The claimant was seriously injured in a 2013 accident and sought a determination that he suffered a catastrophic impairment due to a combined WPI of 55 percent. He also sought entitlement to three treatment plans for further physiotherapy and psychotherapy. The claimant suffered from chronic pain and abused opioids as a result of his injuries. He also suffered cognitive issues from a traumatic brain injury. The claimant was unable to work as a result of these effects. Adjudicator Hines concluded that the claimant did not suffer a catastrophic impairment. There was agreement between the parties that the claimant’s physical injuries had a total WPI of 17 percent. The disagreement focused on the neuropsychological impairment, psychological impairment, and equivalent WPI. Adjudicator Hines accepted the claimant’s expert’s opinion that impairment existed under Table 2 of Chapter 4 (neurocognitive), but did not agree with applying the high end of the range (14 percent). She was critical of the executive summary physician applying the WPI rather than the claimant’s neuropsychologist. She accepted the evidence from the neuropsychologist’s expert testimony that she would have given a rating of 12 percent WPI. With regard to psychological impairment, the claimant was diagnosed with major depressive disorder, and somatic symptom disorder. None of the claimant’s assessors or the insurer’s assessors found any Class 4 Marked Impairments. Both assessors agreed that there were Class 3 Moderate Impairments in Activities of Daily Living, and Adaptation. The differences of opinion existed with regard to Social Functioning, and Concentration, Persistence, and Pace. Adjudicator Hines accepted the opinions of the claimant’s expert who rated him Class 3 Moderate Impairment in both of these spheres of function. In order to convert the rating into a WPI, the claimant’s expert argued that a range of 30 to 40 percent WPI was appropriate by using a GAF score of 45 to 50. The insurer’s expert, who found slightly lower impairment in the two disputed spheres of function, opined that the claimant’s GAF was 54 to 56, which he converted into 21 to 24 percent WPI. Adjudicator Hines was critical of the range provided by the claimant’s expert, and noted that despite no findings of Class 4 Marked Impairments, the WPI range was equivalent to such. She was again critical of the claimant’s psychologist leaving it to the executive summary physician to provide the WPI range. She concluded that the appropriate WPI was 29 percent, based on the insurer’s expert’s testimony that all four Class 3 Moderate Impairments would not exceed that number. The total WPI was 48 percent, which was insufficient to be deemed a catastrophic impairment. However, Adjudicator Hines did award all three claimed treatment plans based on the claimant’s ongoing impairments and the coping and relief the treatment provided. The adjudicator noted that the insurer was only responsible for payment on the treatment plans up to the remaining medical benefits limits of $50,000.
Menu