Decision
[1] The Claimant is entitled to a Canada Pension Plan (CPP) disability pension to be paid as of April 2016.
Overview
[2] The Claimant applied for a CPP disability pension stating that she could no longer work due to symptoms of fibromyalgia, arthritis and other secondary conditions. The Minister received the Claimant’s application on December 29, 2015. The Minister denied the application initially and on reconsideration. The Claimant appealed the reconsideration decision to the Social Security Tribunal.
[3] To qualify for a CPP disability pension, the Claimant must meet the requirements that are set out in the CPP. More specifically, the Claimant must be found disabled as defined in the CPP on or before the end of the minimum qualifying period (MQP). The calculation of the MQP is based on the Claimant’s contributions to the CPP. The Claimant’s MQP is December 31, 2017.
Issues
[4] Did the Claimant’s multiple medical conditions result in her having a severe disability, meaning was she incapable regularly of pursuing any substantially gainful occupation by December 31, 2017?
[5] If so, was the Claimant’s disability also long continued and of indefinite duration?
Analysis
[6] Disability is defined as a physical or mental disability that is severe and prolongedFootnote 1. A person is considered to have a severe disability if incapable regularly of pursuing any substantially gainful occupation. A disability is prolonged if it is likely to be long continued and of indefinite duration or is likely to result in death. A person must prove on a balance of probabilities their disability meets both parts of the test, which means if the Claimant meets only one part, the Claimant does not qualify for disability benefits.
Severe disability
The totality of the Claimant’s medical conditions and symptoms limit her capacity to work
[7] I must assess the Claimant’s condition in its totality, which means I must consider all of the possible impairments, not just the biggest impairments or the main impairmentFootnote 2. In considering the medical conditions, I must focus on how they affect the Claimant’s ability to work, not the name or nature of the diseaseFootnote 3.
[8] The Claimant has a history of fibromyalgia and arthritis. For many years, she was able to work with her conditions. She held multiple jobs, but gradually reduced her workload as her pain became worse. At one point, she had four part-time jobs. She restocked shelves at X, cleaned at a X, assisted her husband with his X and X. She kept working at the X after stopping her other jobs. She worked three days a week, four to five hours per shift. As her condition worsened, her employer tried to accommodate her by giving her lighter duties that did not involve bending or heavy physical labour. Despite trying for a month, the Claimant was unable to continue. She stopped working in December 2015 and has not worked since.
[9] In considering the totality of the Claimant’s medical conditions, I looked at her multiple diagnoses and how her symptoms affect her ability to work. On her CPP Medical Report, Dr. Ruddock, her long-time, but since retired family doctor, indicated that the Claimant had fibromyalgia; asthma; depression; osteoarthritis of the left AC joint, right knee and lumbar spine; obstructive sleep apnea; morbid obesity; mixed urinary incontinence; and fatty infiltration of the liverFootnote 4. Dr. Ruddock identified left shoulder, right knee and low back pain with restricted range of motion due to degenerative arthritis. Morbid obesity limited her mobility. In another letter, Dr. Ruddock documented that she had standing, bending, lifting, stair climbing and walking restrictionsFootnote 5. In his option, she had been just managing to function in the workplace, but the added condition of degenerative arthritis further impaired her functionality.
[10] Investigations of her knee revealed she was not a candidate for surgeryFootnote 6. An orthopedic surgeon, Dr. Porte, found some minor medial compartment degenerative changes on an MRI, but well-preserved joint spaces on an x-ray; however, as noted by the Minister, he saw no serious findings. Still, I consider how his examination was consistent with the Claimant’s pain complaints. Dr. Porte said she had painful terminal range of motion and diffuse tenderness. He did not discount her pain, but described it as generalized in nature. While diagnostic imaging showed minimal findings, I am nonetheless satisfied that Dr. Porte’s report supports the fact that the Claimant had significantly disabling symptoms.
[11] Since completing her application (but within the MQP), the Claimant has been diagnosed with additional conditions that further contribute to her limitations. In June 2017, Dr. Ruddock diagnosed bilateral Dupuytren’s fibrosis of the palmar fasciae and Bouchard’s nodes over some of the PIP joints of her handsFootnote 7. These conditions cause pain, tenderness, stiffness and affect her fine motor skills. In October 2017Footnote 8, she had surgery for a pituitary adenoma. Her new family doctor, Dr. Whyne, wrote in January 2018, that the surgery left her with visual deficiencies from which she may never recoverFootnote 9. She now must take steroids, which have caused weight gain, arthragias and chronic headaches. Her symptoms of fibromyalgia have become worse since the surgery.
[12] In addition to the medical reports, I considered the Claimant’s oral testimony. She reported chronic daily pain. She is unable to sit or stand for prolonged periods. She said she has low energy. She often naps during the day, but also struggles to sleep at night. Her concentration and memory are affected by brain fog stemming from pain, fibromyalgia and medication. The added condition of Dupuytren’s makes it difficult for her to type or write. Since the tumour, she has lost the peripheral vision in her left eye. Her distance vision is also blurred. Weight gain has added to her depressive symptoms and low mood. She feels bad that she has regained weight after having lost approximately 80 pounds last year.
[13] In sum, her conditions limit her ability to sit, stand, walk, lift, bend, climb stairs, see, write, type and concentrate. Accordingly, I am satisfied that the evidence supports that the totality of her conditions and their associated symptoms limit her capacity to work.
The Claimant does not have the capacity for alternate work or retraining within a real world context
[14] I must assess the severe part of the test in a real world context9. This means that when deciding whether a Claimant’s disability is severe, I must keep in mind factors such as age, level of education, language proficiency, and past work and life experience. In addition, the statutory test for severity requires an “air of reality” in making that assessment.
[15] The Claimant was 51 years old at her MQP. She has a grade 8 education. She said she struggled in school and suspects she has an undiagnosed learning disability. She has had no further upgrading. All parties agree that given her current physical limitations, she could no longer perform heavy physical work. However, she has few obvious transferrable skills. She would have difficulty retraining given her multiple limitations, including sitting, fine motor skills and concentration. While fluent in English, she has never held a job that required significant reading or writing. While she has some computer skills, her ability to improve her keyboarding skills are hampered by her Dupuytren’s diagnosis. The Claimant reported that she has not looked for work because she does not believe she could work. She said that she struggles to complete basic activities of living around the home.
[16] I also considered the issue of “predictably” when considering the Claimant’s capacity for work within a real world contextFootnote 10. Dr. Ruddock’s comments dated May 2016 describe “waxing and waning” fibromyalgia symptoms as flagged by the Minister. However, in the same letter, he wrote that it would be “difficult or impossible to predict when or if she could go to work, and then realistically stay there long enough to satisfy any employer”Footnote 11. Given the unpredictable nature of the Claimant’s symptoms, I too had difficulty envisioning any circumstance in which an employer would engage the Claimant in the competitive workforce.
[17] Accordingly, I concluded that it is not realistic to suggest that she has capacity for alternate work or retraining within a real world context.
The Claimant has pursued and complied with reasonable recommended treatment options
[18] Claimants have a responsibility to cooperate in their healthcareFootnote 12. If a Claimant has refused treatment, I must consider whether their refusal to seek treatment is unreasonable and what impact that refusal might have on their disability status within a real world contextFootnote 13.
[19] The evidence documents that the Claimant has tried psychotherapy, cortisone injections, medications, dieting (Weight Watchers), exercise, and assistive devices. Physiotherapy was recommended, but the Claimant explained that she could not afford to pay for it. Given her limited financial means and lack of private medical insurance, I find her explanation reasonable within a real world context. As well, the Minister has submitted that the Claimant has not pursued a chronic pain program; however, there is no specific recommendation in the file for this type of treatment. Where doctors have not made such a recommendation, it cannot be said that a Claimant did not follow a recommended treatment.
[20] A consistent recommendation throughout the medical file is weight loss. Dr. Porte thought that much of her knee pain and limitations were due to the fact that her knee was “overloaded”Footnote 14. Dr. Haaland, rheumatologist, thought she would benefit from weight loss and a fitness programFootnote 15. The file documents that the Claimant was successful in reducing her body mass index (BMI) from 52 to 46. However, after she developed knee pain, Dr. Ruddock explained that she was no longer able to tolerate light exercise due to what he called a “triple whammy”Footnote 16 of fibromyalgia, degenerative arthritis and morbid obesity. Moreover, her added condition, a pituitary adenoma, requires medication that has caused increased weight gainFootnote 17. While I accept that Claimants have a responsibility to participate in their healthcare, “miracles” cannot be expectedFootnote 18. On balance, I am satisfied that the Claimant has made substantial efforts to follow treatment recommendations, including weight loss, but she should not be disqualified from benefits because her efforts were unsuccessful.
[21] Accordingly, I find that the Claimant has proven on a balance of probabilities that the totality of her conditions made her incapable regularly of pursuing any substantially gainful occupation since she could no longer work as of December 2015.
Prolonged disability
The Claimant’s disability is long continued and of indefinite duration
[22] The Claimant has a long history of fibromyalgia and obesity. Degenerative arthritis has further complicated her pain and mobility. She is not a candidate for surgery. Despite treatment efforts, she continues to experience symptoms from her multiple conditions. In considering the prolonged nature of her condition, I looked to Dr. Ruddock’s prognosis where he wrote, “Given the chronicity of her diagnoses, my expectation is for her condition to gradually deteriorate over the months and years ahead.” Footnote 19 As such I concluded that the Claimant’s condition is long continued and of indefinite duration.
[23] Accordingly, I am satisfied that the Claimant’s disability has been prolonged since she could no longer work as of December 2015 due to the totality of her symptoms.
Conclusion
[24] The Claimant had a severe and prolonged disability in December 2015. Payments start four months after the date of disability, as of April 2016Footnote 20.
[25] The appeal is allowed.