed Mood
• Specific Phobia, Situational Type (Driver and Passenger)
• Somatic Symptom Disorder, with Predominant Pain, Persistent

26The report identified Dr. Mills as a supervisor and is co-signed by him. It however does not suggest that he directly assessed or observed the applicant. Rather, the individual who was identified as the “assessor” and a co-signatory to the report, was stated as having an undergraduate degree in history, a master’s degree in counselling psychology and registration as a psychotherapist. No additional information was provided about the assessor’s credentials for conducting assessments and evaluative interviews for the purpose of clinical diagnosis.

27Dr. Mills’ report states that the results of the psychometric tests administered to the applicant were within valid limits and accepted as valid indicators of her psychological functioning. The basis for this conclusion is not articulated so presumably it is based on measures built into the five tests themselves as opposed to any additional evaluative measures having been taken.

28The Mills’ report speaks to restrictions in the applicant’s life because of driving fears. It recounts information from the applicant that she has avoided driving since the accident, was a relatively new driver at the time of the accident, excited to have a licence, had only been driving short distances since the accident, and could not go out with friends because she was afraid of driving. This factual foundation about the applicant’s driving history and effect of the accident on her life recounted in the Mills’ report does not appear to appreciate evidence suggesting that the applicant was not a driver prior to the accident (reported on a March 2014 initial consultation form with the Complete Rehabilitation Centre⁷), and that the applicant obtained her G-2 driver’s licence three weeks after the accident (reported in a 2015 examination with Dr. Arnold Rubenstein).⁸

29In addition, I note that Dr. Mills’ conclusions from 2016 received little corroboration by actions of other health professionals. For example, despite the applicant having been followed fairly regularly by her family physician, there is no evidence that he identified a need to take action recommended by the Mills’ report – such as a consultation with a neurologist to investigate the headaches and reported interruptions in cognitive functioning; assessment of applicant suitability for psychotropic medications for accident-related concerns,⁹ and a possible psychiatric referral.

30The respondent relied on the evidence of Dr. Rubenstein, psychologist, obtained through section 44 assessments in 2015, 2016 and 2020. In his first assessment of the applicant on February 20, 2015, Dr. Rubenstein reviewed the document record, interviewed the applicant and administered a Pain Patient Profile. On July 7, 2016, he observed a marked difference in the applicant’s presentation from his assessment the previous year and on this basis decided to administer a test known as the Structured Inventory of Malingered Symptomatology. On June 8, 2020, he again administered both tests. He assessed the applicant’s results from the Pain Patent Profile as follows: “The claimant’s approach to the P3 [Pain Patient Profile] generated questionable findings from a validity standpoint and are seen as far from robust enough to support interpretations.”¹⁰

31With regard to diagnosis, in his February 2015 assessment, Dr. Rubenstein found that the applicant’s mental status was clear and found no indication that her profile would warrant a diagnosis of any mental disorder according to the criteria set out in the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition.¹¹ In 2016 and 2020, Dr. Rubenstein recognized the applicant’s reported adjustment difficulties, but as stated in the 2020 report, found that they did not achieve the clarity necessary to “both meet a threshold warranting a diagnosis, in addition to being precluded from any diagnosis of a psychological disorder, based on compromised validity findings.” ¹²

32Similar to his findings in 2016, in his 2020 report, Dr. Rubenstein noted that the Structured Inventory of Malingered Symptomatology results suggested that symptom magnification was contributory to the clinically significant levels of affective and somatic distress. Dr. Rubenstein stated that it was difficult if not impossible to lend validity to other test scores. He noted that the applicant acknowledged a high rate of symptoms of depression and anxiety which did not generally occur in a constellation, even in an atypical mood or anxiety disorder¹³. He concluded in both 2016 and 2020 that: “[p]sychological findings suggest the claimant did not achieve reliability as an informant having compromised the validity of objective testing, apparently based on symptom amplification.”¹⁴ Dr. Rubenstein was unable to identify any psychological injury resulting from the accident.

33In addition Dr. Rubenstein directly examined the applicant while Dr. Mills relied on someone else to conduct the direct assessment. As well, the applicant did not provide any updated or additional information to address the substantial concerns raised in Dr. Rubenstein’s reports of 2016 and 2020.

34For all of the above reasons, I prefer the assessment and conclusions of Dr. Rubenstein’s reports over those presented in Dr. Mills’ report.

Psychological Impairment - Michael Smith

35The applicant submitted that, Michael Smith (social worker and psychotherapy practitioner), opined that the applicant suffers from psychological injuries because of the accident.

36The evidence includes records of psychotherapy sessions which the applicant had with Mr. Smith from April to June 2021 for anxiety and driving anxiety.¹⁵ I am not directed to an opinion provided by Mr. Smith in these records. In any event, Mr. Smith is credentialled as a registered social worker; he is not a psychologist or medical doctor. Communicating a psychological diagnosis is outside of his scope of practice.¹⁶

Psychological Impairment – Conclusion

37I find that the applicant has not proven on a balance of probabilities that the accident resulted in psychological impairment that would warrant removal from the Minor Injury Guideline.

Chronic Pain

38In support of the submission that the applicant should be removed from the Minor Injury Guideline because of chronic pain, the applicant relies on her reports of functional limitations, pain ratings of 8 out of 10, and diagnoses of chronic pain from her family physician and Dr. Hawass.

39The applicant submits that the circumstances are very similar to those presented in Hagley v. Intact Ins. Co.¹⁷ where the Tribunal found that an applicant had demonstrated chronic pain warranting removal from the Minor Injury Guideline.

40The respondent submits that a physiatrist, psychologist and a general practitioner insurer assessor are in agreement that the applicant’s accident-related injuries and ongoing complaints do not warrant removal from the Minor Injury Guideline. The respondent relies on BU v. Aviva¹⁸ and L.I. v. TD Insurance,¹⁹ submitting that a chronic pain diagnosis in itself does not remove an applicant from the Guideline and that it must be shown that the chronic pain is not merely sequelae of the soft tissue injuries. The respondent also points to the applicant’s full-time employment in the years since the accident in support of his submission of the applicant’s functionality.

41The applicant’s circumstances bear similarity to the Hagley²⁰ case, insofar that both Ms. Palmer and Ms. Hagley were supported by their family physicians in relation to chronic pain concerns, and both had received treatment from chronic pain specialists, including nerve-block injections. While this can be persuasive, the totality of an individual’s circumstances must be considered when determining whether chronic pain with functional impairment has become an independent head of injury that takes an otherwise minor injury beyond the Minor Injury Guideline.

42The disability certificate (‘OCF-3’)²¹ filed by the applicant’s chiropractor identified the applicant’s accident-related injuries as: “other sprain and strain of cervical spine; sprain and strain of other and unspecified parts of shoulder girdle, sprain and strain of thoracic spine; dislocation, sprain and strain of joints and ligaments of lumbar spine and pelvis; headaches, stress not elsewhere classified; and disorders of initiating and maintaining sleep (insomnias).”²²

43In addition to the previously discussed psychological assessments, the insurer required that the applicant undergo three section 44 assessments to evaluate her physical condition. The most recent such assessment was on August 7, 2020 by general physician Dr. James Kenneth Stewart on August 7, 2020.²³

44Dr. Stewart conducted a physical examination and observations of her cervical spine, upper limb exam, thoracic/lumbar exam, lower extremity exam, and neurological and systems exam. He found that the applicant had minor limitation of lumbar spine flexion and tenderness on palpation over the thoracic paraspinal muscles, but found no positive orthopaedic tests or nerve root tension signs. He reported that “[s]ensation and reflexes were intact, strength was full and there were no functional impairments.” He stated that he was unable to correlate the applicant complaints of pain to the minor soft tissue injuries which she sustained six years earlier. Dr. Stewart concluded that while the applicant would have initially sustained a cervical spine/strain and thoracolumbar sprain/strain as a result of the accident, they would have long since resolved.²⁴

45Dr. Stewart’s 2020 conclusions were in accord with the findings of Dr. Zeeshan Waseem, physiatrist, who conducted two separate section 44 examinations of the applicant in March 2015 and September 2016²⁵. Dr. Waseem’s predominant findings were mechanical neck and back pain, which reportedly increased with movement; normal range of motion of neck, spine and extremities; and no evidence of soft tissue pathology or neurological impairments.²⁶

46As noted above, the applicant was treated by chronic pain specialist, Dr. Hawass.²⁷ The clinical records from Dr. Hawass’s office show that the applicant received nerve block treatments during two periods, December 2015 - January 2016 (three treatments) and February - March, 2021 (three treatments).

47While the applicant might have received nerve-block treatments for somewhat longer periods than what is shown in the clinical records provided,²⁸ there nonetheless has been a multiple year hiatus between 2016 and 2021 treatment periods. Given the limited periods in which treatment has been provided, I find that the evidence is not persuasive in demonstrating that the applicant has been reliant on chronic pain treatment for functionality and daily living.

48In addition, other than the two periods of treatment with Dr. Hawass, the evidence does not show regular reliance on pain medication.²⁹ In March 2015, the applicant reported to Dr. Waseem that she was not taking any medication.³⁰ In his August 2020 section 44 assessment report, Dr. Stewart noted that the applicant had previously trialed Tramacet, Tylenol, Advil and Baclofen, but was not taking prescription medication at the time of his examination.³¹

49Although Dr. Hawass’s February 13, 2021 consult note referenced the applicant’s use of Tylenol, Advil and Baclofen,³² on that same date his chart for the applicant noted “no on med”³³ and patient compliance with pain medication was noted as “not currently taking.”³⁴

Functional Impairment Related to Chronic Pain

50For chronic pain to warrant reclassification of an injury beyond the Minor Injury Guideline, it must not simply be a sequalae of a soft tissue issue.³⁵ There must be some functional impairment.³⁶ The applicant relies on Dr. Hawass’s consult note from February 13, 2021, where the doctor states that the applicant is: “still suffering from severe myofascial and musculoskeletal lower back pain due to the car accident. It is affecting her daily function and she has severe disability because of the chronic pain.”³⁷

51However, Dr. Hawass did not provide particulars of functional impairment in his assessment of the applicant other than to note that sitting increases pain³⁸ and that she was still able to function.³⁹

52The most specific evidence of functional disability from chronic pain is documented by the applicant’s family physician:

a. In January 2019 when the applicant saw her family physician for a physiotherapy referral for back pain, Dr. Okafor’s chart documents the applicant’s report of greater back pain when having to sit a long time at her new workplace, when having to lift heavy items, or clear snow. His objective findings at that appointment noted her general condition to be satisfactory, with some tenderness in the musculoskeletal examination.⁴⁰

b. In a January 2020 follow-up appointment for the accident, under subjective pain findings, Dr. Okafor charted that the pain was off and on and there was “no functional compromise mostly but finds it hard to care for child and do house work when pain at its most. Some mood irritability as a result. This was endorsed by husband.” Dr. Okafor’s objective findings at that appointment noted some trigger points but found her general condition to be satisfactory.⁴¹

53The preponderance of the evidence does not reflect significant functional impairment stemming from accident-based pain. For example, in addition to the limited reliance on pharmacological pain management discussed earlier, the record also reflects the following:

a. After two to three days which the applicant took off work immediately after her 2014 accident, the applicant returned to full hours and regular duties at her workplace, and has continued working full time, with the exception of a period of maternity leave. No evidence has been presented of workplace accommodations.

b. The charting for a general physical examination carried out by Dr. Okafor four years post accident on May 16, 2018, did not identify any functional impairment or pain issues⁴² and Dr. Okafor assessed the applicant as a “well woman.”⁴³ This is generally consistent with other chart entries for applicant appointments during this time.⁴⁴

c. Doctors Hawass, Rubenstein, Waseem and Stewart all directly addressed the applicant’s physical presentations during their interviews/consultations with her; None observed indications of physical pain-related discomfort or issues in their direct observations of the applicant’s general presentation.⁴⁵

d. In her psychotherapy treatment for driving anxiety in April 2021, the applicant had a treatment goal of driving to Niagara Falls on an outing. Even though in February 2021 Dr. Hawass had identified severe disability from back pain which increased with sitting,⁴⁶ there was no suggestion in Mr. Smith’s clinical records that pain or pain management was a factor in achieving the treatment goal of a prolonged drive.

54I find that the applicant has not demonstrated on a balance of probabilities that pain-related impairment from the accident removes her from the Minor Injury Guideline.

55There are three treatment plans at issue:

a. a treatment plan (OCF-18) dated February 19, 2019 for physiotherapy treatment proposed by Focus Physiotherapy in the amount of $2,974.28;

b. an OCF-18 dated February 8, 2020 for aqua therapy treatment proposed by Hydroactive Aquatherapy & Rehabilitation in the amount of $3,162.92; and,

c. an OCF-18 dated February 8, 2021 for psychological treatment proposed by Synoptic Medical Assessments Inc. in the amount of $2,254.72.

56Given that I have determined the applicant’s impairments fall within the treatment limits of the Minor Injury Guideline and that all of the three treatment plans state (at Part 4 of the OCF-18s), that the injuries cannot be treated within the Guideline, there is no reason to determine if the three OCF-18s in dispute are reasonable and necessary pursuant to the Schedule.

Interest

57As there are no overdue payment of benefits, the applicant is not entitled to interest pursuant to s. 51 of the Schedule.

ORDER

58I find that:

a. The applicant’s injuries are predominantly minor and therefore subject to treatment within the $3,500 limit of the Minor Injury Guideline;

b. Physiotherapy treatment in the amount of $2,974.28 is not payable as Part 4 of the OCF-18 listed the injury as not predominantly minor and beyond the Minor Injury Guideline;

c. Aqua therapy treatment in the amount of $3,162.92 is not payable as Part 4 of the OCF-18 listed the injury as not predominantly minor and beyond the Minor Injury Guideline;

d. Psychological treatment in the amount of $2,254.72 is not payable as Part 4 of the OCF-18 listed the injury as not predominantly minor and beyond the Minor Injury Guideline;

e. The applicant is not entitled to interest on any overdue payment of benefits pursuant to s. 52 of the Schedule.

59The application is dismissed.

Released: August 3, 2022

Taivi Lobu

Adjudicator

While the Respondent submissions noted that in June 2019, Clonazepam and Zopiclone had been prescribed by her family physician: Dr. Okafor’s medical chart suggest that these medications were precipitated by other events (Applicant submission, CNRs of Dr. Okafor, pdf 475, 499, 475).

Footnotes

1. 1O. Reg. 34/10.
2. 2Applicant submissions, pdf 595 - 639, chart entries dated April 7, 2021 and April 18, 2021
3. 3Applicant submissions, pdf 600, chart entry dated April 7; 2021
4. 4Applicant submissions, pdf 475, CNRs of Dr. Okafor, 17 June 2019
5. 5Applicant submission, pdf 511–512, CNRs of Dr. Okafor, January 5, 2020
6. 6Applicant submission, pdf 509-510, CNRs of Dr. Okafor, December 7, 2020
7. 7Applicant submissions, pdf 154, Complete Rehab CNRs, Initial Consultation, March 20, 2014
8. 8Applicant submissions, pdf 522, Report of Dr. Rubenstein, February 26, 2015
9. 9The applicant reported to Dr. Rubenstein in 2020 that she had not been prescribed any medication for mental health issues. (Applicant submissions, pdf 577, Report of Dr. Rubenstein, August 20, 2020)
10. 10Respondent submissions, pdf 578, Report of Dr. Rubenstein, August, 20, 2020.
11. 11Respondent submissions, pdf 523, Report of Dr. Rubenstein, April 10, 2015
12. 12Respondent submissions, pdf 579, Report of Dr. Rubenstein, August, 20, 2020
13. 13Ibid pdf 578
14. 14Respondent submissions, Report of Dr. Rubenstein September 29, 2016, pdf 554 and Report of Dr. Rubenstein August, 20, 2020, pdf 578
15. 15Applicant submissions, pdf 641 – 659, CNRs of Michael Smith,
16. 16Regulated Health Professions Act, ss 27(1) and (2); Psychotherapy Act, s. 4
17. 172021 CanLII 69278 (ON LAT)
18. 182015 CanLII 96167 (ON LAT) a t para 17
19. 192018 CanLII 13142 (ON LAT) at para 16
20. 202021 CanLII 69278 (ON LAT)
21. 21Applicant submissions, pdf 159, OCF-3 Disability Certificate, March 29, 2014, Dr. Rahim Jessa
22. 22Applicant submissions, pdf 269, CNRs of Complete Rehab, Initial Consultation, March 29, 2014.
23. 23Respondent submissions, pdf 584- 596, Report of Dr. Stewart dated August 20, 2020
24. 24Respondent submissions, pdf 592, Report of Dr. Stewart dated August 20, 2020
25. 25Respondent submissions, Reports of Dr. Waseem dated March 26, 2015 and September 23, 2016
26. 26Respondent submissions, Report of Dr. Waseem September 23, 2016, pdf 559
27. 27Based on Dr. Hawass’s clinical notes and records from June 15, 2014 to January 21, 2016
28. 28While the records from Dr. Hawass’s office only document nerve block treatments during a two month period from December 2015 to January 2016, the applicant has reported to other health care professionals that the first series of treatments spanned longer: Dr. Rubenstein in his June 2020 assessment noted that the applicant had reported to him that she attended Dr. Hawass’s clinic during this first period “for a few months.” In 2020 the applicant reported to both her family physician (Applicant submissions, pdf 509) and to Dr. Stewart (Respondent submissions, pdf 589) that she stopped nerve block treatments when she became pregnant (according to Applicant submissions, this was in early 2017). No records were apparently requested from Dr. Hawass’s clinic for the period after January 2016 and before 2021.
29. 29Occasional prescriptions for Baclofen, Voltaren, Naproxen and Meloxicam has been noted in Dr. Okafor’s medications chart spanning from May 2014 to December 2020,(Applicant submissions, pp 515-516) A prescription for Tramacet has also been indicated (for example, Report of Dr. Waseem September 29, 2016 report; Respondent submissions pdf 563; Dr. Hawass CNRs, February 13, 2021, Applicant submissions pdf 576)
30. 30Respondent submissions, pdf 621 Report of Dr. Waseem, April 10, 2015
31. 31Respondent submissions, pdf 589. In a hospital attendance for another condition, a June 9, 2015 hospital record identified “no headaches, malaise, myalgia,” and noted “No” beside medication (Applicant submissions, pdf 300)
32. 32Applicant submissions, pdf 592, CNRs of Dr. Hawass, February 13, 2021
33. 33Applicant submissions, pdf 575, CNRs of Dr. Hawass, February 13, 2021
34. 34Ibid. pdf 576
35. 35BU v Aviva Canada Inc., supra, at para. 17.
36. 3617-000640/AABS v TD Insurance Meloche Monnex,(ON LAT) at para 40
37. 37Applicant submissions, pdf 592 CNRs of Dr. Hawass, February 13, 2021
38. 38Applicant submissions, pdf 579 CNRs of Dr. Hawass, February 20, 2021
39. 39Applicant submissions, pdf 592 CNRs of Dr. Hawass, February 13, 2021
40. 40Applicant’s submissions, pdf 477, CNRs of Dr. Okafor, January 23, 2019
41. 41Applicant’s submissions, pdf 512, CNRs of Dr. Okafor, January 5, 2020
42. 42Applicant submissions, pdf 379-383, CNRs of Dr. Okafor, May 16, 2018
43. 43Applicant submissions, pdf 480, CNRs of Dr. Okafor, May 16, 2018
44. 44For example, Applicant submissions pdf 494, CNRs of Dr. Okafor, April 6, 2016, follow-up for another condition noted general condition being satisfactory and no back pain.
45. 45Applicant submissions, pdf 592,CNRs of Dr. Hawass, consult note dated February 13, 2021, Respondent submissions, pdf 552, Report of Dr. Rubenstein, July 14, 2016; Respondent submissions, pdf 436, Report of Dr. Waseem, April 10, 2015; Respondent submissions, pdf 565, Report of Dr. Waseem, September 29, 2016; Respondent submissions, pdf 590, Report of Dr. Stewart, August 20, 2020
46. 46Applicant submissions, pdf 579 CNRs of Dr. Hawass, February 13, 2021```