MIG Update – May 13, 2024

Little Weight Given to Illegible Doctor’s Notes

This week, the Tribunal considers the applicant’s assertion that her family doctor records support a diagnosis of a concussion and ongoing non-minor injuries that should not be subject to the MIG. The trouble was that the records were not legible. What then, was the Tribunal left to consider?

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Factor: CNRS

In Tse v. Economical Insurance Company (22-001701), Ling Tse was involved in a motor vehicle accident on June 8, 2020 and claimed she suffered a concussion as a result which is a diagnosis that doesn’t fall within the MIG. In addition she developed chronic pain, exacerbated pre-existing degenerative disc disease and psychological impairments. All of which impacted her function despite seeking medical attention and treatment.

Tse relied on the CNRs of her family doctor Dr. Hugo Law, July 2, 2020 who prescribed vimovo and baclofen to treat her concussion and prescribed antidepressants to treat her insomnia and constant worrying. In addition, her report of anxiety as a passenger and that she stopped driving after the subject accident as indicated to the IE assessors Dr. Platnick, general practitioner and Ms. Abraham, occupational therapist. She also relied on the imaging report dated June 2020 which stated that there was “very mild degenerative marginal lipping throughout the lumbar spine.”

In her Statutory Declaration dated August 2020 as well as clinic records, she submitted that as a result of the accident, she was unable to engage in the majority of her pre-accident activities including dancing, playing volleyball, and taking care of her in-laws. Although she was able to complete small household tasks and self-care activities, it became painful for her and she was unable to complete bigger tasks like laundry, vacuuming, or outdoor chores.

Economical disagreed, and relied on the IE report of physician Dr. Platnick dated November 2020, that concluded Tse sustained sprain and strain injuries consistent with the MIG, and opined that there were no valid signs to support ongoing accident-related impairment that would cause any limitation or that would prevent her from achieving full recovery from her accident-related injuries. They also relied on the IE report of OT Ms. Abraham dated November 2020 which indicated that she could engage in all previous self-care activities, most housekeeping activities, and that COVID restrictions prevented her from some other activities. Further that the clinical records did not mention any functional limitations.

The Tribunal found:

      • A concussion diagnosis does take one out of the MIG. However, Dr. Law’s note appears to state ‘concussion’ followed by a right pointing arrow followed by ‘vimovo’ but the rest of that section of notes was illegible.
      • “ In my view, the clinical notes are mostly illegible and do not provide a clear indication of a concussion diagnosis. If Dr. Law did diagnose the applicant then further explanation would be required to give weight to his opinion. This is because the hospital record from the date of the accident indicates that the applicant denied having a head injury and that she reported not losing consciousness. As such, I find, on a balance of probabilities, that the applicant did not sustain a concussion in the accident because there is no evidence of a head strike in the hospital records and Dr. Law’s notes provide no explanation as to why he diagnosed the applicant with a concussion.”
      • On the issue of chronic pain once again the records of Dr. Law were difficult to read, requiring the reader to guess at what had been written. “Little weight can be given to this evidence as it cannot be understood.”
      • Despite Tse’s protest, that Dr. Platnik’s report should not be relied upon for the MIG analysis. “I disagree. Evidence is relevant if it speaks to the issue being decided. The IE report addresses the applicant’s accident-related pain and musculoskeletal injuries. This makes it relevant to an assessment of chronic pain.”
      • Dr. Platnik’s examination of Tse found her guarded and self limiting during testing and exhibited a better range of motion in the neck and lumbosacral spine when she was not being tested leading him to conclude the limitations were subjective. This led him to conclude that her reported neck and back limitations are subjective. no hypertonicity, muscle spasm, wasting or guarding along the spine.
      • The continued prescription of Celebrex and Gabapentin in 2022 do not constitute compelling medical evidence as there are no legible notes to provide insight into the reasons and circumstances for these prescriptions.
      • With respect to the evidence of degenerative changes Tse did not make submissions on how the pre-existing condition precludes recovery if kept within the MIG.
      • Psychologically, the only evidence of any issue is the prescription of an antidepressant in May 2021. The evidence does not support Tse’s complaint of driver anxiety but rather that she was not driving because she didn’t have a car. Once again, Dr. Law’s notes are illegible as to why the anti-depressant was prescribed.

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