Citation: Misquitta v. Allstate Insurance Company of Canada, 2022 ONLAT 20-001085/AABS

Licence Appeal Tribunal File Number: 20-001085/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:

Leonard Misquitta

Applicant

and

Allstate Insurance Company of Canada

Respondent

DECISION

ADJUDICATOR:

Ulana Pahuta

APPEARANCES:

For the Applicant:

Steven Sieger, Counsel

For the Respondent:

Nawaz Tahir, Counsel

HEARD:

By Way of Written Submissions

BACKGROUND

1Leonard Misquitta (“applicant”) was involved in an automobile accident on June 18, 2017, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016)¹ (the “Schedule”). At the time of the accident, the applicant was 12 years old. The applicant was denied certain benefits by Allstate Insurance Company of Canada (“respondent”) and submitted an application to the Licence Appeal Tribunal - Automobile Accident Benefits Service (“Tribunal”).

ISSUES

2The following issues are in dispute:

a. Is the applicant entitled to the cost of psychological services in the amount of $3,500.00 recommended by J. Frank in a treatment plan (“OCF-18”) submitted on March 18, 2019?

b. Is the applicant entitled to the cost of physiotherapy services in the amount of $5,665.80 recommended in an OCF-6 submitted on August 21, 2019?

c. Is the applicant entitled to the cost of physiotherapy services in the amount of $2,351.52 recommended by Seksek Chiropractic Professional Corporation in an OCF-18 submitted on November 7, 2019?

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

3In their written submissions for this hearing, both parties provided submissions on the issue of whether the applicant should be held within the Minor Injury Guideline² (“MIG”). As such, I have added the following issue to this hearing:

a. Are the applicant’s injuries predominantly minor as defined in s.3 of the Schedule and therefore subject to treatment within the $3,500.00 limit and in the MIG?

RESULT

4For the reasons outlined below, I find that the applicant’s impairments are predominantly minor as defined by the Schedule and subject to the treatment limits of the MIG.

5As the parties have not expressly confirmed whether the funding within the MIG limit has been exhausted, I have considered the reasonableness and necessity of the three treatment plans in dispute and have found that they are not reasonable and necessary as a result of the accident. As no benefits are owing, no interest is payable.

ANALYSIS

The Minor Injury Guideline

6The MIG establishes a framework available to injured persons who sustain a minor injury as a result of an accident. A “minor injury” is defined in s. 3(1) of the Schedule as, “one or more of a strain, sprain, whiplash associated disorder, contusion, abrasion, laceration or subluxation and includes any clinically associated sequelae to such an injury.” The terms, “strain,” “sprain,” “subluxation,” and “whiplash associated disorder” are defined in the Schedule.

7Section 18(1) of the Schedule limits recovery for medical and rehabilitation benefits for predominantly minor injuries to $3,500.00. An applicant may receive payment for treatment beyond the $3,500.00 cap if they can demonstrate that a pre-existing condition, documented by a medical practitioner, prevents maximal medical recovery under the MIG or if they provide evidence demonstrating that their injuries are not included in the minor injury definition.

8The onus is on the applicant to show, on a balance of probabilities, that his or her injuries fall outside of the MIG.³

9Sections 14, 15 and 16 of the Schedule provide that an insurer is only liable to pay for medical and rehabilitation expenses that are reasonable and necessary as a result of the accident. The applicant has the onus of proving on a balance of probabilities that the benefits he or she seeks are reasonable and necessary.

Did the Applicant sustain predominantly minor physical injuries?

10I find that the evidence establishes that the applicant sustained a physical injury that is defined as a predominantly minor injury and, as such, is subject to the treatment limits of the MIG.

11The applicant submits that he has suffered an injury to his neck, shoulder and back as result of the accident, necessitating ongoing physiotherapy. The applicant relies on the records from Solid Foundation Family Chiropractic⁴ and Koonar Physiotherapy⁵ to establish that he sought treatment post-accident. The applicant further relies upon his Disability Certificate (OCF-3) and OCF-24 Discharge Report which list his whiplash associated disorder, sprain and strain of the cervical spine and vertebral subluxation complex.⁶

12In contrast, the respondent submits that the applicant did not sustain any physical impairments from the accident, outside the MIG. The respondent relies on its Insurer’s Examination (“IE”) Orthopaedic Assessment Report conducted by Dr. S.W. Bartol, orthopaedic surgeon. Dr. Bartol found that the examination showed no objective evidence of ongoing musculoskeletal injury or impairment. He diagnosed the applicant with a soft tissue injury in his neck (whiplash associated disorder grade 1) and possible soft tissue strain of the low back.⁷ He found that the applicant’s injuries were minor injuries as defined in the MIG.

13The respondent further relies upon the medical records of the applicant’s family physician Dr. Seth Aborhey which indicated that the applicant did not complain of any physical impairments after the accident. Finally, the respondent submits that the clinical notes and records (“CNRs”) of the applicant’s treatment provider, Solid Foundation Family Chiropractic, record that in May 2018, the applicant was “almost back to 100%.⁸”

14With respect to the respondent’s IE Orthopaedic Assessment Report, the applicant submits that it should be given limited weight, as it was conducted without the knowledge that the applicant had autistic limitations which limited his ability to properly articulate his symptoms to the assessor.

15After considering the submissions and evidence of the parties, I agree with the respondent that, based on a balance of probabilities, the applicant has not adduced sufficient objective, medical evidence that he has sustained a physical impairment from the subject accident that would remove him from the MIG.

16The applicant did not submit any diagnostic imaging showing a physical injury after the accident or lead any direct evidence that he had reported a physical injury to his family physician in the year after the accident. I note that the applicant visited his family doctor, Dr. Aborhey, one month after the accident for a follow-up on a complete physical. The CNR entry from that date indicates that the applicant did not discuss the accident or report any pain.

17Similarly, in subsequent visits throughout 2017, the applicant had numerous physical examinations but did not report any injury or pain. It does not appear that Dr. Aborhey recommended that the applicant attend physical treatment after the accident. Rather, the applicant’s mother reported that she already had an appointment with a chiropractor scheduled for a day after the accident so, while there, she had the chiropractor assess the applicant and begin treatment.⁹

18The applicant did not report back pain to Dr. Aborhey until August 3, 2018 (more than a year post-accident), when the applicant attended at Dr. Aborhey’s office with reports of intermittent back pain.¹⁰

19Although the applicant points to the fact that he attended chiropractic and physiotherapy treatment post-accident to establish his injury, I do not find that seeking out physical treatment alone establishes physical impairment. Particularly in this case, where the CNRs of the applicant’s treatment provider, Solid Foundation Family Chiropractic, reported that on May 28, 2018, the applicant was almost back to 100%.¹¹ This almost complete improvement was noted more than a year before the disputed treatment plans were submitted. I note that the CNRs of Solid Foundation also showed that at many appointments, the applicant stated that he “feels good today. Great!”¹² As a result, there is little corroborating medical evidence that the applicant was suffering from an ongoing back, neck or shoulder injury as a result of the accident.

20With respect to the respondent’s IE Orthopaedic Assessment Report which showed no objective evidence of ongoing musculoskeletal injury or impairment, the applicant does not submit any medical diagnosis or medical evidence to counter Dr. Bartol’s diagnosis. Rather, the applicant criticizes Dr. Bartol’s report by arguing that the examination was conducted without knowledge of the applicant’s autistic limitations, such that that the applicant could not properly articulate his symptoms to the assessor. The applicant similarly argues in his reply submissions that the reason he did not report his accident-related impairments to his family physician is because as a child with autism, he is unable to articulate his complaints to someone outside his immediate family.

21The applicant claims that both the Neuropsychological Assessment Report of Dr. Saadia Ahmad, psychologist, dated June 9, 2020¹³ and the Psychological Assessment Report of Dr. Catherine Lee, psychologist, dated August 12, 2013¹⁴ both indicate that he has difficulty with answering questions and processing information.

22I do not find the applicant’s argument that he is unable to articulate symptoms to people outside of his immediate family to be persuasive. In fact, the applicant’s own psychological assessors, Dr. Ahmad and Dr. Lee noted in their reports that the applicant readily communicated and engaged in the assessment process. In her Neuropsychological Assessment Report, Dr. Ahmad noted that the applicant participated in approximately 10 hours of testing in two-hour intervals, and was an eager and a very willing participant. Dr. Ahmad further noted that the applicant communicated with normal use of vocabulary and that his behaviour was consistent with that required to obtain a valid and reliable estimate of his neuropsychological strengths and weaknesses.

23Similarly, in her 2013 Psychological Assessment Report, Dr. Lee found only that the applicant had a Mild Intellectual Disability. Dr. Lee communicated directly with the applicant and noted that “throughout most of the assessment, he was cooperative and gave his best effort”.¹⁵

24Given that both of the applicant’s psychological assessors indicated that they were able to effectively communicate with him, and the applicant does not question the validity of their assessments, the applicant has not provided any persuasive evidence as to why he would be unable to similarly properly communicate with his family physician or the respondent’s IE assessor.

25In addition, I note that the applicant’s mother attended all of the applicant’s medical appointments with his family physician, Dr. Aborhey. The CNRs of Dr. Aborhey indicate that the applicant’s mother consistently raised a variety of symptoms with Dr. Aborhey over the years. However, in the year post-accident, the applicant’s mother similarly did not raise any concerns about any accident-related impairments with the doctor.

26Finally, although the applicant disputes the respondent’s IE report, it is not the respondent’s onus to establish that the injury was minor. Rather, the burden of proof rests with the applicant to prove that he suffered a non-minor physical impairment from the accident - not on the respondent to disprove it. As the applicant has not submitted any objective medical evidence that he has suffered such a physical impairment, he has not met his evidentiary burden and, therefore, I find his physical injuries to be predominantly minor.

Did the Applicant sustain a psychological impairment that would remove him from the MIG?

27The applicant claims that he sustained a psychological impairment as a result of the accident that would place his claim outside of the MIG. Psychological injuries, if established, may fall outside of the MIG, because the MIG only governs “minor injuries” and the prescribed definition does not include psychological impairments.

28The applicant relies on the Neuropsychological Assessment Report of Dr. Ahmad, dated June 9, 2020.¹⁶ Dr. Ahmad found that the applicant satisfied the diagnostic criteria for: a mild neurocognitive disorder due to traumatic brain injury; an adjustment disorder with anxiety; and specific phobia, situational – vehicular. In addition, the applicant submits that, after the accident, his anxiety worsened significantly such that he was monitored by his family physician, Dr. Aborhey for generalized anxiety disorder. The applicant was also referred to Dr. Yousha Mirza, psychiatrist, who recommended counselling and prescribed Cipralex for anxiety.¹⁷

29In contrast, the respondent submits that the applicant had a long psychological history which included developmental and cognitive delays and a mild intellectual disability. The respondent relies on the 2013 psychological assessment report¹⁸ that was prepared by Dr. Catherine Lee, psychologist. The respondent further notes that there was a pre-accident diagnosis of anxiety in 2014.¹⁹ As such, the respondent argues that the applicant’s psychological complaints do not stem from the accident but from pre-existing conditions. In addition, as support for its argument that the applicant did not sustain a psychological injury from the accident, the respondent relies on the medical records of the applicant’s family physician²⁰ which indicate that the applicant did not have any psychological complaints for a year after the accident.

30The respondent further relies on the psychological IE Report prepared by Dr. Jay McGrory, psychologist, dated May 22, 2019.²¹ Dr. McGrory found that the applicant did not present with any accident-related psychological condition. Dr. McGrory noted that the only emotional concern was occasional passenger-related anxiety, but Dr. McGrory noted that this did not meet the threshold for a Diagnostic and Statistical Manual of Mental Disorder (“DSM-5”) diagnosis.

31After considering the submissions and evidence of the parties, I find that, based on a balance of probabilities, the applicant has failed to meet his evidentiary onus that he sustained a psychological impairment as a result of the accident.

32The applicant has not provided any evidence that in the year post-accident, he sought out medical attention for psychological impairments. Looking at the CNRs of his family physician, Dr. Aborhey, in the year after the accident, the only mental health concerns discussed related to his ongoing follow-ups for a historic diagnosis of attention deficit disorder. It was not until more than a year post-accident, on July 10, 2018, that the applicant attended at Dr. Aborhey’s office with reports of anxiety and oppositional behaviour. Dr. Aborhey made a psychiatric referral to Dr. Yousha Mirza, psychiatrist and subsequently deferred management of the generalized anxiety to Dr. Mirza.²²

33Dr. Mirza saw the applicant on September 26, 2018, June 17, 2019, and August 8, 2019.²³ In her progress reports, Dr. Mirza does not identify the applicant’s anxiety as being caused by the accident. Rather, in her final August 8, 2019 report, Dr. Mirza notes that, when talking about starting high school, the applicant admitted feeling anxiety about meeting new people and new kids. In terms of the ongoing plan, Dr. Mirza indicated that the applicant was stable and doing well on Cipralex and she was closing the case. However, she noted that if there were to be “any increase in anxiety related to high school or interpersonal situations then he should start counselling.”²⁴

34The applicant similarly reported to the respondent’s IE assessor, Dr. McGrory, that he worried about “being put in CAS (care)” and bullies at school. Although he reported occasional passenger-related anxiety, Dr. McGrory did not feel this reached a clinical level of concern. Rather, Dr. McGrory felt that the major sources of stress for the applicant were social/interpersonal concerns. As a result, Dr. McGrory found that the applicant did not present with any accident-related psychological condition.

35When weighing the assessment reports of Dr. Ahmad and Dr. McGrory, I prefer the report of the respondent’s IE assessor Dr. McGrory, for the following reasons:

a. Dr. Ahmad’s report was a neurological assessment report for academic planning. As such, the bulk of the testing appeared to be related to educational/academic functioning, rather than emotional and psychological assessments. The tests conducted were tests to measure psychometric intelligence, academic achievement abilities, psychomotor functioning, attention and memory, language functioning, information processing, and executive functioning. The psychological testing conducted was the Minnesota Multiphasic Personality Inventory – Adolescent (MMPI-A) and the applicant’s mother competed the Personality Inventory for Children – Second Edition (PIC-2). As a result of this focus on academic planning, there is limited information about the basis for Dr. Ahmad’s psychological diagnoses of the applicant.

b. Dr. Ahmad diagnosed the applicant with a mild neurocognitive disorder due to traumatic brain injury; an adjustment disorder with anxiety; and specific phobia, situational – vehicular. With respect to the traumatic brain injury, I am uncertain on what basis Dr. Ahmad makes this determination, as I do not see any medical information establishing that the applicant sustained a brain injury and the applicant has not made any submissions about a head injury. Moreover, a diagnosis of a brain injury would be outside of the scope of Dr. Ahmad’s expertise, as a psychologist.

c. With respect to Dr. Ahmad’s diagnoses of an adjustment disorder with anxiety; and specific phobia, situational – vehicular, this appears be based on the interviews with the applicant and his mother, in addition to the MMPI-A and PIC-2 testing. However, Dr. Ahmad expressly noted that the applicant’s MMPI-A testing revealed that there were no elevations in his profile consistent with the presence of psychopathology.²⁵ Rather, it was the applicant’s mother’s parent profile that indicated significant concerns in areas such as anxiety. Therefore, it appears that Dr. Ahmad appears to have at least partly based her diagnoses on the concerns raised by the applicant’s mother, rather than objective testing of the applicant. However the applicant’s mother has been noted to be excessively concerned about the applicant’s anxiety. In the August 28, 2019 Progress Note of Dr. Mirza, the applicant’s psychiatrist, Dr. Mirza notes that “Mother reports Leonard’s anxiety is there although it is better. She seems to be overly concerned about Leonard’s anxiety.”²⁶

d. With respect to the documentation that was reviewed in preparation of their reports, the respondent’s IE assessor, Dr. McGrory, reviewed the full medical brief of the applicant, including all imaging, CNRs of treating physicians and treatment providers and all insurance forms. However, Dr. Ahmad reviewed only a 2013 psychological assessment report and the IE Report prepared by Dr. McGrory.

e. Dr. McGrory’s report is consistent with respect to the applicant’s medical history, in that the applicant did not report any accident-related psychological impairment to his family physician in the year post-accident. In addition, Dr. McGrory’s findings that the major sources of stress for the applicant were social/interpersonal concerns is consistent with Dr. Mirza’s finding that interpersonal situations were a cause of anxiety for the applicant.

36As a result, on a balance of probabilities, I find that the applicant has failed to establish that he sustained a psychological impairment as a result of the accident.

Does the Applicant have a Pre-Existing Condition that would Prevent Maximal Recovery under the MIG?

37The applicant submits that he has a pre-existing history of cognitive, development and psychological challenges, which are a barrier to a full recovery under the MIG. The applicant points to the 2013 Psychological Assessment Report of Dr. Lee, which found that the applicant had a mild intellectual disability.²⁷ In addition, in 2014, Dr. Sharon Burey, paediatrician found that the applicant exhibited some autism spectrum disorder traits, and prescribed Prozac for anxiety.²⁸ Finally, the applicant submits that in the Neuropsychological Assessment Report of Dr Ahmad, conducted post-accident, the doctor found that the applicant meets the criteria for autism spectrum disorder, which was previously undiagnosed. As a result, the applicant submits that the accident exacerbated his fragile mental state such that he could not achieve maximal recovery under the MIG.

38Section 18(2) of the Schedule provides that insured persons with minor injuries who have a pre-existing medical condition may be exempted from the $3,500.00 cap on benefits. In order to be removed from the MIG, the applicant must provide compelling evidence meeting the following requirements:

a. There was a pre-existing medical condition that was documented by a health practitioner before the accident; and

b. The pre-existing condition will prevent maximal recovery from the minor injury if the person is subject to the $3,500 on treatment costs under the MIG.

39The standard for excluding an impairment on the basis of pre-existing condition is well-defined and strict. A pre-existing condition will not automatically exclude a person’s impairment from the MIG: it must be shown to prevent maximal recovery within the cap imposed by the MIG.

40After considering the submissions and evidence of the parties, based on a balance of probabilities, I find that the applicant has not provided persuasive evidence that his pre-existing conditions require removal from the MIG to achieve maximal medical recovery.

41I find that the applicant has met the first two requirements for a pre-existing condition, in that he has established a pre-existing medical condition with regards to his cognitive limitations, anxiety and symptoms of autism spectrum disorder and that the condition is documented by medical professionals prior to the subject accident.

42With respect to the final requirement, the applicant states in his submissions that his pre-exiting psychological impairments prevent him from achieving maximal recovery under the MIG limits. However, he does not point to compelling medical evidence or an opinion of a medical practitioner that draws the conclusion that the applicant’s pre-existing condition prevents him from achieving maximal recovery under the MIG.

43Although the applicant’s psychological assessor, Dr. Ahmad, listed the applicant’s pre-existing psychological impairments and recommended psychological and psychiatric intervention, she did not state that this could not be achieved under the MIG.

44In addition, the respondent submits that psychiatric intervention with Dr. Mirza would be covered by the Ontario Health Insurance Plan (“OHIP”) and that the applicant had an extended healthcare provider who would be first payor for ongoing counselling. In response, the applicant states that “extended healthcare typically covers treatment in the hundreds, but not thousands of dollars that the Applicant requires” and that the extended healthcare provider has not provided funding towards outstanding balances.²⁹ However, the applicant did not submit any evidence as to the treatment limits of his extended healthcare provider, what has been claimed and what has been paid.

45Without medical evidence that the applicant’s pre-existing condition prevents him from achieving maximal recovery under the MIG and evidence that OHIP funded care and his extended benefits would not be sufficient treatment, I find that the applicant has not met his onus to establish, on a balance of probabilities that his pre-existing psychological condition prevents him from achieving maximal recovery within the MIG.

Are the Proposed Treatment Plans for Physiotherapy and Psychological Services Reasonable and Necessary?

46In their submissions, the parties have not expressly confirmed whether the funding within the MIG limit has been exhausted. As such, despite finding that the applicant’s injuries are predominantly minor and therefore subject to treatment within the MIG, I have considered the reasonableness and necessity of the three treatment plans (“OCF-18”s) in dispute.

47The applicant argued that the disputed OCF-18s were reasonable and necessary, while respondent disagreed. Both parties relied on the previously addressed evidence to demonstrate this.

48After considering the evidence and submissions of the parties, based on a balance of probabilities, I find that the proposed treatment plans for physiotherapy and psychological services are not reasonable and necessary as a result of the accident.

49As detailed above, the applicant has not adduced sufficient evidence to establish, on a balance of probabilities, that he sustained physical or psychological impairments from the subject accident. Similarly, the applicant has not met his onus to establish that the accident exacerbated pre-existing conditions, such that physiotherapy or psychological services were warranted.

50Given that pursuant to sections 14, 15 and 16 of the Schedule an insurer is only liable to pay for reasonable and necessary expenses which arise as a result of the accident, the applicant has not met his onus in this regard.

Interest

51Section 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.

52As no benefits are overdue, no interest is payable under s.51.

CONCLUSION and order

53The applicant’s injuries fall within the Minor Injury Guideline.

54The applicant is not entitled to the disputed treatment plans.

55The applicant is not entitled to interest.

Footnotes

1. 1O. Reg. 34/10 as amended.
2. 2Minor Injury Guideline, Superintendent’s Guideline 01/14, issued pursuant to s. 268.3(1.1) of the Insurance Act
3. 3Scarlett v. Belair Insurance, 2015 ONSC 3635, para. 24 (Div. Ct.).
4. 4Applicant’s Submissions, Tab 6, Clinical Notes and Records of Solid Foundation Family Chiropractic.
5. 5Applicant’s Submissions, Tab 9 Clinical Notes and Records of Koonar Physiotherapy.
6. 6Applicant’s Submissions, Tab 5, OCF-3 dated October 10, 2017 and OCF-24 dated September 19, 2017.
7. 7Applicant’s Submissions, Tab 11 Dr. Bartol Orthopedic Report dated October 22, 2018, p.5.
8. 8Applicant’s Submissions, Tab 6, Solid Foundation Family Chiropractic CNRs, Entry dated May 28, 2018.
9. 9Applicant’s Submissions, Tab 1, Dr. Bartol Orthopaedic Report dated October 22, 2018, Interview with applicant’s mother at p.3.
10. 10Applicant’s Submissions, Tab 7, CNRs of Dr. Seth Aborhey, entry dated August 3, 2018.
11. 11Applicant’s Submissions, Tab 6, Solid Foundation Family Chiropractic CNRs, Entry dated May 28, 2018.
12. 12Applicant’s Submissions, Tab 6, Solid Foundation Family Chiropractic CNRs.
13. 13Applicant’s Submissions, Tab 3, Neuropsychological Assessment Report of Dr. Ahmad, dated June 9, 2020.
14. 14Applicant’s Submissions, Tab 4, Psychological Assessment Report of Dr. Catherine Lee dated August 12, 2013.
15. 15Applicant’s Submissions, Tab 4, Psychological Assessment Report of Dr. Catherine Lee dated August 12, 2013, p.3.
16. 16Applicant’s Submissions, Tab 3, Neuropsychological Assessment Report of Dr. Ahmad, dated June 9, 2020.
17. 17Applicant’s Submissions, Tab 8, CNRs of Dr. Yousha Mirza.
18. 18Applicant’s Submissions, Tab 4, Psychological Assessment Report of Dr. Catherine Lee dated August 12, 2013.
19. 19Respondent’s Submissions, Tab E, Report of Dr. Sharon Burey dated April 29, 2014.
20. 20Applicant’s Submissions, Tab 7, CNRs of Dr. Seth Aborhey
21. 21Respondent’s Submissions, Tab G, Psychological IE Report of Dr. McGrory dated May 22, 2019
22. 22Applicant’s Submissions, Tab 7, CNRs of Dr. Seth Aborhey, entry dated April 29, 2019
23. 23Applicant’s Submissions, Tab 8, CNRs of Dr. Yousha Mirza
24. 24Applicant’s Submissions, Tab 8, CNRs of Dr. Yousha Mirza progress note dated August 28, 2019
25. 25Applicant’s Submissions, Tab 3, Neuropsychological Assessment Report of Dr. Ahmad, dated June 9, 2020 at p.16 and 19
26. 26Applicant’s Submissions, Tab 8, CNRs of Dr. Yousha Mirza, Part 1 August 28, 2019 Progress Note
27. 27Applicant’s Submissions, Tab 4, Psychological Assessment Report of Dr. Catherine Lee dated August 12, 2013.
28. 28Respondent’s Submissions, Tab E, Report of Dr. Sharon Burey dated April 29, 2014.
29. 29Applicant’s Reply Submissions, par 5.```