KB v Minister of Employment and Social Development

KB v Minister of Employment and Social Development Collection Canada Pension Plan (CPP) disability Decision date 2022-09-16 Neutral citation 2022 SST 915 Reference number AD-22-198 Member Kate Sellar Division Appeal Division Decision Appeal allowed Featured decisions Yes Related decisions SST - KB v Minister of Employment and Social Development - 2021 SST 87 - 2021-12-22 - General Division Subjects Appeal Division - Error of law - Misinterpreting or not following case law Appeal Division - Remedy - Decide appeal or return to General Division Summary: The Claimant immigrated to Canada in 2000. He worked in a factory from 2000 to 2006. He then worked as an electrician from 2006 until July 2010, when he injured his left knee in a workplace accident. He then applied for a Canada Pension Plan (CPP) disability pension on March 5, 2018. The Minister refused his application initially and on reconsideration. The Claimant appealed the Minister’s decision to the General Division (GD). The GD dismissed the appeal on the basis that the Claimant did not show that his disability was severe and prolonged on or before December 31, 2012. The Claimant then appealed this decision to the Appeal Division (AD). The AD found that the GD failed to properly apply the test for a severe disability. It required too much from the Claimant’s medical evidence alone. This is inconsistent with what the law requires. The GD stated that the Claimant must provide medical evidence that his functional limitations affected his ability to work by December 31, 2012. This is incorrect in law. The Claimant had a workplace injury in 2010 and stopped working. He had to show that he had a severe and prolonged disability on or before December 31, 2012. The Claimant testified about a series of limitations, and the GD listed them in the decision. The GD decided that the Claimant genuinely believed that his functional limitations affected his ability to work, but that the medical evidence didn’t “support” his testimony. There is no legal requirement for Claimants to establish all of their functional limitations through medical evidence alone. Finding that a disability is severe is not conditional on having medical evidence that establishes the functional limitations. The AD allowed the appeal and gave the decision the GD should have given. It found that the Claimant was entitled to a disability pension and that the earliest the Claimant can be considered disabled for the purpose of the disability pension was December 2016 and payments start four months later in April 2017. Decision Content Citation: KB v Minister of Employment and Social Development, 2022 SST 915 Social Security Tribunal of Canada Appeal Division Decision Applicant (Claimant): K. B. Representative: J. J. Respondent: Minister of Employment and Social Development Representative: Jordan Fine Decision under appeal: General Division decision dated December 22, 2021 (GP-20-1368) Tribunal member: Kate Sellar Type of hearing: On the Record Decision date: September 16, 2022 File number: AD-22-198 On this page Decision Overview Issues Analysis Fixing the error Conclusion Decision [1] The appeal is allowed. The General Division made an error of law. I will give the decision that the General Division should have given. The Claimant is entitled to a disability pension under the Canada Pension Plan. Payments start effective June 2019. Overview [2] K. B. (Claimant) immigrated to Canada in 2000. He worked in a factory from 2000 to 2006. He then worked as an electrician from 2006 until July 2010, when he injured his left knee in a workplace accident. [3] The Claimant applied for a Canada Pension Plan (CPP) disability pension on May 14, 2020. The Minister of Employment and Social Development (Minister) refused his application initially and on reconsideration. [4] The Claimant appealed the Minister’s decision to this Tribunal. The General Division dismissed the Claimant’s appeal, deciding that he did not show that his disability was severe and prolonged on or before December 31, 2012. [5] I must decide whether the General Division made any errors according to the Department of Employment and Social Development Act (Act). If the General Division did make an error, I need to decide what I will do to remedy (fix) the error. [6] The General Division made an error of law by requiring that the Claimant’s medical information alone show which functional limitations he had during his minimum qualifying period. I will give the decision that the General Division should have given: the Claimant is entitled to a disability pension. Issues [7] The issues in this appeal are as follows: a) Did the General Division make an error of law by failing to apply properly the test for a severe disability (specifically when considering the Claimant’s medical reports and functional limitations)? b) Did the General Division make an error of law by failing to consider whether the Claimant was capable of working in the real world by considering his personal circumstances (like his age, ability to communicate in English, education, and life and work history)? c) If the General Division made an error, how should I fix it? Analysis [8] In this decision, I’ll describe the approach the Appeal Division takes when reviewing General Division decisions. Then I’ll explain how I’ve decided that the General Division made an error of law. Then I will give the decision that the General Division should have given: the Claimant is entitled to a disability pension. Reviewing General Division decisions [9] The Appeal Division does not give the Claimant or the Minister a chance to re-argue their case again from the beginning. Instead, the Appeal Division reviews the General Division’s decision to decide whether it contains errors. [10] That review is based on the wording of the Act, which sets out the “grounds of appeal.” Failing to follow the legal analysis that the CPP and case law require is an error of law. That is one of the grounds of appeal.Footnote 1 Error of law [11] The General Division made an error of law by failing to apply properly the test for a severe disability under the CPP. I will explain what a severe disability is and how claimants prove that they meet the definition for a severe disability generally. Then, I will explain how the General Division made an error in applying that test for a severe disability when analyzing the Claimant’s medical evidence and functional limitations. In the final part of these reasons, I will give the decision that the General Division should have given. The definition of a severe disability [12] A disability has to be severe and prolonged on or before the end of the minimum qualifying period (MQP).Footnote 2 A claimant with a severe disability is incapable regularly of pursuing any substantially gainful work. Each part of that definition has meaning. Since the focus is on capacity for work, it is important to look at functional limitations that affect the ability to work, not just diagnoses. Making the case for a severe disability [13] When claimants apply for a CPP disability pension, the law requires them to provide “a report of any physical or mental disability,” including the nature, extent, and prognosis of the disability the findings upon which the diagnosis and prognosis were made any limitation resulting from the disability any other pertinent information, including recommendations for further diagnostic work or treatment, that may be relevantFootnote 3 [14] So, when a claimant applies for a disability pension, there is a CPP Medical Report form (CPP medical report) that a medical professional can complete and sign. A completed form may well cover most information about the claimant’s physical and mental disability listed above. [15] There are cases from the Federal Courts that this Tribunal has to follow when making decisions about eligibility for CPP disability pensions.Footnote 4 We know from these decisions that: some kind of objective medical evidence is needed to support an application for a disability pensionFootnote 5 objective evidence (or “medical information”) must relate to the MQP to show that the disability is severeFootnote 6 [16] It is clear from the requirements set out in the CPP and decisions from the Federal Court of Appeal that a claimant is not eligible for a disability pension if they do not have any medical evidence at all that speaks to their condition on or before the end of the MQP. [17] A claimant needs to show medical evidence about the underlying medical condition. But they do not have to show that the disability is severe—that their functional limitations make them incapable regularly of any substantially gainful job—solely through the objective medical evidence. [18] A claimant can show that they are eligible for a disability pension with a combination of medical documents and their own testimony. There is no requirement in the legislation or case law that tells us that the focus should be on making sure that there is medical evidence to support everything the claimant says about their functional limitations. [19] The idea is to assess and weigh all the evidence (from the claimant and any medical professionals and witnesses) and decide whether the disability is severe. The CPP disability pension is not just for claimants who have access to extensive medical documentation, or medical documentation that fully answers each aspect of the legal test without further explanation or testimony. The purpose of medical evidence is to help support the claim that a disability is severe and prolonged.Footnote 7 Failing to apply properly the test for a severe disability [20] The General Division failed to apply properly the test for a severe disability. The General Division required too much from the Claimant’s medial evidence alone. This is inconsistent with what the law requires. The General Division stated that the Claimant must provide medical evidence that his functional limitations affected his ability to work by December 31, 2012. This is incorrect in law. [21] The Claimant had a workplace injury in 2010 and stopped working. He had to show that he had a severe and prolonged disability on or before December 31, 2012.Footnote 8 The Claimant testified about a series of limitations, and the General Division listed them in the decision.Footnote 9 The General Division decided that the Claimant’s testimony about his functional limitations was sincere. [22] The General Division decided that the Claimant genuinely believed that his functional limitations affected his ability to work, but that the medical evidence didn’t “support” his testimony. The General Division noted that: Although the medical evidence mentioned left knee pain, right knee pain, low back pain, and osteoarthritis, there wasn’t details of associated functional limitations by his MQP date. Left knee surgery in 2011 reduced pain and he had normal range of motion in his left knee by October 3, 2012. The medical evidence mentioned mild depression, anxiety, and insomnia in 2011. However, the medical did note any further details or associated functional limitations by the end of the MQP.Footnote 10 [23] The General Division concluded that Unfortunately, [the Claimant] hasn’t provided objective medical evidence of a severe disability existing on or before his MQP date of December 31, 2012. The medical evidence he provided doesn’t show that he had functional limitations that affected his ability to work by his MQP date. As a result, he hasn’t proven he had a severe disability.Footnote 11 [24] The Minister argues that the General Division made no error.Footnote 12 It is the Claimant’s job to show that his disability is severe. The Minister argues that the Regulation requires the medical reports to detail “any limitations resulting from the disability.” [25] The Minister argues that the General Division did not require the medical evidence alone to show the functional limitations. Instead, the General Division did what it is required to do in a case called Villani, which is to test how accurate the Claimant testimony was against the medical evidence.Footnote 13 The medical record did not back up the Claimant’s testimony about his pain, and anyway, pain is not an element of the test for disability.Footnote 14 [26] The Minister points out that the General Division found the Claimant’s testimony to be credible, but that there were inconsistencies between the medicals and the testimony that meant that the Claimant’s evidence was not as reliable. [27] The Minister argues that the General Division did not discount the Claimant’s testimony just because the medical evidence didn’t back it up. The General Division explained that the knee surgery reduced the Claimant’s pain, and returned him to a normal range of motion before the end of the MQP, which does not support his testimony that he could not stand, bend, walk, lift or carry objects, or sit for extended periods. [28] In my view, the General Division made an error of law. There is no legal requirement for Claimants to establish all of their functional limitations through medical evidence alone. Finding that a disability is severe is not conditional on having medical evidence that establishes the functional limitations. The General Division does not seem to be saying that the medical evidence contradicted the Claimant’s sincere belief about his limitations, but rather that the evidence was silent on some of the corresponding limitations. [29] To make an application for a disability pension, the Claimant must provide a medical report.Footnote 15 Claimants must show through medical evidence that they had serious medical conditions on or before the end of the MQP.Footnote 16 But claimants can establish functional limitations in multiple ways, including the limitations they list on the application for the disability pension, their testimony at the General Division hearing, and any witness testimony they might bring. [30] Finding that the Claimant was sincere or genuinely believes that he has limitations and dismissing the appeal because the medical evidence doesn’t support his testimony simply because it does not provide detailed functional limitation information is an error of law. [31] In my view, the General Division focused more on the lack of information in the medical evidence about functional limitations than it did in identifying any inconsistencies between the medical record and the Claimant’s testimony. The General Division made note of medical records stating that the Claimant had normal range of motion after surgery. But that doesn’t seem to be the key issue the General Division identified with the Claimant’s testimony. Particularly since the very same part of the medical record also says “still left knee pain” along with a prescription for Tylenol 3.Footnote 17 The note nine days after the end of the MQP still notes more pain on the right and a decrease in the range of motion in the right kneeFootnote 18. [32] I do not see evidence of the General Division making the distinction between credibility and reliability the Minister references. The decision does not focus on inconsistencies between what the Claimant said about his functional limitations and the medical record, and then explain which evidence it preferred and why. [33] Given that this error goes to the heart of the question about whether the Claimant is entitled to a disability pension, I will move on to remedy that error. Fixing the error [34] Once I find that the General Division made an error, I have a choice about how to fix the error. I can give the decision that the General Division should have given, or I can send the file back to the General Division to reconsider its decision.Footnote 19 I can decide any question of law necessary for deciding an appeal.Footnote 20 [35] If I found an error, the parties didn’t object to me giving the decision that the General Division should have given. This is an efficient way to move forward in many cases.Footnote 21 [36] I will give the decision that the General Division should have given. I have listened to the General Division hearing and reviewed the documents in the case. I have the information that I need to decide whether the Claimant is eligible for a disability pension. Giving the decision that the General Division should have given is fair, fast, and just in the circumstances. The Claimant has a severe disability [37] A severe disability in the CPP context is connected to what a person can and cannot do (when it comes to work). The things people cannot do because of a disability are sometimes called “functional limitations.” [38] In my view, the Claimant has proven that he has a severe and prolonged disability within the meaning of the CPP. I have considered: the Claimant’s medical conditions (which involves assessing the conditions in their totality—all of the possible impairments that could affect capacity to work)Footnote 22 the Claimant’s background (including age, level of education, language abilities, and past work and life experience)Footnote 23 the steps the Claimant has taken to manage the medical conditions, and whether he has unreasonably refused any treatmentFootnote 24 Medical conditions [39] The Claimant’s psychiatrist completed the CPP medical report form. However, his family doctor provided medical information from his file, including progress notes from 2010 forward. [40] The medical documents show that the Claimant injured his left knee at work in September 2010. He saw an orthopedic surgeon and staff admitted him to hospital on September 20, 2010. He had an MRI, which showed a partial tear in the ACL of left knee also a partial tear of the meniscus on the left knee. A doctor referred him to an orthopedic surgeon. By January 2011, he still had left knee pain and the doctor diagnosed post-traumatic osteoarthritis.Footnote 25 [41] The doctor prescribed arthritis medication but by April 2011, the pain was 9 out of 10 and they discussed a knee replacement due to the severity of the pain. The Claimant had the surgery that summer, but his pain after the surgery was still 9 out of 10. He was taking Tylenol 3’s. By the end of July, he had insomnia, anxiety, and mild depression. This doctor did treat these conditions at the time with Ativan.Footnote 26 [42] In a note dated November 17, 2017, the doctor stated that he Claimant had difficulties walking, standing and climbing the stairs since his accident.Footnote 27 Further, the psychiatrist notes that the Claimant was under his care for severe acute and chronic depressive disorder since 2015 (after the end of the MQP) which he suffered after his work related injury in 2010 resulting in severe pain, suffering and functional incapacity leading to pain and depression. His psychiatrist notes that his chronic pain resulted in episodes of severe depression/insomnia and anxiety.Footnote 28 [43] By October of 2011, the Claimant developed pain in his other knee (his right knee). He had prescription medication again for osteoarthritis but saw his doctor in both October and November for that pain.Footnote 29 [44] By April 2012, he had pain in both knees, right osteoarthritis and left post-surgical pain. He saw his doctor again in the summer for the right knee pain. By the fall of 2012, just a few months before the end of the MQP, the left knee post-surgical pain was 7 out of 10.Footnote 30 [45] As the General Division pointed out, the left knee pain had a normal range of motion and no swelling by October 2012. He was taking Tylenol 3 for pain. However, only 9 days after the end of the MQP, the doctor noted knee pain in both knees, more on the right, and a decreased range of motion in the right knee.Footnote 31 [46] The Claimant also had degenerative changes in his cervical spine just before the end of the MQP in October 2012, and a small spur on his left shoulder.Footnote 32 [47] The Federal Court of Appeal’s decision in Angheloni is often referenced for the idea that the Claimant’s suffering isn’t an element on which the test of disability rests.Footnote 33 This means that it isn’t “suffering” alone that makes claimants eligible for a disability pension. The question is whether, in a real world sense, the Claimant’s disability makes them incapable regularly of pursuing any substantially gainful work. [48] Angheloni does not mean that suffering or pain is irrelevant in the test for a severe disability. In my view, the decision in Angheloni requires me to consider the medical evidence about the claimant’s conditions. Angheloni is consistent with the idea that some medical evidence is required to support a disability pension application. The decision in Angheloni is really about the fist decision maker (the Pension Appeals Board) failing to analyze the evidence adequately and disregarding evidence. [49] Pain is important in the Claimant’s appeal. It is pain that limits the Claimant’s ability to work. So, it is the Claimant’s experience of that pain that results in functional limitations. Functional limitations are important when deciding whether the disability is severe. Descriptions of the Claimant’s pain (which impact his ability to sleep, bend, walk, and stand) should not be equated with simple descriptions of “suffering” and therefore dismissed as irrelevant. [50] The Claimant’s pain is also important because the medical records describe it as chronic. Given that the pain became chronic, it isn’t surprising or inconsistent to see that objective testing does not reflect the extent and impact of the pain.Footnote 34 This is an important reason to consider the Claimant’s testimony about his pain along with the descriptions in the medical records. [51] I’m satisfied that the Claimant had serious medical conditions by December 2012. Osteoarthritis, even if it might be common, was serious enough that the Claimant required surgery, and the post-operative pain was quite serious for this Claimant. Coupled with the fact that by the time of the MQP, the Claimant was developing OA pain the other knee as well. [52] The Claimant also had anxiety before the end of the MQP, which was affecting his sleep and was serious enough that his doctor prescribed a benzodiazepine, Ativan. The Claimant testified and I accept that when he became anxious he was isolating and that he had many mood swings. He was easily irritated and did not want to be around people, even socially. He had trouble sleeping. He was worried 24 hours a day. These are all limitations that would negatively affect the Claimant’s ability to work. [53] I accept the Claimant’s testimony about his functional limitations. He was forthright and his evidence was reliable. The Claimant explained that he does not do household chores. The pain never subsided enough after his surgery to get back to work. He testified about his limitations in terms of standing, walking, reaching, and bending. He testified about disturbed sleep. The Claimant testified about mood swings and anger getting in the way of his ability to work and to learn (and it is clear that his depression got worse after the end of the MQP). The Claimant testified that he could drive but only for short periods for necessities like medication and groceries. [54] The medical evidence and the Claimant’s testimony lead me to conclude that at the end of the MQP, he was experiencing ongoing pain in his knees (one knee was post-operative) and he was having trouble sleeping. He was limited in his ability to stand, walk, reach, and bend. I have no trouble concluding that his pain and disturbed sleep would also have a negative impact on his ability to work. His job was physically demanding and he could not return to it. The Claimant’s background [55] When deciding whether the Claimant has functional limitations that affect his ability to work, I need to consider how employable the Claimant is in the real world, given his: Age level of education ability to speak, read, and write in English past work and life experienceFootnote 35 [56] The Claimant was 54 years old on the last day of his MQP, December 31, 2012. He stopped working in July 2010 when he was almost 52. Retirement under the CPP can be as early as age 60, but traditionally is 65. The Claimant therefore had some working years left until the standard age of retirement, although retraining and then employment in a new field would involve some challenges in relation to workers at the beginning of their careers. [57] The Claimant is well educated with a Bachelor of Sciences degree from India. In Canada, he became a certified electrician in 2006. As of the end of the MQP, the Claimant wasn’t limited by a lack of education. However, it is not clear to me how much English he studied either in India or in Canada. [58] It is difficult to assess the Claimant’s language abilities in English. The Claimant requested and received a translator during his General Division hearing. It was clear that he was following at least some of what the General Division member said before the translator spoke, and at times the Claimant’s answers were a mix of Punjabi and English. The Claimant testified that when he first came to Canada he struggled to understand people’s accents, but that this improved over time at work. He says he cannot write in English properly. He received instructions verbally in English when he was working as an electrician, but says that he did not need to speak much in English at all when he was doing that work. [59] I find that the Claimant’s has some English skills, but not necessarily enough to be competitive in less physical labour. It seems that he would likely need to improve his written and verbal skills in English. [60] The Claimant’s work history in Canada was made up of what he refers to as “survival jobs” working in factories and general labour until he got his first job with his cousin at a company and then worked in a physically demanding job as an electrician in construction. The Claimant testified that he does not have the knowledge to use a computer. [61] The Claimant’s age, level of education, language abilities, and personal and life circumstances each represent some challenges to employment in the real world. None of these challenges is necessarily insurmountable, but the Claimant has some real-world challenges to accessing work in addition to his functional limitations. He is an older worker, his experience is in work that exceeds his physical limitations, and he would likely need to upgrade his English or retrain in order to access work that better suits his physical limitations. Without increasing his language ability, it’s not likely that the Claimant’s education is as helpful to him in Canada as it might otherwise be. [62] When I consider the Claimant’s medical evidence, testimony, and personal circumstances all together, I conclude that the Claimant had a severe disability within the meaning of the CPP by December 2012. While the medical evidence shows that he could not return to his old work, his personal circumstances result in some additional barriers that mean he is incapable regularly of any substantially gainful work. Sedentary or part-time work within the Claimant’s physical restrictions would be difficult for him to access given his history in general labour jobs, his English language skills, and to some extent, his age. Steps to manage medical conditions [63] The Claimant has taken steps to manage his conditions, and he has not refused any treatment unreasonably. [64] Claimants have an obligation to show efforts to manage their medical conditions.Footnote 36 Claimants can jeopardize their eligibility for a disability pension if they refuse treatment unreasonably.Footnote 37 [65] The Claimant testified about the rehabilitation he completed after his knee surgery, as well as his efforts to complete exercises from physiotherapy when his other knee started to hurt. [66] He took arthritis medications as well as the medication I already referenced for his anxiety. [67] The Claimant did not wait until 2014 to be treated for his mental health conditions. The family doctor treated him until 2014 when the conditions worsened and doctor recommended a specialist. [68] This is consistent with the Claimant’s testimony about his anxiety starting after his surgery, but it did not start with the kinds of memory and concentration problems that he has now. [69] The Claimant testified that the Ativan was always a short-term solution for the anxiety, and that the medications he took for arthritis only helped manage the pain and provided only short-term relief. He testified that physiotherapy provided short-term relief for pain when it gets severe, but it does not get better enough that he can walk or stand any longer. The disability is prolonged [70] The Claimant’s disability is likely to be long continued and of indefinite duration. This means it is prolonged within the meaning of the CPP.Footnote 38 [71] The evidence shows that he Claimant’s mental health only deteriorated over the years after the end of the MQP. His current psychiatrist completed the CPP medical report. He stated that the Claimant’s prognosis is poor and that his current global assessment of functioning is low.Footnote 39 [72] I find that the Claimant has shown he had a severe and prolonged disability beginning December 31, 2012. By that point, both of the Claimant’s knees were painful (post-operative pain plus pain in the other knee), he was depressed and avoiding people, he was anxious, and he had back pain. [73] He applied for the CPP disability pension on May 14, 2020. Pension eligibility cannot start more than 15 months before the Claimant applies. Therefore, the earliest the Claimant can be considered disabled for the purpose of the disability pension is February 2019. Payments start four months later in June 2019.Footnote 40 Conclusion [74] I am allowing the appeal. The General Division made an error of law. I gave the decision that the General Division should have given: the Claimant is entitled to a disability pension under the Canada Pension Plan. Footnotes Footnote 1 See section 58(1)(b) of the Department of Employment and Social Development Act (Act). Footnote 2 See section 42(2) of the Canada Pension Plan. The minimum qualifying period (MQP) is the period that the Claimant has coverage under the CPP. It’s calculated based on the Claimant’s contributions to the CPP. Footnote 3 See section 68(1) of the Canada Pension Plan Regulations. Footnote 4 The Federal Courts write those decisions when a party asks them to decide whether a tribunal decision was reasonable (this is called judicial review). As a result, decisions from the Federal Courts do not always tell us everything we need to know about applying the test for a disability pension in every case. Footnote 5 See Warren v Canada (Attorney General), 2008 FCA 377. Footnote 6 See paragraph 38 of the Federal Court decision in Canada (Attorney General) v Dean, 2020 FC 206 (Dean). Dean was a case about a claimant who had given no objective medical evidence in support of her application for a disability pension. Footnote 7 See paragraph 16 in Klabouch v Canada (Social Development), 2008 FCA 33. Footnote 8 See section 42(2) of the Canada Pension Plan for the definition of “severe” and “prolonged.” Footnote 9 See paragraph 19 in the General Division decision. Footnote 10 See paragraph 23 in the General Division decision. Footnote 11 See paragraph 24 of the General Division decision. Footnote 12 See AD2-9 to 15, paragraphs 15 to 19. Footnote 13 See Villani v Canada (Attorney General), 2001 FCA 248. Footnote 14 The General Division relies on a decision called Canada (Minister of Human Resources Development) v Angheloni 2003 FCA 140 at paragraph 27 and 35 for this argument about the relationship between pain and making a case for a disability pension. Footnote 15 See section 68.1 of the Canada Pension Plan Regulations, requiring Claimants to provide a medical report in support of their application for the disability pension. Footnote 16 See Canada (Attorney General) v Dean, 2020 FC 206. Footnote 17 See GD2-76. Footnote 18 GD2-77. Footnote 19 See section 59 of the Act. Footnote 20 See section 64 of the Act. Footnote 21 See section 2 of the Social Security Tribunal Regulations about the need to proceed in a way that is fast and fair. Footnote 22 The Federal Court of Appeal discussed this in a case called Bungay v Canada (Attorney General), 2011 FCA 47. Footnote 23 The factors I need to consider come from a case called Villani v Canada (Attorney General), 2001 FCA 248. Footnote 24 See Klabouch v Canada (Social Development), 2008 FCA 33; and Sharma v Canada (Attorney General), 2018 FCA 48. In those cases, the Federal Court of Appeal explained that claimants need to make reasonable efforts to manage medical conditions. In Lalonde v Canada (Minister of Human Resources Development), 2002 FCA 211, the Federal Court of Appeal stated that claimants cannot unreasonably refuse treatment. Footnote 25 See GD2-74. Footnote 26 See GD2-75. Footnote 27 See GD2-93. Footnote 28 See GD2-103. Footnote 29 See GD2-75. Footnote 30 See GD2-76. Footnote 31 GD2-77. Footnote 32 See GD2-77 for neck pain and GD2-14 for the results of the cervical spine ad shoulder scans. Footnote 33 See paragraph 33 of Canada (Minister of Human Resources Development) v Angheloni, 2003 FCA 140. Footnote 34 The Supreme Court of Canada talked about chronic pain in Nova Scotia (Workers' Compensation Board) v Martin, 2003 SCC 54. Footnote 35 See Villani v Canada (Attorney General), 2001 FCA 248. Footnote 36 The Federal Court of Appeal explained this requirement in a case called Inclima v Canada (Attorney General), 2003 FCA 117. Footnote 37 The Federal Court of Appeal explained this in a case called Lalonde v Canada (Minister of Human Resources Development), 2002 FCA 211. Footnote 38 See section 42(2) of the Canada Pension Plan. Footnote 39 See GD2-200. Footnote 40 See section 69 of the Canada Pension Plan.