Warsame v. Co-operators General Insurance Company, 2022 CanLII 75154

Citation: Warsame v. Co-operators General Insurance Company, 2022 ONLAT 20-004286/AABS

Licence Appeal Tribunal File Number: 20-004286/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:

Sadia Warsame

Applicant

and

Co-operators General Insurance Company

Respondent

DECISION

ADJUDICATOR: Ulana Pahuta

APPEARANCES:

For the Applicant: Thomas M. Enright, Counsel

For the Respondent: Emily Schatzker, Counsel

HEARD: BY WAY OF WRITTEN SUBMISSIONS

OVERVIEW

1Sadia Warsame (the “applicant”) was involved in an automobile accident on December 4, 2017, and sought benefits pursuant to the Statutory Accident Benefits Schedule, Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”)¹. The applicant was denied certain benefits by Co-operators General Insurance Company (the “respondent”) and submitted an application to the Licence Appeal Tribunal - Automobile Accident Benefits Service (“Tribunal”).

ISSUES

2The disputed issues in this claim are:

a. Is the applicant entitled to $1,102.48 for chiropractic treatment, recommended by Absolute Physio in a treatment plan (OCF-18) denied July 3, 2019?

b. Is the applicant entitled to $2,045.50 for physiotherapy, recommended by Absolute Physio in an OCF-18 denied July 3, 2019?

c. Is the applicant entitled to $2,260.00 for a chronic pain assessment, recommended by All Health Medical Centre in an OCF-18 denied October 24, 2019?

d. Is the applicant entitled to $11,142.70 for a chronic pain treatment program, recommended by All Health Medical Centre in an OCF-18 denied December 31, 2019?

e. Is the respondent liable to pay an award under Regulation 664 because it unreasonably withheld or delayed payments to the applicant?

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

RESULT

3I find that the applicant is not entitled to the disputed treatment plans, as she has not met her onus to prove they are reasonable and necessary. As no benefits are owing, no interest is payable. In addition, the applicant has failed to establish a basis for an award under Regulation 664. The application is dismissed.

BACKGROUND

4The applicant was involved in a motor vehicle accident on December 4, 2017. She did not attend at a hospital immediately after the accident but did attend at her family physician’s office the following day, reporting various injuries.

5Prior to the accident, on March 30, 2017, the applicant had an arthroscopic surgical procedure to her left knee, for a meniscal tear.

6The applicant submits that since the motor vehicle accident, she continues to suffer from long-lasting physical injuries, necessitating the medical benefits for chiropractic and physiotherapy services currently in dispute. The applicant also asserts that she has developed chronic pain as a result of the accident, necessitating multi-disciplinary treatment for such chronic pain.

7The respondent submits that the applicant’s impairments are not accident-related. In the alternative, the respondent submits that the proposed treatment plans are not reasonable and necessary as a result of the accident.

ANALYSIS

Causation – Did the Accident Cause the Applicant’s Injuries?

8As the respondent argues that the accident did not cause the applicant’s injuries, I will first address the issue of causation.

9The respondent submits that the accident did not cause the applicant’s current impairments, relying on the section 44 Orthopaedic Assessment of Dr. Greg Jaroszynski, orthopaedic surgeon, dated August 9, 2019. In his assessment, Dr. Jaroszynski found that the applicant had sustained only soft tissue injury to the cervicothoracic region (whiplash associated disorder) and a left knee contusion from the accident. Rather, he concluded that applicant’s current symptoms were due to pre-existing and evolving aging/degenerative changes.² The respondent submits that the applicant’s pre-accident imaging records indicate degenerative changes and/or osteoarthritis in her knees and back, which the respondent asserts lead to tears in first the left and then the right knee.

10The applicant’s surgery to her left knee to repair a meniscal tear, was on March 30, 2017 and pre-dated the accident. The respondent submits that the same degenerative changes and/or osteoarthritis were what caused the subsequent injury to the applicant’s right knee, more than a year after the accident. The respondent argues that given the degenerative changes seen on the imaging, the fact that identical surgery that had been performed on the left knee pre-accident, and the applicant’s very physically demanding job as a personal support worker (PSW), the current knee injuries cannot be linked to the accident.

11With respect to the applicant’s left shoulder pain, the respondent submits that the applicant had a history of left supraspinatus tendinosis³, which is a degenerative condition from repetitive use. Although the respondent concedes this shoulder pain may have resolved prior to the accident, the respondent argues that the applicant’s doctor does not specifically link the partial left rotator cuff tear (found by ultrasound on June 29, 2018)⁴, nor the subsequent full tear of the supraspinatus tendon and sub deltoid bursitis (found by ultrasound on August 7, 2019)⁵, to the accident.

12To determine causation, the Divisional Court confirmed in Sabadash v. State Farm⁶ that the test to be applied is the “but for” test. The onus is on the applicant to prove that “but for” the accident, she would not have suffered the impairment which forms the basis for her claim for accident benefits.

13Upon review of the submissions and medical evidence, based on a balance of probabilities, I find that even if the accident did not directly cause all of the applicant’s current symptoms, at a minimum, it did exacerbate certain conditions, namely her left shoulder and left knee, making them become more symptomatic post-accident.

14With respect to the applicant’s right knee, I agree with the respondent that this injury does not appear to be linked to the accident. The first reference to right knee pain in the family physician’s records was on October 25, 2018, more than a year post-accident. In this note, Dr. Sadaf Ahmed, family doctor, stated “R knee painful, no injury occurred, pain x 1 month”⁷. An x-ray dated October 25, 2018 showed degenerative changes and the applicant subsequently had an arthroscopic procedure to repair the torn meniscus on February 14, 2019. Given that the applicant did not complain of any pain in the right knee for more than a year post-accident, and that she did not adduce any evidence linking the injury to the accident, I find that the right knee injury is not an accident-related impairment.

15With respect to the left knee, which was operated on prior to the accident, there is some evidence that the applicant’s left knee pain was exacerbated in the period post-accident. From December 2017 to April 2018, there are entries in Dr. Ahmed’s clinical notes and records (CNRs) where the applicant has reported left knee pain. On April 18, 2018, Dr. Ahmed expressly noted “MVA has aggravated the knee”⁸. Therefore, I find that the applicant’s knee pain immediately post-accident, was caused by the subject accident. However, after April 2018, I do not see any further complaints to Dr. Ahmed about left knee pain.

16It appears that the applicant’s most serious complaint that can be linked to the accident, is her left shoulder pain. Soon after the accident the applicant began complaining of pain in her left shoulder. Dr. Ahmed’s CNRs indicate that she attended at his office multiple times in the six months after the accident complaining of such pain. An ultrasound taken June 19, 2018 revealed the partial tear to the rotator cuff.

17While I agree with the respondent that Dr. Ahmed did confirm that the applicant had some history with tenderness of the supraspinatus muscle, and I note that the Insurer’s Examination (IE) assessor concluded that the rotator cuff tear was degenerative in nature, however, immediately prior to the accident the applicant was not reporting any shoulder pain. The only entry I see in the CNR’s pre-accident with respect to left shoulder pain was in 2014 or three years before the accident⁹. In contrast, I find that the applicant consistently reported to Dr. Ahmed that the pain in her left shoulder was symptomatic post-accident. As such, I find that even if the accident did not directly cause the rotator cuff partial tear, it did exacerbate it such that the injury became symptomatic.

18Whether these injuries (along with reported neck and back pain) were ongoing post-accident and whether they meet the threshold of requiring rehabilitative treatment will be discussed in the analysis of the reasonableness and necessity of the proposed treatment plans. However, in terms of linking the impairment to the accident, while I recognize that injuries may occur as a result of degenerative changes, the immediate reporting of pain post-accident (after years of silence on the issue), implies that some of the applicant’s conditions were exacerbated by the accident.

Are the Treatment Plans Reasonable and Necessary?

19Sections 14, 15 and 16 of the Schedule set out that an insurer shall pay for all reasonable and necessary expenses incurred by or on behalf of an insured as a result of an accident.

20The applicant has the onus of proving on a balance of probabilities that the treatment plans are reasonable and necessary because of the accident. To meet this burden, the applicant should identify the goals of the plan, how the goals are being met to a reasonable degree and whether the time and cost expended to achieve these goals is proportional to the benefit.

Is the Applicant Entitled to $1,102.48 for Chiropractic Treatment and $2,045.50 for Physiotherapy Treatment from Absolute Physio?

21As both the applicant and the respondent assessed the chiropractic and physiotherapy treatment plans proposed by Absolute Physio collectively, I will similarly address them together.

22The applicant submits that continued physiotherapy and chiropractic treatment is reasonable and necessary, as she continues to suffer from shoulder, knee, back and neck injuries following the accident. The applicant asserts that such treatment improves her quality of life and temporarily decreases her pain levels.

23In contrast, the respondent argues that: the stated injuries were not caused by the accident; that the applicant has already undergone a significant amount of physiotherapy and has not demonstrated that she would benefit any further from such therapy; and that the applicant’s treating physicians have not recommended additional physiotherapy or chiropractic treatment.

24After considering the evidence and the submissions of the parties, I find that the applicant has failed to meet her evidentiary onus to demonstrate that the treatment plans for chiropractic and physiotherapy treatment are reasonable and necessary.

25Firstly, the OCF-18’s in question lists numerous impairments, including back, neck, shoulder and knee injuries. However, a number of the impairments are not corroborated by the medical records. With respect to back pain, there is no record of the applicant having complained of back pain after she completed physiotherapy with CBI Health Group in July 2018, where it was noted that her lower back pain had improved considerably¹⁰. This was a year before the proposed OCF-18s were submitted. The CNRs of Dr. Ahmed similarly do not report ongoing complaints of back pain.

26Secondly, the applicant lists bilateral knee injury on her OCF-18 for physiotherapy treatment. However, as previously noted, I have found that with respect to the right knee, there is no evidence to link this injury to the motor vehicle accident. With respect to the left knee impairment, which was aggravated by the accident, the CNRs of Dr. Ahmed to not show any reports of left knee pain after April, 2018.

27With respect to the left shoulder and neck impairments, I agree with the respondent that the applicant has not adduced sufficient objective, medical evidence that further physical treatment would provide any therapeutic benefit.

28The applicant attended at rehabilitative treatment with CBI Health Group from January 3, 2018 to July 27, 2018 and subsequently with Absolute Physio, who completed the proposed treatment plans for additional chiropractic and physiotherapy treatment. The respondent points to the applicant’s reported Lower Extremity Function Index (LEFI) and Upper Extremity Functional Index (UEFI) scores, while attending at Absolute Physio as evidence that physiotherapy treatment was not effective. In both metrics, the applicant did not report any significant improvement in the period from April 30, 2019 to June 24, 2019, while she was receiving treatment. Given such lack of progress, it is difficult to argue that the applicant sustained a significant improvement from physiotherapy, making such treatment reasonable and necessary.

29This is lack of improvement is especially true with respect to the applicant’s most significant accident related injury – her left shoulder impairment. In the Discharge Report from CBI Health Group (CBI) dated July 27, 2018, CBI noted that over the course of physiotherapy, while the applicant’s lower back improved considerably, her left shoulder pain had progressively worsened¹¹.

30Further, the applicant had two ultrasounds done of her left shoulder – one in June 2018 and one in August 2019, which showed that while the applicant had only a partial tear in June 2018, this had developed into a full tear by the following year. This worsening condition developed despite the applicant having attended ongoing physiotherapy throughout that year, as reported to Dr. Ahmed¹². The applicant also reported to Dr. Matthew Denkers, her orthopaedic surgeon, that she had previously done physiotherapy, without sufficient benefit¹³.

31In fact, the applicant’s doctors were not recommending any kind of physical therapy for her shoulder injury. Dr. Denkers, the orthopaedic surgeon, recommended corticosteroid injection (which the applicant declined) and arthroscopic surgery, which the applicant consented to¹⁴. Although in her submissions the applicant states that Dr. Ahmed endorsed further physiotherapy for her back, neck and shoulders, I do not see this reflected in the CNRs of Dr. Ahmed, at least post 2017 and 2018. While I do see that Dr. Ahmed recommended physiotherapy soon after the accident in December 2017, I do not see that he recommended further physiotherapy in 2019, other than potentially with respect to the right knee surgery, which I found to be unrelated to the motor vehicle accident. Therefore, I find this treatment plan not to be reasonable and necessary for the applicant as a result of the accident.

Sufficiency of the Respondent’s Denial of the OCF-18s for Physiotherapy and Chiropractic Treatment

32Section 38(8) of the Schedule states that within 10 business days of an insurer receiving a treatment and assessment plan, it shall give the insured person notice that identifies the goods/services/assessment/examinations described in the treatment and assessment plan that it will pay for or refuses to pay for and provide the medical reasons and all other reasons why said goods/services/assessment/examinations or said costs are not reasonable and necessary.

33Section 38(11) of the Schedule states that if an insurer fails to give a notice in accordance with section 38(8) of the Schedule, related to a treatment and assessment plan, the insurer is prohibited from taking the position that the insured person has an impairment where the Minor Injury Guideline applies and that the insurer shall pay for all goods/services/assessment/examinations described in the plan related to the period, starting on the 11th business day after the day the insurer received the plan, and ending on the day the insurer provides a notice that complies with section 38(8) of the Schedule.

34The applicant disputes the sufficiency of the respondent’s denial of the treatment plans for physiotherapy and chiropractic treatment, submitting that the initial denial letter only referenced the shoulder and knee injuries but not her back or neck injuries. I find that the respondent’s denial was not deficient in that regard.

35The initial denial letter of the respondent dated July 3, 2019 noted that it was now 19 months post-accident, that the applicant had returned to work as a PSW, that the medical records indicated a pre-existing shoulder and knee injury, and that there was no medical rationale for further treatment for her accident-related impairments as the medical records indicate that the accident-related injuries were soft tissue in nature. The respondent’s denial letter further indicated that they would like to arrange an examination. I find nothing improper with this denial correspondence.

36The subsequent denial dated August 22, 2019, unequivocally states that the respondent does not agree to pay for the services of the OCF-18s. It provides the reason being that Dr. Jaroszynski opined in his IE that there were no accident-related impairments, that the complaints were due to pre-existing and evolving, aging/degenerative changes and therefore, the plans were not required as a result of the accident. The applicant further enclosed Dr. Jaroszynski’s IE report. I find that the respondent adequately explained why they were denying the proposed treatment. The applicant may disagree with the findings of the IE assessor and with the respondent’s reasoning to deny the proposed treatment, but this does not mean that the denial was improper under s.38(11) of the Schedule, as it provided sufficient medical and other reasons for the disputed denial.

Is the Applicant Entitled to $2,260.00 for a Chronic Pain Assessment and $11,142.70 for Chronic Pain Treatment?

37After considering the submissions and evidence of the parties, based on a balance of probabilities, I find that the applicant has failed to meet her onus of proving that the proposed chronic pain assessment and treatment are reasonable and necessary.

38The applicant submitted an OCF-18 dated September 9, 2019, proposing a chronic pain assessment in the amount of $2,260.00. The OCF-18 states that the applicant suffers from impairments including ongoing pain in the neck, back, left shoulder, bilateral knees, headaches, whiplash associated disorder, sleep difficulties, anxiety and depressive disorder. This OCF-18 was denied by the respondent on the basis that the IE report of Dr. Jaroszynski, which opined that there were no accident-related impairments, and that all impairments stemmed from pre-existing, evolving and degenerative changes.

39The applicant subsequently underwent the denied chronic pain assessment with Dr. Inese Robertus, chronic pain specialist, on November 6, 2019 and submitted another OCF-18 on December 20, 2019 for chronic pain treatment comprising of physical rehabilitation, physical therapy, chiropractic treatment, massage, social work and psychotherapy treatment, in the amount of $11,142.70. The respondent again denied the treatment plan based on the IE Report of Dr. Jaroszynski, which had held that the applicant’s impairments were not accident related, but due to pre-existing evolving and degenerative changes. The respondent further noted in its denial letter that the medical records from the family physician did not note any psychological complaints.

40The applicant submits that ongoing pain complaints can be found in her family doctor’s records, physiotherapy records, specialist reports and assessments, which supports her assertion that she suffers from chronic pain. Given this ongoing pain, the applicant argues that she required a plan of care and guidance on how to improve her condition, which resulted in the applicant undergoing the denied chronic pain assessment with Dr. Robertus on November 6, 2019.

41As a result of the assessment, Dr. Robertus diagnosed the applicant with multiple injuries as a result of the accident, namely: chronic pain disorder, chronic post-traumatic headaches, chronic whiplash associated disorder (WAD) type II, strain and sprain of the cervical spine, bilateral shoulder thoracic spine, lumbar spine and left knee; full thickness tear of the left supraspinatus tendon; depression; anxiety; post traumatic insomnia; post traumatic fatigue; fibromyalgia and post-traumatic stress disorder (PTSD) – to be confirmed by a psychologist. The applicant argues that since the respondent did not conduct its own chronic pain assessment and solely relied on the previous orthopaedic IE assessment of Dr. Jaroszynski, which concluded that her impairments were not accident related, Dr. Robertus’ diagnosis must be preferred.

42The respondent submits that the OCF-18 for the chronic pain assessment was properly denied, as its IE assessor had previously determined that the applicant’s injuries were not caused by the accident. Moreover, the respondent disputes that this treatment plan was reasonable and necessary, as it described symptoms and impairments that were not corroborated by the applicant’s medical file, making it unreliable. Finally, the respondent criticizes Dr. Robertus’ assessment, noting that the report contained numerous inconsistencies, mischaracterized the applicant’s symptoms and diagnosed the applicant with conditions that are contradicted by the medical evidence.

43With respect to the treatment plan submitted December 20, 2019 proposing chronic pain treatment, the respondent again maintains that the applicant’s impairments were not caused by the accident, or in the alternative, that the treatment proposed is not reasonable and necessary, as neither the applicant’s doctor nor orthopaedic surgeon had recommended any further physical treatment and that the medical file does not establish any psychological diagnoses. Finally, the respondent cites the case Y.Y. v. Allstate¹⁵, where the Tribunal found that a chronic pain assessment that was inconsistent with the medical file was not reliable and therefore not reasonable.

44In determining whether an assessment is reasonable and necessary, it should be noted that assessments are by nature, speculative. The purpose of an assessment is to determine if a condition exists. Notwithstanding their speculative nature, the applicant still bears the onus of establishing on a balance or probabilities that an assessment is reasonable and necessary. To do so, the applicant must point to objective evidence that there are grounds to suspect that she has the condition for which she seeks the assessment. On the evidence, I find that the applicant has failed to satisfy that onus, and therefore, is not entitled to the proposed chronic pain assessment for the following reasons:

45The OCF-18 dated September 9, 2019, itemized a broad list of impairments including: ongoing pain in the neck, back, left shoulder, bilateral knees, headaches, whiplash, sleep difficulties, anxiety and depressive disorder. I agree with the respondent that the medical records do not support many of the claims. The applicant attended at her family physician’s office almost 30 times in the 2.5 years post-accident with various complaints. However, I do not see any references to her having raised concerns with sleeping, anxiety or depression with Dr. Ahmed or any referral being made for mental health concerns.

46With respect to back pain, as previously noted, there is no record of the applicant having complained of back pain after she completed physiotherapy with CBI in July 2018, more than a year before the OCF-18 was submitted. Similarly, with the bilateral knee pain, as previously noted, I have found that with respect to the right knee, there is no evidence to link this injury to the accident. With respect to the left knee, the CNRs of Dr. Ahmed to not show any reports of left knee pain, after April 2018.

47Finally, with respect to the applicant’s left shoulder and neck pain, while I acknowledge that applicant did report pain in these areas, from the medical records, it does not appear to be a severe, persistent and functionally limiting pain.

48In terms of the applicant’s range of motion, both Dr. Jaroszynski and Dr. Robertus had found an essentially normal range of motion. Moreover, there is no evidence that the applicant had to stop working due to accident related impairments or chronic pain in her neck and shoulder. The OCF-18 dated September 9, 2019, stated that the applicant was unable to carry out her employment and stopped working on November 4, 2018, which I find to be inaccurate. The applicant took a short-term disability leave for her right knee pain until she recovered from her arthroscopic procedure to repair the torn meniscus which took place on February 14, 2019. However, as previously noted, I do not find that this injury stemmed from the accident.

49In fact, it does not appear that the applicant has taken any time off work for her neck and shoulder pain. Over the years, the applicant has attended at Dr. Ahmed’s office a number of times, to request that he complete forms for various medical leaves from work. However, from Dr. Ahmed’s records, it does not appear that the applicant ever sought leave for her accident-related impairments.

50Similarly, the applicant has not presented evidence that she needs to take prescription medicine for her accident related injuries. In addition, although the OCF-18 dated September 9, 2019 lists one of the stated goals to be a return to the Activities of Daily Living (ADLs), the applicant has not produced corroborating evidence that her ADLs are restricted.

51The applicant submits that the diagnosis of chronic pain by the applicant’s chronic pain specialist Dr. Inese Robertus must be given extreme deference, as the respondent did not obtain its own chronic pain assessment. While I agree with the applicant that the respondent’s Orthopaedic IE assessment by Dr. Jaroszynski does not directly address the issue of chronic pain, I do not find that the respondent’s lack of a chronic pain assessment is determinative of the issue, given that extensive objective medical evidence has been submitted. Further, the burden of proof is on the applicant to prove entitlement, and not on the respondent to disprove it.

52I agree with the respondent that the many of symptoms and impairments listed in Dr. Robertus’ assessment are contradicted by the applicant’s medical file. I give Dr. Ahmed’s records great weight because he was the applicant’s treating physician both pre and post accident and has the most familiarity with the applicant. As previously noted, there is an extensive history of CNR’s from Dr. Ahmed which contradict Dr. Robertus’ findings of mental concerns, headaches, sleep disturbance, functionality complaints and reports of ongoing back pain. Given that Dr. Robertus’ diagnosis of chronic pain disorder is based upon impairments that are not corroborated (and even are contradicted) by the medical evidence, it calls into question the reliability of the diagnosis.

53Moreover, Dr. Robertus provides limited details of the diagnostic criteria she used to assess the applicant for chronic pain syndrome. The report includes a summary of the interview with the applicant, a list of the medical records reviewed, a list of the applicant’s complaints and the physical examination findings. However, Dr. Robertus does not provide a meaningful analysis for her conclusion that the applicant meets the duration, dysfunction and depressive criteria for chronic pain syndrome. As such, I place less weight on Dr. Robertus’ chronic pain assessment, than on the medical records of the applicant’s treating physicians.

54Finally, with respect to the chronic pain treatment proposed in the OCF-18 submitted on December 20, 2019, I find that the applicant has not met her onus to establish that the proposed treatment is reasonable and necessary. The OCF-18 proposes physical rehabilitation, physical therapy, chiropractic treatment, massage, social work and psychotherapy treatment, in the amount of $11,142.70.

55As previously noted, the bulk of the listed impairments are not corroborated by medical evidence, or were found not to have been caused by the accident. In addition, the applicant has not adduced sufficient objective, medical evidence that further physical treatment would provide any therapeutic benefit, particularly with respect to her left shoulder impairment. Neither the applicant’s family physician, nor her orthopaedic surgeon were recommending further physical therapy.

56Finally, with respect to the proposed psychotherapy and social work therapy, the applicant has not provided any corroborative evidence that she had sustained a psychological impairment from the accident. The CNR’s of Dr. Ahmed indicate that the only time the applicant raised a mental health concern was in September 2019; said entry states that when discussing her chest pain, the applicant noted that her pain could be due to stress, but believed that her stress was related to her family or work.

57As a result, I find that the applicant has not met her burden of proof to establish that the OCF-18s for a chronic pain assessment and treatment are reasonable and necessary pursuant to the Schedule.

Award

58Section 10 of Regulation 664 provides that a special award may be granted if the respondent unreasonably withheld or delayed payments.

59As I found that the applicant is not entitled to any of the disputed benefits, there was no payment unreasonably withheld or delayed. The respondent’s denial of the proposed treatment plans was not unreasonable given the evidence. For these reasons, the applicant is not entitled to an award.

Interest

60Section 51(1) of the Schedule states that interest is due on a benefit that is overdue if the insurer does not pay the benefit within the time stated by the Schedule.

61As no benefits are overdue, no interest is payable under s.51.

CONCLUSIONS

62For the reasons outlined above, I find that the applicant is not entitled to the disputed treatment plans claimed. No award is made. No interest is payable. The application is dismissed.

Footnotes

1. 1O. Reg. 34/10, as amended.
2. 2Respondent’s Submissions, p.51, S.44 Orthopaedic Assessment by Dr. Greg Jaroszynski dated August 9, 2019
3. 3Applicant’s Submissions, Clinical Notes and Records of Dr. Sadaf Ahmed, p. 269
4. 4Applicant’s Submissions, Tab 2, Ultrasound of Left Shoulder dated June 29, 2018
5. 5Applicant’s Submissions, Tab 3, Ultrasound of Left Shoulder dated August 7, 2019
6. 6Sabadash v. State Farm, 2019 ONSC 1121
7. 7Applicant’s Submissions, Clinical Notes and Records of Dr. Ahmed, entry dated October 25, 2018, p.440
8. 8Applicant’s Submissions, Clinical Notes and Records of Dr. Ahmed, entry dated April 18 2018, p.425
9. 9Applicant’s Submissions, Clinical Notes and Records of Dr. Ahmed, entries dated March 26, 2014 and August 20, 2014
10. 10Applicant’s Submissions, Discharge Report from CBI dated July 27, 2018, p. 569
11. 11Ibid.
12. 12Applicant’s Submissions, Clinical Notes and Records of Dr. Ahmed, entry dated July 16, 2019 at p.490
13. 13Respondent’s Submissions, Orthopaedic Consultation of Dr. Denkers, dated November 19, 2019
14. 14Ibid.
15. 15Y.Y v. Allstate, 2020 CanLII 34499