Dexter Burke v. Economical Mutual Insurance Company, 2022 CanLII 81528

Citation and File Number

Citation: Burke v. Economical Mutual Insurance Company, 2022 ONLAT 20-008233/AABS

Licence Appeal Tribunal File Number: 20-008233/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.

Parties

Between:

Dexter Burke Applicant

and

Economical Mutual Insurance Company Respondent

Decision [and Order]

Vice-Chair: Brett Todd

Appearances:

For the Applicant: Virginia Essipova, Counsel

For the Respondent: Yann Grand-Clement, Counsel

Heard By Way of Written Submissions

Background

1Dexter Burke (the “applicant”) was injured in an automobile accident on March 9, 2018 and sought benefits pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 2010 (the “Schedule”)¹ from Economical Mutual Insurance Company (the “respondent”).

2The applicant was driving westbound across the intersection between Lawrence Avenue East and Howden Road in Toronto on March 9, 2018. His vehicle struck another vehicle traveling southbound in a T-bone collision.² The applicant did not seek immediate medical assistance when leaving the scene of the accident, although he did attend the emergency room of Scarborough and Rouge Hospital later that same day as a walk-in patient. He reported numerous injuries to his neck, lower back, and knees, and highlighted an injury to his left shoulder as the most notable injury sustained during the accident.³

3The applicant initiated a claim for medical benefits. The respondent determined the applicant’s injuries fell within the Minor Injury Guideline (the “MIG”)⁴ and refused to pay for certain treatment plans (“OCF-18”s). As a result, the applicant applied to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”) for resolution of this dispute.

Issues in Dispute

4The following issues are to be decided:

(i) Has the applicant sustained predominantly minor injuries as defined in section 3 of the Schedule, subject to treatment within the $3,500.00 limit in the MIG?

(ii) Is the applicant entitled to $1,977.05 for chiropractic services proposed by Mackenzie Medical Rehabilitation Centre in an OCF-18 dated July 10, 2018?

(iii) Is the applicant entitled to $1,384.70 for chiropractic services proposed by Mackenzie Medical Rehabilitation Centre in an OCF-18 dated October 18, 2018?

(iv) Is the applicant entitled to $2,460.00 for an orthopaedic assessment proposed by 101 Assessments in an OCF-18 dated August 30, 2018?

(v) Is the applicant entitled to $2,128.51 for an occupational therapy assessment proposed by 101 Assessments in an OCF-18 dated August 30, 2018?

(vi) Is the applicant entitled to $2,569.40 for chiropractic services proposed by Mackenzie Medical Rehabilitation in an OCF-18 dated January 25, 2019?

(vii) Is the applicant entitled to $2,569.40 for chiropractic services proposed by Mackenzie Medical Rehabilitation in an OCF-18 dated July 22, 2019?

(viii) Is the applicant entitled to $2,569.40 for chiropractic services proposed by Mackenzie Medical Rehabilitation in an OCF-18 dated October 7, 2019?

(ix) Is the applicant entitled to interest on any overdue payment of benefits?

Result

5I find the applicant has proven that he suffers from chronic pain as a result of the accident. Chronic pain is not included in the minor injury definition. As a result, he is not subject to the $3,500.00 MIG funding limit provided by s. 18(1) of the Schedule.

6The applicant has also demonstrated that his accident-related impairments warrant treatment beyond the MIG and that the five Mackenzie Medical Rehabilitation Centre treatment plans listed above (ii, iii, vi, vii, and viii) are reasonable and necessary. The applicant is entitled to these plans, plus applicable interest.

7The applicant is not entitled to the two 101 Assessments treatment plans listed above (iv and v), as he has not demonstrated that they are reasonable and necessary. Accordingly, no interest is applicable.

Analysis

Minor Injury Guideline and Chronic Pain

8The MIG establishes a treatment framework available to injured persons who sustain a minor injury as a result of an accident. A “minor injury” is defined in s. 3 of the Schedule and includes sprains, strains, whiplash associated disorder, contusion, abrasion, laceration or subluxation, and any clinically associated sequelae. The MIG provides that a strain is an injury to one or more muscles and includes a partial tear. Minor injuries are subject to the treatment methodologies outlined in the MIG. Under s. 18 of the Schedule, injuries that are defined as minor are subject to a $3,500.00 funding limit on treatment. An applicant may receive payment for treatment beyond the $3,500.00 limit if they can demonstrate that a pre-existing condition, documented by a medical practitioner, prevents maximal recovery under the MIG, or if they provide evidence of a psychological impairment or chronic pain with a functional impairment as a result of the accident.

9As noted above, the applicant sought treatment on the day of the accident in the emergency room of the Scarborough Rouge Hospital. He reported injuries to his neck, lower back, knees, and left shoulder. The applicant then met with Dr. C. Chang, family physician, on March 26, 2018.⁵ He complained once again of knee, shoulder, and back pain. Dr. Chang diagnosed the applicant with “whiplash injury,” “left shoulder sprain/strain,” and “back muscle strain.” Dr. Chang recommended therapy, x-rays of the spine and left shoulder, and that the applicant return to the clinic as needed.⁶

10The applicant met again with Dr. Chang a week later on April 3, 2018. Dr. Chang noted that the applicant was unable to return to work immediately following the accident, diagnosed left shoulder tendinitis, and recommended physical therapy.⁷

11Diagnostic imaging including multiple ultrasounds on March 27, 2018, June 27, 2018, and March 3, 2019, and an MRI on October 31, 2019 showed left shoulder tendinitis, degenerative changes, and an injury that progressed to a partial tear of the supraspinatus tendon and then to a healed state.⁸ On August 20, 2018, the applicant was diagnosed with chronic left shoulder pain by Dr. V. Dao, family physician and operator of the Dr. Dao Pain Clinic.⁹

12The applicant enrolled in physiotherapy and chiropractic/physical therapy treatment programs at Mackenzie Medical Rehabilitation Centre starting in July, 2018.¹⁰

13The applicant was treated on multiple occasions in 2019 with cortisone injections into his left shoulder by Dr. H. Cameron, orthopaedic surgeon.¹¹

14The applicant attended a chronic pain assessment on December 21, 2020 conducted by Dr. G. Karmy, family physician and operator of the Karmy Chronic Pain Medical Clinic.¹² The resulting chronic pain assessment report dated January 11, 2021 noted that this examination included a clinical interview, physical examination, and a review of medical investigations such as x-rays, ultrasounds, and an MRI. Dr. Karmy concluded that the applicant sustained the following impairments as a result of the subject accident: chronic post-traumatic headache, chronic mechanical neck pain likely originating from the cervical discs and facet joints, chronic mechanical left shoulder pain, chronic mechanical lower back pain, chronic mechanical left knee pain, and myofascial pain syndrome.¹³

15I give significant weight to the report of Dr. Karmy, as his opinion is supported by Dr. Dao. In his report, Dr. Dao diagnosed the applicant with chronic left shoulder pain following the subject accident along with myofascial pain. Dr. Dao recommended physical therapy to deal with these injuries.¹⁴

16Dr. Karmy and Dr. Dao’s diagnosis are consistent with the opinions from the applicant’s other healthcare providers. The applicant submitted clinical notes and records (“CNRs”) from Dr. Chang, Dr. Cameron, and Dr. C. Godfrey, physical medicine and rehabilitation specialist.¹⁵ These records show that the applicant experienced ongoing shoulder and back pain following the accident. Both Dr. Chang and Dr. Cameron recommended physical therapy. Dr. Godfrey observed that the applicant demonstrated a “good range of movement in the cervical spine” and the records included an electromyographic examination report that showed “normal motor and sensory conduction times for the median, ulnar, and radial nerves,” but no treatment recommendations.¹⁶ I acknowledge that this conflicts with Dr. Chang and Dr. Cameron’s findings, although I place greater weight on the reports of the latter, as they saw the applicant on multiple occasions over a year (see paragraph 19, below), while Dr. Godfrey saw the applicant a single time, on May 9, 2019.

17Ultrasound reports dated from March 27, 2018 through March 3, 2019 show left shoulder injuries that progressed from supraspinatus tendinosis to a “low grade partial thickness tear in the mid substance of the tendon near the insertion measuring 7x5x3mm.”¹⁷ An MRI report of the applicant’s left shoulder dated October 31, 2020 did not reveal the tear, but it did show degenerative and hypertrophic change.¹⁸

18The applicant participated in an insurer’s examination, (“IE”), with Dr. L. Weisleder, orthopaedic surgeon, on April 24, 2018. During that assessment, the doctor noted that the applicant complained of persistent pain in both shoulders, but also an improvement of 50% since the accident. The report also cites the applicant’s persistent upper and lower back pain, but noted an improvement of 50% and 60%, respectively. Dr. Weisleder concluded that the applicant sustained only minor injuries in the accident and did not observe any other factors or sequelae that would warrant removal from the MIG.¹⁹

19Although the Dr. Weisleder report indicates considerable progress in the applicant’s recovery from his injuries, I need to emphasize that this examination occurred on April 24, 2018, before the medical and diagnostic evidence provided by the applicant revealed worsening physical symptoms warranting further treatment. The applicant’s history of seeking medical assistance and diagnostic imaging to fully assess his injuries from immediately post-accident in 2018 to the end of 2020 takes precedence over the report by Dr. Weisleder. The applicant had 13 appointments with Dr. Chang from shortly after the accident on March 26, 2018 through July 16, 2019.²⁰ The applicant also saw Dr. Cameron on six occasions from September, 2018 through July 30, 2019, complaining of consistent shoulder pain that was treated on at least three occasions with cortisone injections.²¹

20The reports of Dr. Chang and Dr. Cameron, as well as imaging taken during the same time period, reveal a progression of the applicant’s injuries and that his situation worsened in the months following the Dr. Weisleder report. As a result, I do not have enough evidence before me to contradict the applicant’s self-reports and the reports of Dr. Chang and Dr. Cameron, or to form the basis of any criticism of the Dr. Karmy report and his diagnosis.

21Timeliness is not the only concern that I find with the report by Dr. Weisleder. Whereas Dr. Weisleder viewed the applicant’s lower back strain as his predominant injury, all the other reports focus much more on the left shoulder as the primary injury. Imaging revealed a tear and degenerative changes in the left shoulder, as well. The left shoulder was also the focus of treatment, including the multiple cortisone injections cited above. Given that Dr. Weisleder did not fully diagnose the extent of the injury to the applicant’s left shoulder, I have doubts about the thoroughness of his examination.

22The respondent’s criticism of Dr. Karmy’s report do not rise to the level of detracting from Dr. Karmy’s report, particularly when it comes to how the doctor assessed the levels of pain in the applicant’s knees and shoulder. No medical opinions were provided by the respondent to refute the final Dr. Karmy diagnosis of chronic pain, or to demonstrate how a pain rating of 5 out of 10 in a left shoulder and lower back, or even a 2 out of 10 in a neck and knees, could not be medically consistent with such a conclusion.²² Instead, the respondent simply submitted that “Dr. Karmy’s diagnoses are nonsensical,” which does not carry any weight given that there is no contemporaneous medical opinion to back up this assertion.²³ The respondent relies almost entirely on the Dr. Weisleder report in its submissions when it comes to medical evidence. As has already been noted, this report was conducted before the progression of the applicant’s injuries. It does not account for later medical developments, let alone address the chronic pain report done over two years later.

23The respondent submits that the applicant’s claim of chronic pain should be assessed against the six criteria described in the American Medical Association (“AMA”) Guides.²⁴ The respondent refers to an applicant needing to meet at least three of the six criteria. The criteria are:

(i) Use of prescription drugs beyond the recommended duration and/or abuse of or dependence on prescription drugs or other substances;

(ii) Excessive dependence on health care providers, spouse, or family;

(iii) Secondary physical deconditioning due to disuse and or fear-avoidance of physical activity due to pain;

(iv) Withdrawal from social milieu, including work, recreation, or other social contacts;

(v) Failure to restore pre-injury function after a period of disability, such that the physical capacity is insufficient to pursue work, family, or recreational needs; and

(vi) Development of psychosocial sequelae after the initial incident, including anxiety, fear-avoidance, depression, or nonorganic illness behaviours.

24I do not find it appropriate to overrule the diagnosis and advice of a regulated medical professional in the absence of any contemporaneous opinion to the contrary. As such, Dr. Karmy’s report holds significant weight here. The AMA criteria is an excellent guideline, but it is not the only standard in which one can be diagnosed with chronic pain and, as a result, be removed from the MIG and no longer be subject to the $3,500.00 funding limit.

25Regardless, I do find that the applicant meets three of the criteria (ii, iii, and v) listed in the AMA Guides.

26The applicant has an excessive dependence on his family, satisfying criterion two. Dr. Karmy’s report notes that the applicant separated from his wife and son and moved in with his mother following the accident.²⁵ Although there could be various reasons for this separation, I place weight on the event as a contributing factor when it comes to assessing chronic pain. The separation took place not long after the subject accident during a span of time when the applicant was seeking assistance for his injuries from numerous physicians and was experiencing injury-related work difficulties. I find it credible that the injuries sustained in the subject accident and the resulting pain played a role in the applicant moving in with his mother, and that family dependence is demonstrated by his leaving the home he shared with his wife and son to return to the home of his parent.

27As an additional point supporting criterion two, the applicant’s submissions show a significant reliance on health care providers in the years following the subject accident. The applicant attended his family physician on 13 occasions in 2018 and 2019, specialists on at least another half-dozen occasions, and appointments for numerous medical imaging tests, along with regular physiotherapy sessions.

28The applicant has experienced fear-avoidance of physical activity due to pain, satisfying criterion three. Dr. Karmy’s report noted that the applicant was experiencing “significant difficulties while attempting to engage in heavy-duty household tasks” and had to hire a contractor to do all of the yard, sidewalk, and driveway maintenance at the home he was living in with his mother. By the time of the report in December 2020, the applicant had resumed doing most household chores, but reported that he was limited in his abilities and had to do them slowly to avoid “significant pain flare-ups.”²⁶

29The applicant has failed to restore pre-injury function after a period of disability, particularly when it comes to work, satisfying criterion five. The applicant was medically advised to take time off work at both of his full-time jobs (he was employed as both a steward in a hotel and as a labeler in a factory) immediately after the accident. He did return to work on July 25, 2018, but according to Dr. Karmy’s report, he experienced significant problems with physically demanding activities involving bending, heavy lifting, and prolonged standing. At the time of the report, the applicant had left the labeler job due to family obligations and the steward position due to the Covid-19 pandemic.²⁷ Although chronic pain was not cited as the direct cause of the applicant leaving those places of employment, his experiencing physical difficulty in both of those positions leads me to conclude that this would impact negatively on him re-entering the workforce and impede his return to pre-injury function.

30Further satisfying criterion five, I also find that there is evidence of functional impairment rising to the level which removes him from the MIG. The functionality exhibited by the applicant, as outlined in the reports of Dr. Chang, Dr. Cameron, Dr. Dao, and particularly Dr. Karmy, indicates prolonged pain as a result of the subject accident. This caused him to take a leave of absence from work for more than four months, left him unable to perform standard household tasks for a period of time, and resulted in extended difficulty with core duties of both of his laborer jobs that required repetitive lifting, bending, and prolonged standing.

31The applicant’s work status also needs to be addressed in the context of criterion five, as it is the subject of conflicting information in the submissions. The respondent states that the applicant returned to work as scheduled on July 25, 2018. Both applicant and respondent seem to agree on this. But the respondent does not note his workplace difficulties and his later unemployment, or him moving in with his mother, all included in the report by Dr. Karmy.²⁸ The respondent does not challenge these facts. I accept the assertions of the Dr. Karmy report due to the credibility of this document that I have noted above—and in light of no compelling medical evidence to the contrary from the respondent.

32The respondent relies on the IE report of Dr. D. Mandel, psychologist, to refute the applicant’s claims of chronic pain.²⁹ I find this assessment to be unpersuasive for two reasons. First, she examined the applicant on May 9 and May 16, 2018, well before the applicant’s condition worsened through 2019 and 2020 (shown by the medical evidence detailed above), and long before the Dr. Karmy assessment at the end of 2020. As a result, this report is untimely and irrelevant with regard to chronic pain. The respondent attempts to emphasize the applicant’s responses to Dr. Mandel’s questions about the level of pain he was experiencing in his left shoulder and left neck, and lower back and lower knees (3 out of 10 and 1 out of 10, respectively).³⁰ But these self-assessments are inconsequential given that they were provided before the applicant’s condition deteriorated. Second, Dr. Mandel provided no direct commentary on chronic pain in her report. Her examinations focused on two of the physical treatment plans proposed by Mackenzie Rehabilitation, and she declined to answer a number of the questions posed at the end of her report, saying these were “not applicable” as she has no expertise in these areas.³¹ As a result, I assign the Dr. Mandel report little weight regarding chronic pain.

33Chronic pain with a functional impairment is a condition that warrants removal from the MIG and the $3,500.00 finding limit. Considering Dr. Karmy’s diagnosis of chronic pain, the supporting opinion of Dr. Dao, the numerous CNRs provided by the applicant showing the progression of his injuries after the accident, the applicant’s record of visits to his family doctor and other specialists, the diagnostic imaging, and my finding that the applicant satisfies three criteria in the AMA Guides, I find the applicant suffered injuries which are outside the definition of a minor injury and are thus not subject to the $3,500.00 funding limit.

The Mackenzie Medical Rehabilitation Centre Treatment Plans

34Furthermore, the applicant has met his onus to prove that the five disputed treatment plans from Mackenzie Medical Rehabilitation are reasonable and necessary.

35As noted above in the analysis on chronic pain, the injuries sustained as a result of the subject accident progressed through 2019 into 2020. Medical treatment was consistent throughout that time period. This resulted in the submission of considerable medical evidence of chronic left shoulder pain, headaches, neck pain, lower back pain, left knee pain, and myofascial pain syndrome, all caused by the accident. The applicant’s family physicians and specialists recommended physical therapy, and the applicant was also treated with multiple cortisone injections into his left shoulder.

36In his chronic pain assessment, Dr. Karmy recommended physical therapy, including exercise, massage, and acupuncture, all of which were performed at Mackenzie Medical Rehabilitation Centre in the disputed treatment plans. These treatment plans involved all of the above therapies in addition to chiropractic treatment, despite being listed on the appeal documentation and in the applicant’s written submissions as being solely “chiropractic services” plans.³²

37The respondent provided no contemporaneous medical evidence to dispute these treatment plans beyond the Dr. Weisleder report, which is unpersuasive due to the reasons noted above.

38The Dr. Mandel report³³ is timelier here when considered with the Mackenzie treatment plans in dispute, as it was completed in early 2018 not long before the dates of those plans. With that said, the Dao report done at roughly the same time does provide an adequate refutation of Mandel, as noted above. Also, as previously noted as well, Dr. Mandel refuses to comment on the two Mackenzie plans she was asked by the insurer to assess, due to her lack of expertise in such matters. As a result, I did not give it much weight in this portion of my evaluation.

The 101 Assessments Treatment Plans

39The applicant has not met his burden to demonstrate that the orthopedic and occupational assessments in the two 101 Assessments treatment plans are reasonable and necessary.

40The applicant has provided virtually no evidence regarding these treatment plans in his written submissions. These submissions focus almost entirely on the chronic pain issue necessitating removal from the MIG and the aforementioned physical treatment plans from Mackenzie Medical Rehabilitation. These OCF-18s seem to have been prepared with regard to an attendant care benefit matter not at dispute here, so little attention was paid to them in the applicant’s arguments.

41Virtually all of the applicant’s argument with regard to these two orthopedic assessments is contained in a single paragraph in his written submissions. It simply cites that these are reasonable because the applicant suffers from “osteoarthritis and nerve pain in the left AC joint,” and concludes that this gives the applicant reason to “explore the etiology of his pain symptoms.”³⁴ There are no direct citations to medical reports that include specific recommendations for these orthopedic assessments. Where the written submissions certainly note these recommendations when it comes to the physical treatments addressed in the Mackenzie treatment plans, they are silent here, a conspicuous omission.³⁵

42Given no significant medical evidence to the contrary, I accept the respondent’s contention, as provided in the denial letter dated September 25, 2018, that the assessments could have been handled with an OHIP-covered orthopedic specialist.³⁶ Granted, using OHIP for assessments can result in a delay in obtaining such services, which can be an issue for those recovering from accident injuries. But the applicant makes no argument with regard to timeliness being a factor behind the reasonable and necessary nature of these OCF-18s, which renders it impossible to assess whether or not this was a factor here.

43The applicant has simply not provided enough evidence to prove the reasonable and necessary nature of the 101 Assessments treatment plans. No specific medical recommendations are cited to support these orthopedic assessments, in contrast to the physical treatment plans. The respondent also provides a credible counterargument to their necessity, noting that the same services could have been provided through OHIP.

Conclusion and Order

44For the reasons outlined above, I find that the applicant is entitled to:

(i) The July 10, 2018 OCF-18 for chiropractic services proposed by Mackenzie Medical Rehabilitation ($1,977.05);

(ii) The October 18, 2018 OCF-18 for chiropractic services proposed by Mackenzie Medical Rehabilitation ($1,384.70);

(iii) The August 30, 2018, OCF-18 for chiropractic services proposed by Mackenzie Medical Rehabilitation ($2,569.40);

(iv) The January 25, 2019, OCF-18 for chiropractic services proposed by Mackenzie Medical Rehabilitation ($2,569.40);

(v) The July 2, 2019, OCF-18 for chiropractic services proposed by Mackenzie Medical Rehabilitation ($2,569.40); and

(vi) Interest on the above according to s. 51 of the Schedule.

45For the reasons outlined above, I find that the applicant is not entitled to:

(i) The August 30, 2018 OCF-18 for an orthopaedic assessment proposed by 101 Assessments ($2,460.00);

(ii) The August 30, 2018 OCF-19 for an occupational therapy assessment proposed by 101 Assessments ($2,128.51); and

(iii) Interest on the above according to s. 51 of the Schedule.

Footnotes

1. 1O. Reg. 34/10 as amended.
2. 2Document Brief of the Applicant, Tab 3.
3. 3Document Brief of the Respondent, Tab 2.
4. 4O. Reg 34/10 as amended, s. 3(1).
5. 5Written Submissions of the Applicant, page 2 refers to this appointment as being with a Dr. Amarasekera, but the medical notes in the applicant’s Document Brief were filed by Dr. Chang. As a result, I prefer Dr. Chang here.
6. 6Document Brief of the Applicant, Tab 2, pages 11-12.
7. 7Ibid. Tabs 2 and 19 (page 86), respectively.
8. 8Ibid. Tabs 20, 21, 22, and 25, respectively.
9. 9Ibid. Tab 23: Pinnacle Health Sciences Centre Report (Dr. Dao Assessment).
10. 10Ibid. Tabs 4, 6, 12, 14, and 16: OCF-18s.
11. 11Ibid. Tab 19, pages 93, 95, 98-100, Tab 24.
12. 12Ibid. Tab 26.
13. 13Ibid. Tab 26 (Dr. Karmy Chronic Pain Assessment).
14. 14Ibid. Tab 23 (Pinnacle Health Sciences Centre Report, Dr. Dao Assessment).
15. 15Ibid. Tabs 2 and 19, pages 79 and 86-92 (Chang); Tab 19, pages 93, 95, 98, 99, 100 (Cameron); Tab 19, page 94 (Godfrey).
16. 16Ibid. Tab 19, page 94.
17. 17Ibid. Tab 19, pages 96-97, 106; Tabs 20, 21, and 22.
18. 18Ibid. Tab 25 (Scarborough Health Network MRI Report).
19. 19Document Brief of the Respondent, Tab 12 (DirectIME Dr. Weisleder Orthopedic Examination).
20. 20Document Brief of the Applicant, Tab 19, pages 79-80, 86-92.
21. 21Ibid. Tab 19, pages 93, 95, 98, 99, 100; Tab 24.
22. 22Ibid. Tab 26, page 131 (Dr. Karmy Chronic Pain Assessment).
23. 23Written Submissions of the Respondent, page 9.
24. 24American Medical Association Guides to the Evaluation of Permanent Impairment, 6th Ed.
25. 25Document Brief of the Applicant, Tab 26, page 133 (Dr. Karmy Chronic Pain Assessment).
26. 26Ibid.
27. 27Ibid. Tab 26, pages 132-133.
28. 28Document Brief of the Applicant, Tab 26, pages 132-133 (Dr. Karmy Chronic Pain Assessment).
29. 29Document Brief of the Respondent, Tab 14 (DirectIME Dr. Mandel Psychological Examination).
30. 30Written Submissions of the Applicant, page 12.
31. 31Document Brief of the Respondent, Tab 14, pages 62ff. (DirectIME Dr. Mandel Psychological Examination).
32. 32Document Brief of the Applicant, Tabs 4, 6, 12, 14, and 16 (Mackenzie Medical Rehabilitation Clinic OCF-18s).
33. 33Document Brief of the Respondent, Tab 14 (DirectIME Dr. Mandel Psychological Examination).
34. 34Written Submissions of the Applicant, page.8.
35. 35Ibid., pages 7-8.
36. 36Document Brief of the Applicant, Tab 9, page 35 (Economical correspondence September 25, 2018).```