Written by Jennifer Yeung
In this article, we will be reviewing the Tribunal decision of 17-006236 v Royal Sun Alliance Insurance (RSA), 2018 CanLII 110936 (ON LAT) [1].
When determining entitlement to income replacement benefits, a key question often arises:
Can the applicant still perform the essential tasks of their employment after their accident?
While medical diagnoses and symptom reports are important, the assessing clinicians must ultimately consider how the applicant’s impairments affect their functional ability to return to work.
This is where occupational therapy functional assessment and ability to work assessment can provide valuable evidence.
The applicant, a 17-year-old male, was involved in a motor vehicle accident on September 18, 2015. Following the accident, he experienced ongoing physical, cognitive, and emotional difficulties, experiencing persistent headaches, pain, sleep disturbances, mood changes, depression, and difficulties with concentration related to sustaining a mild traumatic brain injury.
The applicant applied for benefits through Royal Sun Alliance Insurance, the respondent, under the Statutory Accident Benefits Schedule (SABS). Following the denial of benefits, the matter proceeded to a written hearing before the Licence Appeal Tribunal.
One of the issues in the dispute included whether the applicant was entitled to receive income replacement benefits?
According to section 5(1) 1. ii.C. of the SABS, an individual may be entitled to income replacement benefits if, within the first 104 weeks following the accident, they suffer a “substantial inability to perform the essential tasks of that employment” [2].
In this case, prior to the accident, the client was working as a produce clerk. He did not return to work after the accident.
Occupational therapy evidence played an important role in helping the Tribunal understand how the applicant’s injuries affected his ability to perform the physical demands of his job as a produce clerk.
The in-home occupational therapy assessment identified ongoing pain and functional limitations affecting both household and work-related activities, as a result of the injuries he suffered from his motor vehicle accident. The occupational therapist noted that the applicant was unable to tolerate prolonged bending, carrying, lifting, pulling, and dragging heavy objects. The OT concluded that as a result of his limitations, he would not be able to return to work as a produce clerk.
The occupational therapist further noted that the applicant experienced difficulties with activities, such as grocery shopping, lawn mowing, snow shovelling, and bathtub cleaning. All of which require physical effort.
While these activities may appear unrelated to employment, they provide important insight into the applicant’s functional capacity and tolerance for physical activity, which can help us understand why the client would not be able to fulfill his duties at work as a produce clerk.
Importantly, the occupational therapist directly related these findings to the essential duties of the applicant’s employment.
The assessment concluded that the applicant would likely be unable to safely and consistently:
➢ Unload produce skids using a pump jack,
➢ Drag loaded produce skids throughout the store, and
➢ Lift and re-pile and re-stock boxes of produce.
The applicant also attempted to return to work following the accident. However, he experienced increased pain while performing work tasks and was unable to tolerate regular employment hours. Eventually, he stopped working due to his ongoing symptoms.
The occupational therapy assessment provided objective functional evidence supporting these reported difficulties.
In contrast, the respondent’s evidence provided by 2 physicians did not meaningfully address the applicant’s functional limitations or ability to perform the essential tasks of his employment. The assessor’s reports were not as compelling as the OT report.
Ultimately, the Tribunal found the OT functional assessment report compelling and determined that the applicant had sustained a substantial inability to perform the essential tasks of his employment within 104 weeks of his accident and was therefore entitled to income replacement benefits under the SABS.
This case decision highlights the important role of occupational therapists in accident benefits disputes.
At GLA Rehab, our occupational therapists assess the physical, cognitive, emotional, and functional impacts experienced following a motor vehicle accident.
Our team of clinicians provides comprehensive functional assessments, return-to-work support, FCE, Cognitive-FCE, and vocational ad psycho-vocational assessments related to return to work. We help clients navigate the accident benefits process and support rehabilitation planning.
References
[1] 17-006236 v Royal Sun Alliance Insurance (RSA), 2018 CanLII 110936 (ON LAT), <https://canlii.ca/t/hw6wh>
[2] O. Reg. 34/10: Statutory Accident Benefits Schedule – Effective September 1, 2010, https://www.ontario.ca/laws/regulation/100034