Insured's IE Reports Support Claims of Chronic Pain - Treatment Plans Approved

February 27, 2017, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

Shanmuganathan and State Farm – Entitlement to treatment; chronic pain syndrome; entitlement to interest on overdue benefits; Insured’s IE reports and physician’s reports support claim of chronic pain

Shanmuganathan and State Farm

Date of Decision: October 17, 2016
Heard Before: Adjudicator Morris Winer

REASONS FOR DECISION

Issues:

Pirashanthini Shanmuganathan was injured in a car accident on January 10, 2009, when she was a passenger with her drunk husband driving. He collided with a police car. She sought accident benefits from State Farm however, when the parties were unable to resolve their disputes through mediation Ms. Shanmuganathan at the FSCO.

The issues in this Hearing are:

1. Is Ms. Shanmuganathan entitled to payment of $2,002.96 for a rehabilitation services plan, dated May 26, 2014?
2. Is Ms. Shanmuganathan entitled to payment of $6,594.75 for an occupational therapy (OT) services plan, dated August 18, 2014?   
3. Is Ms. Shanmuganathan entitled to payment of $7,152.36 for a rehabilitation support worker (RSW) services plan, dated November 19, 2014?
4. Is Ms. Shanmuganathan entitled to payment of $2,294.54 for a psychological services plan, dated October 6, 2014?
5. Is Ms. Shanmuganathan entitled to payment of $1,619.05 for a rehabilitation services plan, dated May 25, 2015?
6. Is Ms. Shanmuganathan entitled to payment of $1,557.29 for a rehabilitation services plan, dated January 22, 2016?
7. Is State Farm liable to pay a special award because it unreasonably withheld or delayed payments to Ms. Shanmuganathan?
8. Is Ms. Shanmuganathan entitled to interest on any overdue benefits?

Result:

1. Ms. Shanmuganathan is entitled to payment of $2,002.96 for a rehabilitation services plan, dated May 26, 2014.
2. Ms. Shanmuganathan is entitled to payment of $6,594.75 for an OT services plan, dated August 18, 2014.
3. Ms. Shanmuganathan is entitled to payment of $7,152.36 for a rehabilitation support worker services plan, dated November 19, 2014.
4. Ms. Shanmuganathan is entitled to payment of $2,294.54 for a psychological services plan, dated October 6, 2014.
5. Ms. Shanmuganathan is entitled to payment of $1,619.05 for a RSW services plan, dated May 25, 2015.
6. Ms. Shanmuganathan is entitled to payment of $1,557.29 for a rehabilitation services plan, dated January 22, 2016.
7. State Farm is not liable to pay a special award because it unreasonably withheld or delayed payments to Ms. Shanmuganathan.
8. Ms. Shanmuganathan is entitled to interest on overdue benefits found to be due herein.

EVIDENCE AND ANALYSIS:

Because of the accident, she suffered pain to her neck and upper, middle and lower back, spreading to the right arm and leg. She suffered from headaches, sleeplessness, anxiety and depression. These symptoms have persisted to the present. She has had limited movement and strength for household duties and work. She has since borne resentment against her husband for injuring her and jeopardizing the family’s security. She became pregnant about a year and a half after the accident and had an abortion in December 2010.

Prior to the accident, she had none of the above physical and mental problems. She did almost all the cooking, cleaning and washing, worked out regularly, cared for the children and was a sociable person. She was working as a cook, cleaner and server at a Sri Lankan restaurant. She had had other heavy work in a warehouse before. All of this changed because of the accident.

Her family doctors prescribed pain killers, anti-inflammatory medication and tranquilizers. Her husband took over the household duties and looked after the boys. She was unable to work. She was irritable and rude with the boys. She blamed the abortion on her husband. She felt that she wouldn’t be able to take care of a child. She was less sociable. She said she was “dying of guilt” because of the abortion. She couldn’t face her God at the temple. She started rehabilitation treatments about two to three days per week and State Farm paid for them until about July 2010, when they took the position that based on medical information she had recovered. She also started psychological treatment sessions paid for by State Farm for 48 sessions until October 2014.

In 2014, she attempted some activities. She increased helping with activities around the house. Her children could now look after themselves. She took an English as a second language (ESL) course for 3 hours per day, 5 days per week. She tried working at an Adidas warehouse, but had to quit after 4 days because of pain. She took a High School equivalency course at Sheridan College to enable her to eventually pursue a diploma in Early Childhood Education. However, this course was difficult for her because of the pains. She enrolled but did not start the Early Childhood Education course in 2016. She worked at displaying sauces at a store, but had to quit again after 4 days because of pain. She then worked at the 2015 election for a day. She started rehabilitation again once a week in 2014 and paid for it, but she was still in much pain and depressed.

She applied for the 6 treatment plans in dispute, and all were denied by State Farm following her doctor’s supply proof of continuity and consistency of symptoms of pain, depression and disability over the years. Three functional evaluations were made by exercise physiologist who concluded that she could not perform most household tasks or sedentary work on a sustained basis. 

The Arbitrator found that Ms. Shanmuganathan gave her evidence in a straightforward and sincere manner without any apparent contradictions. There was nothing in her demeanor which led the Arbitrator to the conclusion that her evidence is not truthful. The Arbitrator reviewed the IE reports, and Ms. Shanmuganathan’s own physician’s reports and agreed that the evidence supports Ms. Shanmuganathan’s claim of chronic pain syndrome notwithstanding objective findings. The Arbitrator reviewed the rehabilitation plans, OT, and RSW plans proposed by Ms. Shanmuganathan’s physicians and health care providers and determined they were reasonable and necessary for her continued recovery and mental health.

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Deutschmann Law serves South-Western Ontario with offices in Kitchener-Waterloo, Cambridge, Woodstock, Brantford, Stratford and Ayr. The law practice of Robert Deutschmann focuses almost exclusively in personal injury and disability insurance matters. For more information, please visit www.deutschmannlaw.com or call us at 1-519-742-7774.

The opinions expressed here, while intended to provide useful information, should not be interpreted as legal recommendations or advice.