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A.C.G. v. Aviva Insurance Company (19-004820)

  • November 17, 2020

The claimant sought entitlement to NEB, physiotherapy treatment, and a chronic pain assessment. Vice Chair McGee found that the claimant sustained an impairment that continuously prevented her from engaging in substantially all of the activities in which she ordinarily engaged before the accident. Vice Chair McGee assigned greater weight to the activities that the claimant identified as being important to her pre-accident life. Also, Vice Chair McGee placed considerable weight on the clinical notes and records of the claimant’s treating physician of many years which contained frequent notations of concern over the claimant’s inability to cope as a result of the accident. Further, the factors from Heath v. Economical made clear that a claimant who merely “goes through the motions” cannot be said to be “engaging in” an activity. The factual record showed a young woman “going through the motions” of caring for her children and herself in the face of incapacitating mental illness and persistent physical limitations. Therefore, the claimant was found to suffer a complete inability to carry on a normal life as a result of the accident and her accident-related incapacity was fundamentally psychological in nature. With respect to the disputed medical benefits, Vice Chair McGee held that the evidence did not demonstrate that the disputed treatment plans were reasonable and necessary. While there was evidence that the claimant found physical therapy helpful in providing temporary pain relief, there was no evidence as to her program in physical therapy, or how well her treatment goals were being met. Moreover, the claimant’s pain complaints in themselves did not warrant a diagnosis of chronic pain syndrome nor investigation by a chronic pain specialist.

Full decision here

TGP Analysis

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  • FILED UNDER Medical Benefits, Non-Earner Benefits
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