Paraplegia or Tetraplegia

Persons who sustained paraplegia or tetraplegia as a direct result of a motor vehicle accident, and meet the following criteria:

i. The insured person’s neurological recovery is such that the person’s permanent grade on the ASIA Impairment Scale, as published in Marino, R.J. et al, International Standards for Neurological Classification of Spinal Cord Injury, Journal of Spinal Cord Medicine, Volume 26, Supplement 1, Spring 2003, can be determined.

ii. The insured person’s permanent grade on the ASIA Impairment Scale is or will be,

a. A, B or C, or

b. D, and

i. the insured person’s score on the Spinal Cord Independence Measure, Version III, item 12 (Mobility Indoors), as published in Catz, A., Itzkovich, M., Tesio L. et al, A multicentre international study on the Spinal Cord Independence Measure, version III: Rasch psychometric validation, Spinal Cord (2007) 45, 275-291 and applied over a distance of up to 10 metres on an even indoor surface is 0 to 5,

ii. the insured person requires urological surgical diversion, an implanted device, or intermittent or constant catheterization in order to manage a residual neuro-urological impairment, or

iii. the insured person has impaired voluntary control over anorectal function that requires a bowel routine, a surgical diversion or an implanted device.

Severe Impairment of Ambulatory Mobility or Use of an Arm, or Amputation

Persons who sustained a severe impairment of ambulatory mobility or use of an arm, or amputation as a direct result of a motor vehicle accident, and meet the following criteria:

i. Trans-tibial or higher amputation of a leg.

ii. Amputation of an arm or another impairment causing the total and permanent loss of use of an arm.

iii. Severe and permanent alteration of prior structure and function involving one or both legs as a result of which the insured person’s score on the Spinal Cord Independence Measure, Version III, item 12 (Mobility Indoors), as published in Catz, A., Itzkovich, M., Tesio L. et al, A multicentre international study on the Spinal Cord Independence Measure, version III: Rasch psychometric validation, Spinal Cord (2007) 45, 275-291 and applied over a distance of up to 10 metres on an even indoor surface is 0 to 5.

Loss of Vision of Both Eyes

Persons who sustained a loss of vision of both eyes as a direct result of a motor vehicle accident, and meet the following criteria:

i. Even with the use of corrective lenses or medication,

a. visual acuity in both eyes is 20/200 (6/60) or less as measured by the Snellen Chart or an equivalent chart, or

b. the greatest diameter of the field of vision in both eyes is 20 degrees or less.

ii. The loss of vision is not attributable to non-organic causes.

Adult Traumatic Brain Injury

Persons who are older than 18 years of age and sustained a traumatic brain injury as a direct result of a motor vehicle accident, and meet the following criteria:

i. The injury shows positive findings on a computerized axial tomography scan, a magnetic resonance imaging or any other medically recognized brain diagnostic technology indicating intracranial pathology that is a result of the accident, including, but not limited to, intracranial contusions or haemorrhages, diffuse axonal injury, cerebral edema, midline shift or pneumocephaly.

ii. When assessed in accordance with Wilson, J., Pettigrew, L. and Teasdale, G., Structured Interviews for the Glasgow Outcome Scale and the Extended Glasgow Outcome Scale: Guidelines for Their Use, Journal of Neurotrauma, Volume 15, Number 8, 1998, the injury results in a rating of,

a. Vegetative State (VS or VS*), one month or more after the accident,

b. Upper Severe Disability (Upper SD or Upper SD*) or Lower Severe Disability (Lower SD or Lower SD*), six months or more after the accident, or

c. Lower Moderate Disability (Lower MD or Lower MD*), one year or more after the accident.

Child Traumatic Brain Injury

Persons who are 18 years of age or younger and sustained a traumatic brain injury as a direct result of a motor vehicle accident, and meet the following criteria:

i. The insured person is accepted for admission, on an in-patient basis, to a public hospital named in a Guideline with positive findings on a computerized axial tomography scan, a magnetic resonance imaging or any other medically recognized brain diagnostic technology indicating intracranial pathology that is a result of the accident, including, but not limited to, intracranial contusions or haemorrhages, diffuse axonal injury, cerebral edema, midline shift or pneumocephaly.

ii. The insured person is accepted for admission, on an in-patient basis, to a program of neurological rehabilitation in a paediatric rehabilitation facility that is a member of the Ontario Association of Children’s Rehabilitation Services.

iii. One month or more after the accident, the insured person’s level of neurological function does not exceed category 2 (Vegetative) on the King’s Outcome Scale for Childhood Head Injury as published in Crouchman, M. et al, A practical outcome scale for paediatric head injury, Archives of Disease in Childhood, 2001: 84: 120-124.

iv. Six months or more after the accident, the insured person’s level of neurological function does not exceed category 3 (Severe disability) on the King’s Outcome Scale for Childhood Head Injury as published in Crouchman, M. et al, A practical outcome scale for paediatric head injury, Archives of Disease in Childhood, 2001: 84: 120-124.

v. Nine months or more after the accident, the insured person’s level of function remains seriously impaired such that the insured person is not age-appropriately independent and requires in-person supervision or assistance for physical, cognitive or behavioural impairments for the majority of the insured person’s waking day.

55% Whole Person Impairment: Singular or Combination of Physical Impairment(s)

Persons who sustained a physical impairment or combination of physical impairments as a direct result of a motor vehicle accident, that in accordance with the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, results in 55 per cent or more physical impairment of the whole person.

The person must also meet the following criteria:

a. two years have elapsed since the accident; or

b. an assessment conducted by a physician three months or more after the accident determines that,

i. the insured person has a physical impairment or combination of physical impairments determined that results in 55 per cent or more impairment of the whole person, and

ii. the insured person’s condition is unlikely to improve to less than 55 per cent impairment of the whole person.

Analogous Impairment

Also, persons whose impairment can reasonably be believed to be a catastrophic impairment by being analogous to the aforementioned impairment, after taking into consideration the development implications of the impairment.

55% Whole Person Impairment: Mental or Behavioural Impairment combined with a Physical Impairment

Persons who sustained a mental or behavioural impairment, excluding traumatic brain injury as a direct result of a motor vehicle accident, determined in accordance with the rating methodology in Chapter 14, Section 14.6 of the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 6th edition, 2008, that, when the impairment score is combined with a physical impairment described in paragraph 6 in accordance with the combining requirements set out in the Combined Values Table of the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, results in 55 percent or more impairment of the whole person.

The person must also meet the following criteria:

a. two years have elapsed since the accident; or

b. an assessment conducted by a physician three months or more after the accident determines that,

i. the insured person has a combination of a mental or behavioural impairment and a physical impairment that results in 55 per cent or more impairment of the whole person, and

ii. the insured person’s condition is unlikely to improve to less than 55 per cent impairment of the whole person.

Analogous Impairment

Also, persons whose impairment can reasonably be believed to be a catastrophic impairment by being analogous to the aforementioned impairment, after taking into consideration the development implications of the impairment.

Mental or Behavioural Disorder: Class 4 Marked Impairment or Class 5 Extreme Impairment

Persons who sustained an impairment as a direct result of a motor vehicle accident, that, in accordance with the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993 results in a class 4 impairment (marked impairment) in three or more areas of function that precludes useful functioning or a class 5 impairment (extreme impairment) in one or more areas of function that precludes useful functioning, due to mental or behavioural disorder.

The person must also satisfy the following criteria:

a. two years have elapsed since the accident; or

b. a physician states in writing that the insured person’s impairment is unlikely to improve to less than a class 4 impairment (marked impairment) in three or more areas of function that precludes useful functioning, due to mental or behavioural disorder.

Analogous Impairment

Also, persons whose impairment can reasonably be believed to be a catastrophic impairment by being analogous to the aforementioned impairment, after taking into consideration the development implications of the impairment.

Injuries and Impairments that Fall within the Non-Minor or Non-Catastrophic Second Tier Classification with Policy Limits of $65,000

Persons who, from an Accident Benefits perspective, are automatically excluded from the Minor Injury Guideline, and either fall within the 2nd tier non-catastrophic category.

Spine and Pelvis Injuries

Persons who meet the criteria of the American Medical Association Guidelines, 6th Edition, for evaluating permanent impairment due to impairments of the spine and pelvis, as divided into the following four regions:

1. Cervical spine: including occiput through T1 (motion segments occiput-C1 through to C7-T1);
2. Thoracic spine: including T1-T12 (motion segments T1-2 through T11-12);
3. Lumbar spine: including T12-S1 (motion segments T12-L1 through L5-S1); and
4. Pelvis: including ilium, sacrum, and pelvic rami,

And further to the International Classification of Functioning, Disability and Health (ICF) Model that relies on an anatomic, diagnostic, and functional bases for determining impairment, and more specifically, the Diagnosis-Based Impairment (DBI) regional grids, which include five columns containing impairment classes, numbered from 0 to 4, sustain the following impairment classes (Class 3: severe problems and Class 4: very severe problem approaching total functional loss) and impairment ranges:

		Whole Person Impairment (%)
CLASS	PROBLEM	CERVICAL SPINE	THORACIC SPINE	LUMBAR SPINE	PELVIS
3	Severe	15%-24%	12%-16%	15%-24%C	7%-11%
3	Very Severe	25%-30%	17%-22%	25%-33%C	12%-16%

Cervical Spine Injuries

Motion Segment Lesions

Persons diagnosed with Motion Segment Lesions, who have an impairment class of 3 or 4.

Intervertebral Disc Herniation and/or AOMSI

Persons diagnosed with an intervertebral disc herniation and/or AOMSI, who have an impairment class of 3 or 4
(includes instability (specifically as defined in the Guides), arthrodesis, failed arthrodesis, dynamic stabilization or arthroplasty, or combinations of those in multiple-level conditions)

● Class 3: 15% – 24%
● Intervertebral disk herniations or AOMSI at multiple levels, with medically documented findings; with or without surgery and with documented signs of residual radiculopathy at a single clinically appropriate level present at the time of examination.

● Class 4: 25% – 30%
● Intervertebral disk herniation(s) or AOMSI, with medically documented findings; with or without surgery and with documented signs of residual bilateral or multiple-level radiculopathy at the clinically appropriate levels present at the time of examination.

Pseudarthrosis

Person diagnosed with pseudarthrosis, who have a class impairment of 3 or 4
(Note: Only applies after spinal surgery intended for fusion with resultant documented motion (not necessarily AOMSI by definition provided in footnote) with consistent radiographic findings or hardware failure; with or without surgery to repair.)

● Class 3: 15% – 24%
● Pseudarthrosis (post surgery) at a multiple levels with medically documented findings and with documented radiculopathy at a single clinically appropriate level present at the time of examination.

● Class 4: 25% – 30%
● Pseudarthrosis (post surgery) at multiple levels with medically documented findings and with documented signs of bilateral or multiple-level radiculopathy at the clinically appropriate levels present at the time of examination.

Spinal Stenosis

Person diagnosed with spinal stenosis, who have a class impairment of 3 or 4
(Noted: AOMSI includes instability (specifically as defined in the Guides), arthrodesis, failed arthrodesis, failed arthrodesis, dynamic stabilization or arthroplasty, or combinations of those in multiple-level conditions)

● Class 3: 15% – 24%

● Cervical stenosis at multiple levels with or without AOMSI with medically documented findings; with or without surgery and with documented residual radiculopathy at a single clinically appropriate level present at the time of examination.

● Class 4: 25% – 30%
● Cervical stenosis at multiple levels with or without AOMSI with medically documented findings; with or without surgery and with documented signs of residual bilateral or multilevel radiculopathy at the clinically appropriate levels present at the time of examination.

Fractures/Dislocations of the Spine

Persons diagnosed with Fractures/Dislocations of the Spine, who have a class impairment of 3 or 4

Fractures of 1 or More Vertebral Bodies, Fracture of Posterior Element, and Burst Fracture

Person diagnosed with fractures of 1 or more vertebral bodies, a fracture of posterior element (pedicle, lamina, articular process, transverse process) and a burst fracture.

● Class 3: 15% – 24%
● Single- or multiple level fractures with >50% compression of 1 vertebral body; with or without bony retropulsion, with or without pedicle and/or posterior element fracture.
● Healed, with or without surgical intervention; with residual deformity.
● May have radiculopathy at a single clinically appropriate level present at the time of examination.

● Class 4: 25% – 30%
● Single- or multiple level fractures with >50% compression of 1 vertebral body; with or without bony retropulsion; with or without pedicle and/or posterior element fracture.
● Healed, with or without surgical intervention; with residual deformity.
● May have documented signs of bilateral or multiple-level radiculopathy at the clinically appropriate levels present at the time of examination.

Dislocation/Fracture-Dislocation

Persons diagnosed with a dislocation/fracture-dislocation, who have a class impairment of 3 or 4.

● Class 3: 15% – 24%
● Multiple-level dislocation with or without surgical intervention, including fusion.
● May have documented radiculopathy at a single clinically appropriate level present at the time of examination

● Class 4: 25% – 30%
● Multiple-level dislocation with or without surgical intervention, including fusion.
● May have signs of bilateral or multiple-level radiculopathy at the clinically appropriate levels present at the time of examination.

Postoperative Complications (Non-Neurologic)

Persons diagnosed with postoperative complications (non-neurologic), who have a class impairment of 3 or 4.
(Note: Neurologic complications are rated in Chapter 13, The Central and Peripheral Nervous System)
• Class 4: 25% – 30%
• Deep spinal wound infection requiring chronic suppressive antibiotics; or chronic osteomyelitis.

Thoracic Spine Injuries

Motion Segment Lesions

Persons diagnosed with Motion Segment Lesions, who have a class impairment of 3 or 4.

Intervertebral Disk Herniation and/or AOMSI

Persons diagnosed with intervertebral disk herniation and/or AOMSI, who have a class impairment of 3 or 4.

(Note: AOMSI includes instability (specifically as defined in the Guides), arthrodesis, failed arthrodesis, failed arthrodesis, dynamic supral stabilization or arthroplasty, or combinations of those in multiple-level conditions).

● Class 3: 12% – 16%
● Intervertebral disk herniation(s) or AOMSI at multiple levels with medically documented findings; with or without surgery and with documented findings of residual radiculopathy at a single clinically appropriate level present at the time of examination.

● Class 4: 17% – 22%
● Intervertebral disk herniation(s) or AOMSI, at multiple levels, with medically documented injury; with or without surgery and with documented signs of residual bilaterally or multiple-level radiculopathy at the clinically appropriate levels present at the time of examination.

Pseudarthrosis

Persons diagnosed with pseudarthrosis, who have a class impairment of 3 or 4.
(Noted: Only applies after spinal surgery intended for fusion with resultant documented motion (not necessarily AOMSI by definition provided in footnote) with consistent radiographic findings or hardware failure; with or without surgery to repair)

● Class 3: 12% – 16%
● Pseudarthrosis (post surgery) at multiple levels with medically documented findings.
● May have documented radiculopathy at a single clinically appropriate level present at the time of examination.

● Class 4: 17% – 22%
● Pseudarthrosis (post surgery) at multiple levels with medically documented findings.
● May have documented signs of bilateral or multiple-level radiculopathy at the clinically appropriate levels present at the time of examination.

Fractures/Dislocation of the Spine

Persons diagnosed with Fractures/Dislocation of the Spine, who have a class impairment of 3 or 4.

Fractures of 1 or More Vertebral Bodies: Compression Fractures, Fracture of Posterior Element, and a Burst Fracture

Persons diagnosed with fractures of 1 or more vertebral bodies including compression fractures, a fracture of posterior element (pedicle, lamina, articular process, transverse process) and a burst fracture, who have a class impairment of 3 or 4.

● Class 3: 12% – 16%
● Single- or multiple-level fractures with >50% compression of any vertebral body; with or without bony retropulsion into the canal, pedicle and/or posterior element fracture.
● Healed with or without surgery (including vertebroplasty or kyphoplasty) with or without residual deformity.
● May have documented radiculopathy at a single clinically appropriate level present at the time of examination.
● With signs of spinal cord injury or myelopathy.

● Class 4: 17% – 22%
● Single or multiple-level fractures with >50% compression of any vertebral body; with or without bony retropulsion into the canal, pedicle and/or posterior element fracture.
● Healed with or without surgery (including vertebroplasty) with or without residual deformity.
● May have documented signs of bilateral or multiple-level radiculopathy at the clinically appropriate levels present at the time of examination.
● With signs of spinal cord injury or myelopathy.

Dislocations/Fracture Dislocation

Persons diagnosed with dislocations/fracture dislocation, who have a class impairment of 3 or 4.

● Class 3: 12% – 16%
● Multiple-level dislocation with or without fracture.
● Healed with or without surgical intervention, including fusion.
● May have documented radiculopathy at a single clinically appropriate level present at the time of examination.
● With signs of spinal cord injury or myelopathy.

● Class 4: 17% – 22%
● Multiple-level dislocation with or without fracture.
● Healed with or without surgical intervention, including fusion.
● May have documented signs of bilateral or multiple-level radiculopathy at the clinically appropriate levels present at the time of examination.
● With signs of spinal cord injury or myelopathy.

Postoperative Complications (non-neurologic)

Persons diagnosed with postoperative complications (non-neurologic), who have a class impairment of 3 or 4.

(Note: Neurologic complications are rated in Chapter 13, The Central and Peripheral Nervous System).

● Class 4: 17% – 22%
● Deep spinal wound infection requiring chronic suppressive antibiotics; or chronic osteomyelitis.

Lumbar Spine Injuries

Motion Segment Lesions

Persons diagnosed with Motion Segment Lesions, who have a class impairment of 3 or 4.

Intervertebral Disk Herniation

Persons diagnosed with intervertebral disk herniation and/or AOMSI

(Note: AOMSI includes instability (specifically as defined in the Guides), arthrodesis, failed arthrodesis, dynamic stabilization or arthroplasty, or combinations of those in multiple-level conditions)

● Class 3: 15% – 24%
● Intervertebral disk herniation or AOMSI at multiple levels, with medically documented findings; with or without surgery and with documented residual radiculopathy at a single clinically appropriate level present at the time of examination.

● Class 4: 25% – 33%
● Intervertebral disk herniations and/or AOMSI, at multiple levels, with medically documented findings; with or without surgery and with documented signs of residual bilateral or multiple-level radiculopathy at the clinically appropriate levels present at the time of examination.

Pseudarthrosis

Persons diagnosed with pseudarthrosis, who have a class impairment of 3 or 4.

(Note: Only applies after spinal surgery intended for fusion with resultant documented motion (not necessarily AOMSI by definition provided in footnote) with consistent radiographic findings or hardware failure; with or without surgery to repair)

● Class 3: 15% – 24%
● Pseudarthrosis (post-surgery) at multiple levels with medically documented findings.
● May have documented radiculopathy at a single clinically appropriate level present at the time of examination.

● Class 4: 25% – 33%
● Pseudarthrosis (post-surgery) at multiple levels with medically documented findings.
● May have documented signs of bilateral or multiple level radiculopathy at the clinically appropriate levels present at the time of examination.

Spinal Stenosis

Persons diagnosed with spinal stenosis, who have a class impairment of 3 or 4.
(may include AOMSI)

(Note: AOMSI includes instability (specifically as defined in the Guides), arthrodesis, failed arthrodesis, dynamic stabilization or arthroplasty, or combinations of those in multiple-level conditions)

● Class 3: 15% – 24%
● Lumbar stenosis, at multiple levels with or without AOMSI with medically documented findings; with or without surgery (decompression) and documented neurogenic claudication, walking limited to <10 minutes (see Table 17-7 to grade radiculopathy, but not claudication)
● May have documented signs of radiculopathy at a single clinically appropriate level present at the time of examination with signs of cauda equina syndrome: sue Chapter 13 to calculate additional impairment.

● Class 4: 24% – 33%
● Lumbar stenosis, at multiple levels with or without AOMSI with medically documented findings; with or without surgery (decompression) and severe neurogenic claudication and inability to ambulate without assistive devices.
● May have documented signs of bilateral or multiple-level radiculopathy at the clinically appropriate levels present at the time of examination with signs of cauda equine syndrome: use Chapter 13 to calculate additional impairment.

Spondylolisthesis

Persons diagnosed with spondylolisthesis, who have a class impairment of 3 or 4.

● Class 3: 15% – 24%
● Spondylolisthesis with medically documented injury; with or without surgery at multiple levels and with documented signs of radiculopathy at a single clinically appropriate level present at the time of examination.

● Class 4: 25% – 33%
● Spondylolisthesis with medically documented injury; with or without surgery at multiple levels and with documented signs of bilateral or multiple-level radiculopathy at the clinically appropriate levels present at the time of examination.

Degenerative Spondylolisthesis

Persons diagnosed with degenerative spondylolisthesis with or without spinal stenosis, who have a class impairment of 3 or 4.

● Class 3: 15% – 24%
● Degenerative spondylolisthesis at multiple levels with medically documented injury; with or without surgery and documented neurogenic claudication, walking limited to <10 minutes (see Table 17-7 to grade radiculopathy, but not claudication).
● May have documented radiculopathy at a single clinically appropriate level present at the time of examination with signs of cauda equina syndrome: use Chapter 13 to calculate additional impairment.

● Class 4: 25% – 33%
● Degenerative spondylolisthesis is at multiple levels with medically documented injury; with or without surgery and severe neurogenic claudication and inability to ambulate without assistive devices.
● May have documented signs of bilateral or multiple-level radiculopathy at the clinically appropriate levels present at the time of examination with signs of cauda equina syndrome: use Chapter 13 to calculate additional impairment.

Fractures/Dislocations of the Spine

Persons diagnosed with Fractures/Dislocations of the Spine, who have a class impairment of 3 or 4.

Fractures of 1 or More Vertebral Bodies: Compression Fractures, Fracture of Posterior Element, and a Burst Fracture

Persons diagnosed with fractures of 1 or more vertebral bodies, including compression fractures, a fracture of posterior element (pedicle, lamina, articular process, transverse process) and a burst fracture.

● Class 3: 15% – 24%
● Single- or multiple-level fractures with >50% compression of any vertebral body; with or without retropulsion into the canal; pedicle and/or posterior element fracture.
● Healed, with or without surgery (including vertebroplasty or kyphoplasty) with or without residual deformity and may have significant radiculopathy at a single clinically appropriate level present at the time of examination (see Table 17-7 to grade radiculopathy) with signs of cauda equina syndrome: use Chapter 13 to calculate additional impairment.

● Class 4: 25% – 33%
● Single- or multiple-level fractures with >50% compression of any vertebral body; with or without retropulsion; pedicle and/or posterior element fracture.
● Healed, with or without surgery (including vertebroplasty or kyphoplasty) with or without residual deformity and may have significant radiculopathy bilaterally or at multiple clinically appropriate levels present at the time of examination (see Table 17-7 to grade radiculopathy) with signs of cauda equina syndrome: use Chapter 13 to calculate additional impairment.

Dislocations/Fracture Dislocation

Persons diagnosed with dislocations/fracture dislocation, who have a class impairment of 3 or 4.

● Class 3: 15% – 24%
● Multiple-level dislocation with or without fracture
● Healed, with or without surgical intervention, including fusion.
● May have documented radiculopathy at a single clinically appropriate level present at the time of examination (see Table 17-7 to grade radiculopathy) with signs of cauda equina syndrome: use Chapter 13 to calculate additional impairment.

● Class 4: 25% – 33%
● Multiple-level dislocation with or without fracture.
● Healed, with or without surgical intervention, including fusion and with documented signs of bilateral or multiple level radiculopathy at the clinically appropriate levels present at the time of examination (see Table 17-7 to grade radiculopathy) with signs of cauda equina syndrome: use Chapter 13 to calculate additional impairment.

Post-Operative Complications (non-neurologic)

Persons diagnosed with post-operative complications (non-neurologic), who have a class impairment of 4.

(Note: Neurologic complications are rated in Chapter 13, The Central and Peripheral Nervous System)

● Class 4: 25% – 33%
● Deep spinal wound infection requiring chronic suppressive antibiotics; or chronic osteomyelitis.

Upper Extremities Injuries

Digit Region Injury

Joint Dislocation or Sprain

Persons diagnosed with Joint Dislocation or Sprain, who have a class impairment of 3 or 4.

Thumb Carpometacarpal

Persons diagnosed with thumb CMC (carpometacarpal), who have a class impairment of 3.

● Class 3: 26% – 49% Digit
● >20◦ Instability

Ankylosis/Arthrodesis
Persons diagnosed with Ankylosis/Arthrodesis, who have a class impairment of 3 or 4.
(Rate per Section 15.7, Range of Motion Impairment)

Thumb Carpometacarpal
Persons diagnosed with thumb CMC (carpometacarpal), who have a class impairment of 3.
• Class 3: 26% – 49% Digit
• Residual symptoms, consistent objective findings and/or functional loss, with normal motion.

Wrist Region Injury
Ligament, Bone and/or Joint Injury
Persons diagnosed with Ligament/Bone/Joint, who have a class impairment of 3 or 4.

Wrist Arthrodesis (Fusion)
Persons diagnosed with wrist arthrodesis (fusion), who have a class impairment of 3 or 4.
(If motion loss is present, this impairment may alternatively be assessed using Section 15.7, Range of Motion Impairment. A range of motion impairment stands alone and is not combined with diagnosis impairment).
● Class 3: 26% – 49% UE
● Wrist arthrodesis in functional position (10◦ extension to 10◦ flexion, radial 5◦ to ulnar 10◦).

● Class 4: 50% – 100% UE
● If nonoptimal positioning, assess per Section 15.7, Range of Motion Impairment.

Arthroplasty
Persons diagnosed with arthroplasty, who have a class impairment of 3 or 4.
(Wrist (total) arthroplasty)
• Class 3: 26% – 49% UE
• Complicated, unstable, or infected.

Elbow Region Injury
Ligament, Bone and/or Joint Injury
Persons diagnosed with Ligament/Bone/Joint, who have a class impairment of 3 or 4.

Persistent Elbow Subluxation or Dislocation
Persons diagnosed with persistent elbow subluxation or dislocation, who have a class impairment of 3.
● Class 3: 26% – 49%
● Severe: cannot be reduced.

Arthrodesis (Fusion)
Persons diagnosed with arthrodesis (fusion), who have a class impairment of 3 or 4.
● Class 3: 26% – 49% UE
● Elbow arthrodesis in functional position (70◦ to 80◦ flexion, 20◦ to 30◦ pronation).

● Class 4: 50% – 100% UE
● If nonoptimal positioning, assess per Section 15.7, Range of Motion Impairment.

Shoulder Region Injuries
Ligament, Bone and/or Joint Injury
Persons diagnosed Ligament/Bone/Joint, who have a class impairment of 3 or 4.

Arthrodesis (Fusion)
Persons diagnosed with arthrodesis (fusion), who have a class impairment of 3 or 4.
● Class 3: 26% – 49% UE
● Shoulder arthrodesis in functional position (20◦ to 40◦ flexion, 20◦ to 40◦ abduction, 20◦ to 50◦ internal rotation).

● Class 4: 50% – 100% UE
● If nonoptimal positioning assess per Section 15.7, Range of Motion Impairment.

Shoulder Arthroplasty
Persons diagnosed with shoulder arthroplasty, who have a class impairment of 3.
● Class 3: 26% – 49% UE
● Resection with normal motion 34 37 40 43 46.
● Complicated, unstable, or infected.

The Lower Extremities Injuries
Foot and Ankle Region Injuries

Muscle/Tendon Injury
Persons diagnosed with a Muscle/Tendon injury, who have a class impairment of 3 or 4.

Strain, Tendonitis, or History of Ruptured Tendon
Persons diagnosed with a strain; tendonitis; or h/o ruptured tendon, specifically involving posterior tibial, anterior tibial, achilles, or peroneal tendon (all other tendons below), who have a class impairment of 3.
● Class 3: 26% – 49% LE
● Fixed deformity and loss of specific tendon function.

Fracture/Dislocation
Persons diagnosed with a Fracture/Dislocation, who have a class impairment of 3 or 4.

Tibia (extra-articular) Fracture/Dislocation
Persons diagnosed with a tibia (extra-articular) fracture/dislocation, who have a class impairment of 3 or 4.
● Class 3: 26% – 49% LE
● Very severe misalignment, non-union with angulation or rotational deformity or union with osteomyelitis.

● Class 4: 50% – 100% LE
● Infected union.

Tibia (intra-articular – pilon/plafond) Fracture/Dislocation
Persons diagnosed with a tibia (intra-articular – pilon/plafond) fracture/dislocation, who have a class impairment of 3 or 4.
● Class 3: 26% – 49% LE
● Very severe malalignment, non-union with angulation or rotational deformity or union osteomyelitis.

● Class 4: 50% – 100% LE
● Infected nonunion.

Ankle (malleolar, bimalleolar, trimalleolar) Fracture/Dislocation
Persons diagnosed with an ankle (malleolar, bimalleolar, trimalleolar) fracture/dislocation, who have a class impairment of 3 or 4.
● Class 3: 26% – 49% LE
● Very severe malalignment, non-union with angulation or rotational deformity or union with osteomyelitis.

● Class 4: 50% – 100% LE
● Infected non-union.

Calcaneus Fracture/Dislocation
Persons diagnosed with a calcaneus fracture/dislocation, who have a class impairment of 3.
● Class 3: 26% – 49% LE
● Very severe malalignment or non-union with angulation.

Navicular/Cuboid (transtarsal), Charcot Fracture/Dislocation
Persons diagnosed with a navicular/cuboid (transtarsal)/charcot fracture/dislocation, who have a class impairment of 3.
● Class 3: 26% – 49% LE
● Very severe malalignment or non-union with angulation.

Metatarsal – Tarsal Fracture/Dislocation (lisfranc)
Persons diagnosed with a metatarsal – tarsal fracture/dislocation (Lisfranc), who have a class impairment of 3.
● Class 3: 26% – 49% LE
● Very severe malalignment or non-union with angulation, or involvement of 4th and 5th tarsal – metatarsal joints.

Pan-Talar (tibial-talar, talar-calcaneal, talar-navicular) Fracture/Dislocation
Persons diagnosed with a pan-talar (tibial-talar, talar-calcaneal, talar-navicular) fracture/dislocation, who have a class impairment of 3 or 4.
● Class 3: 26% – 49% LE
● 1-2 mm cartilage interval all 3 joints.

● Class 4: 50% – 100% LE
● 0-1 mm cartilage interval all 3 joints or severe loss of motion in all 3 joints.

Arthritis
Persons diagnosed with Arthritis, who have a class impairment of 3 or 4.

Ankle Arthritis
Persons diagnosed with ankle arthritis, who have a class impairment of 3.
● Class 3: 26% – 49% LE
● No cartilage interval.

Arthrodesis (joint ankylosis, fusion)
Persons diagnosed with an Arthrodesis (Joint Ankylosis, Fusion), who have a class impairment of 3 or 4.

Pan-Talar (tibial-talar, talar-calcaneal, talar-navicular)
Persons diagnosed with a pan-talar (tibial-talar, talar-calcaneal, talar-navicular), who have a class impairment of 3 or 4.
● Class 4: 50% – 100% LE
● 50 45 60 64 64
● Neutral position.
● 59 67 75 75 75
● Malalignment.

Ankle Arthrodesis (joint ankylosis, fusion)
Persons diagnosed with ankle arthrodesis (joint ankylosis, fusion), who have a class impairment of 3 or 4.
● Class 3: 26% – 49% LE
● Moderate malalignment (dorsiflexion >19◦, plantar flexion 20-29◦, varus position 10-19◦, valgus position 10-19◦, internal malrotation 10-29◦, or external malrotation 20-39◦) or non-union.

● Class 4: 50% – 100% LE
● Severe malalignment (plantar flexion varus position >19◦, internal malrotation >19◦, internal malrotation >29◦, or external malrotation >39◦) or infected non-union.

Subtalar Arthrodesis (joint ankylosis, fusion)
Persons diagnosed with a subtalar arthrodesis (joint ankylosis, fusion), who have a class impairment of 3 or 4.
● Class 3: 26% – 49% LE
● Moderate malalignment (varus position, 4◦-6◦ greater than the opposite normal or valgus 10-14◦ of normal.

● Class 4: 50% – 100% LE
● Severe malalignment (varus position, 4◦-6◦ greater than the opposite normal or valgus 10-14◦ of normal).

Double or Triple Arthrodesis (talar-calcaneal, talar-navicular, calcaneal-cuboid)
Persons diagnosed with a double or triple arthrodesis (talar-calcaneal, talar-navicular, calcaneal-cuboid), who have a class impairment of 3 or 4.
● Class 3: 26% – 49% LE
● Moderate malalignment (varus position, 4◦-6◦ greater than the opposite normal or valgus 10-14◦ of normal).

● Class 4: 50% – 100% LE
● Severe malalignment (varus position, 4◦-6◦ greater than the opposite normal or valgus 10-14◦ of normal).

Total Ankle Replacement
Persons diagnosed with a total ankle replacement, who have class impairment of 3 or 4.
● Class 3: 26% – 49% LE
● Fair result (fair position, mild instability and/or mild motion deficit).

● Class 4: 50% – 100% LE
● Poor result (poor position, moderate to severe instability, and/or moderate to severe motion deficit)
● 67 71 75 79 83
● Poor result with chronic infection.

Knee Region Injuries
Ligament, Bone and/or Joint Injuries
Persons diagnosed with a Ligament/Bone/Joint injury, who have a class impairment of 3 or 4.

Cruciate and Collateral Ligament Injury
Persons diagnosed with a cruciate and collateral ligament injury; surgery not rating factor, who have a class impairment of 3.
● Class 3: 26% – 49% LE
● Severe laxity.

Facture in the Knee Region
Persons diagnosed with a Fracture in the knee region, who have a class impairment of 3 or 4.

Femoral Shaft Fracture
Persons diagnosed with a femoral shaft fracture, who have a class impairment of 3 or 4.
● Class 3: 26% – 49% LE
● 20◦ + angulation.

● Class 4: 50% – 100% LE
● Non-union and/or infected.

Supracondylar or Intercondylar Fracture
Persons diagnosed with a supracondylar or intercondylar fracture, who have a class impairment of 3 or 4.
● Class 3: 26% – 49% LE
● 20◦ + angulation or >2 mm articular surface step off.

● Class 4: 50% – 100% LE
● Non-union and/or infected.

Tibial Plateau Fracture
Persons diagnosed with a tibial plateau fracture, who have a class impairment of 3 or 4.
● Class 3: 26% – 49% LE
● 20◦ + angulation or >2 mm articular surface step off.

● Class 4: 50% – 100% LE
● Non-union and/or infected, or severe comminuted, displaced.

Proximal Tibial Shaft Fracture
Persons diagnosed with a proximal tibial shaft fracture, who have a class impairment of 3 or 4.
● Class 3: 26% – 49% LE
● 20◦ + angulation.

● Class 4: 50% – 100% LE
● Non-union and/or infected.

Arthritis in the Knee Region
Persons diagnosed with Arthritis in the knee region, who have a class impairment of 3 or 4.

Knee Joint Arthritis
Persons diagnosed with primary knee joint arthritis, who have a class impairment of 3 or 4.
● Class 3: 26% – 49% LE
● 1 mm cartilage interval.

● Class 4: 50% – 100% LE
● No cartilage interval.

Arthrodesis in the Knee Region
Persons diagnosed with an Arthrodesis in the knee region, who have a class impairment of 3 or 4.

Arthrodesis (joint ankylosis, fusion)
Persons diagnosed with an arthrodesis (joint ankylosis, fusion), who have a class impairment of 4.
● Class 4: 50% – 100% LE
● 10◦-15◦ flexion contracture and good alignment.
● >15◦ flexion or poor alignment.

Osteotomy/Knee Replacement
Persons diagnosed with an Osteotomy/Knee Replacement, who have a class impairment of 3 or 4.

Tibial Osteotomy
Persons diagnosed with a s/p tibial osteotomy, who have a class impairment of 3.
● Class 3: 26% – 49% LE
● Poor result (effusion, limited motion, instability).

Total or Partial Knee Replacement
Persons diagnosed with a total or partial knee replacement, who have a class impairment of 3 or 4.
● Class 3: 26% – 49% LE
● Fair result (fair position, mild instability and/or mild motion deficit).

● Class 4: 50% – 100% LE
● Poor result (poor position, moderate to severe instability, and/or moderate to severe motion deficit.
● Poor result with chronic infection.

Hip Region Injuries
Ligament, Bone and/or Joint Injury in the Hip Region
Persons diagnosed with a Ligament/Bone/Joint injury in the hip region, who have a class impairment of 3 or 4.

Hip Dislocation
Persons diagnosed with a hip dislocation, who have a class impairment of 3.
● Class 3: 26% – 49% LE
● Hip dislocation, recurrent.

Avascular Necrosis
Persons diagnosed with an avascular necrosis, who have a class impairment of 3.
● Class 3: 26% – 49% LE
● Avascular necrosis of hip with severe range of motion deficit.

Fracture in the Hip Region
Persons diagnosed with a Fracture in the hip region, who have a class impairment of 3 or 4.

Fractures above the Hip Joint (acetabulum and proximal femur)
Persons diagnosed with fractures above the hip joint (acetabulum and proximal femur), who have a class impairment of 3 or 4.
● Class 3: 26% – 49% LE
● Femoral neck, intertrochanteric, or subtrochanteric fracture with severe motion deficits and/or malalignment (malunion).
● Acetabular fracture with = or > 5 mm displacement of articular surface.

● Class 4: 50% – 100% LE
● Infected.

Arthrodesis in the Hip Region
Persons diagnosed with an Arthrodesis in the hip region, who have a class impairment of 3 or 4.

Hip Joint Arthrodesis (ankylosis, fusion)
Persons diagnosed with a hip joint arthrodesis (ankylosis, fusion), who have a class impairment of 4.
● Class 4: 50% – 100%
● 50 50 50 54 58
● Fused in 25-40◦ flexion and neutral rotation, adduction and abduction.
● 67 71 75 79 83
● Moderate malposition.
● 80 85 90 95 100
● Severe malposition.

Osteotomy/Joint Replacement in the Hip Region
Persons diagnosed with an Osteotomy/Joint Replacement in the hip region, who have a class impairment of 3 or 4.

Femoral Osteotomy in the Hip Region
Persons diagnosed with a s/p femoral osteotomy, who have a class impairment of 3.
● Class 3: 26% – 49% LE
● Poor result (effusion, limited motion, instability).

Partial or Total Hip Replacement
Persons diagnosed with a partial or total hip replacement, who have a class impairment of 3 or 4.
● Class 3: 26% – 49% LE
● Fair result (fair position, mild instability and/or mild motion deficit).

● Class 4: 50% – 100% LE
● 59 63 67 71 75
● Poor result (poor position, moderate to severe instability, and/or moderate to severe motion deficit).
● 67 71 75 79 83
● Poor result with chronic infection.

Visual Acuity Impairment
Persons diagnosed with either a profound loss (restricted functioning, marginal performance, even with aids) or near-total or total loss of vision (cannot perform; needs substitution skills).

Profound Low Vision
● Visual Acuity à US Notation à 20/500, 20/630, 20/800, 20/100
● Visual Acuity à 1 m Notation à 1/25, 1/32, 1/40, 1/50

● Visual Acuity Score (ability) à 30, 25, 20, 15
● Impairment Rating (ability loss) à 70, 75, 80, 85

● Marginal with reading aids.
● Uses magnifiers for spot reading, but may prefer talking books.

Near-Blindness
● Visual Acuity à US Notation à 20/250, 20/600, 20/2000, or less
● Visual Acuity à 1 m Notation à 1/63, 1/80, 1/100, or less

● Visual Acuity Score (ability) à 10, 5
● Impairment Rating (ability loss) à 90, 95

● No visual reading.
● Must rely on talking books, braille, or other nonvisual sources.

Total Blindness
● Visual Acuity à No light perception.

● Visual Acuity Score (ability) à 0
● Impairment Rating (ability loss) à 100

Chronic Pain

Chronic pain has been recognized as pain that persists beyond the normal healing time after a tissue injury, and it adversely affects the function and well-being of an individual.

It continues for more than the normal recovery period, despite appropriate therapy and reasonable accommodations. Usually pain is regarded as chronic when it lasts or recurs for more than 3 to 6 months.

It is ongoing pain lasting longer than 6 months as diagnostic, or 3 months as the minimum criterion. In contrast to acute pain that arises suddenly in response to a specific injury and is usually treatable, chronic pain is often resistant to medical treatments and lacks the acute warning physiological function.

Chronic pain is a condition that is very complex and multifactorial in origin. It substantially interferes with all daily activities of the individual. Chronic pain is also associated with psychological problems, such as anxiety, depression, and sleep disturbances, which may further increase the severity of the existing pain experience. The feasible sources of chronic musculoskeletal pain can be simultaneously associated with multiple sources, such as muscles, tendons, ligaments, intervertebral discs, facet joints, articular cartilage, periosteum, peripheral nerves, neural pathways, and involvement of the nerve roots at the levels of the cervical, thoracic and lumbar spine.

The evidence-based recommendations support a multimodal, multidisciplinary or interdisciplinary approach for patients who suffer from chronic pain.

Musculoskeletal Chronic Pain

Musculoskeletal pain is pain that affects the bones, muscles, ligaments and tendons. Musculoskeletal pain can result from various causes including sports or occupational injuries, motor vehicle collisions, repetitive strain injuries and disease processes, such as arthritis.

Neuropathic Chronic Pain

Neuropathic pain is a complex, multi-faceted state of chronic pain that may have no obvious cause. It can involve damaged tissue, injury or malfunctioning nerve fibers or changes in brain processing. An example of neuropathic pain is phantom limb syndrome. The brain still receives signals from nerves that originally carried impulses from the now missing limb. Other types of neuropathic pain include numbness, burning, “pins and needles” sensations and shooting pain.

Chronic Must Result in a Serious Impairment of Ability to Function

The chronic pain has seriously impaired the insured person’s ability to perform many daily functions and the person’s ability to work. This will continue into the future.

Chronic pain that is more than sequelae from soft tissue injuries, but is rather chronic pain syndrome or continuous, and is of a severity that it causes suffering and distress accompanied by functional impairment or disability.