Introduction

The post-104-week income replacement test reads like it was written for desk jobs. Complete inability to engage in any employment for which the insured is reasonably suited by education, training, or experience. For someone with a documented orthopaedic injury, a CRPS diagnosis, or chronic pain, the natural question is whether any physical file can clear that bar.

The 2025 and 2026 decisions answer with a split: a small number of clean physical wins, and a long list of losses that teach as much as the wins do. The line between them is drawn by the quality of the medical evidence, not by the severity of the symptoms. This post maps both sides of that line. The psychological side of the same test has its own companion piece, how psychological evidence wins post-104 IRB cases, and the year itself is framed by the 2026 LAT decisions affecting HCAI invoicing.

The Test That Screens Out Most Physical Files

Section 6(2)(b) of the Schedule requires complete inability in any employment, not the substantial inability test of the first 104 weeks. The insured bears the onus on a balance of probabilities.

The 2025 Court of Appeal decision (2025 ONCA 656) frames the weighing: an evidence-based, contextual analysis, where status, remuneration, and comparability to pre-accident employment are considerations, not stand-alone requirements. A 2023 Aviva decision (2023 CanLII 58513) adds the point that shapes every report: the post-104 test is a legal test, not a medical question. A report that recites diagnoses without engaging the test leaves the decision to someone else, usually a transferable skills analysis that lists light work the insurer says the claimant can do.

The Centre Piece: The Accommodations Argument Is Closed

The most useful physical-track holding of 2026 comes from a Security National decision (2026 CanLII 6221). The applicant had CRPS confirmed by a treating chronic pain specialist, a pain medicine physician, and her own expert, with loss of the functional use of the dominant right arm. The insurer's orthopaedic file review said the impairment "could be accommodated," and that the employment options in the transferable skills analysis were therefore open.

The adjudicator closed that door. Neither s. 6(2)(b) nor the 2025 Court of Appeal decision makes potential future accommodations a factor in the complete inability test. And while the onus is on the applicant, it does not extend to hunting for future jobs and employers to prove whether accommodations could be offered.

Real-world example: the same decision ran the numbers on the transferable skills analysis. Part-time work in the proposed customer service occupation paid $17.20 to $31.42 per hour, or roughly $17,888 to $32,677 a year at 20 hours a week, against pre-accident income of $88,629 to $107,032. The adjudicator found that level of compensation not comparable in status and rewards to the pre-accident employment. A list of possible jobs is not enough. The compensation and the function both have to be real.

Objective Injury Plus Surgery Still Wins

The cleanest physical wins pair a demonstrable lesion with functional consequence. A 2025 Jevco decision (2025 CanLII 129057) involved a shoulder injury requiring surgery, with the accident accepted as the precipitating cause despite a pre-accident shoulder history. The vocational evidence finished the file: the applicant had no post-secondary credentials, and the family restaurant's accommodations meant he would be a liability to a potential employer.

The pattern matches the psychological track: objective, confirmed, functional, and tied to the statutory test. No single one of those elements carries a physical file alone.

Why the Losing Files Lost

The losses are just as instructive, and they cluster around a few recurring flaws.

A 2025 CAA decision (2025 CanLII 31149) shows the killer phrase. An insurer's assessor characterized the lower back pain as "uncomplicated self-resolving soft tissue," and a later stroke was not accident-related. Once the file is framed as benign and self-resolving, the claim has nowhere to go.

A 2018 RBC decision (2018 CanLII 112103) shows the consistency rule. The claimant's pain narrative, including self-medication, conflicted with the medical evidence, and there was no physiotherapy attendance. Physical claims live and die on congruent records.

A 2020 Wawanesa decision (2020 CanLII 61466) shows what a bare Disability Certificate is worth. The steel worker's file had conflicting assessors on causation of the radiating leg symptoms, and the certificate alone was insufficient.

A 2019 Certas decision (2019 CanLII 34591) is the report-writing warning: the treating pain specialist's report never addressed the post-104 test, so the insurer's IE and transferable skills analysis carried the file.

And a 2023 Intact decision (2023 CanLII 26941) shows the CPP-D trap: the application was denied, the insurer's vocational report listed concrete available jobs, and there was no rebuttal evidence of inability.

Pain Files Need the Psychiatric Component Documented

The pure pain file is the weakest position in the modern caselaw. The wins almost all include a documented psychological component, and the losses, like a 2025 Certas decision (2025 CanLII 69506), often fail where the combination of physical, chronic pain, and psychological disabilities is asserted but never proven to meet the complete-inability test.

A 2026 Wawanesa decision (2026 CanLII 68589) shows the defence working. The insurer framed the applicant's pain behaviour as inconsistent with minor range-of-motion findings. The framing lost because the s. 25 psychiatrist had documented somatic symptom disorder with predominant pain, plus mood and anxiety diagnoses. The adjudicator accepted the psychiatric explanation of the pain experience. The same report quality standard applies as in any psychological file, including surviving validity testing scrutiny at the LAT.

CPP-D Is Corroboration, Not Proof

A 2024 Aviva decision (2024 CanLII 115418) shows CPP-D used properly. The applicant's physiatrist consistently opined the applicant was unable to work in any capacity, sedentary or physical, the treating clinical notes were contemporaneous, and the CPP-D approval was cited as corroboration.

The contrast is the 2023 Intact decision: a denied CPP-D application was given little weight and used against the claim. CPP-D helps where the Schedule-focused evidence is already strong. It never carries a file alone.

Lessons for Assessors

1. Document the objective structural basis. Surgical findings, imaging, and confirmed diagnoses like CRPS carry physical files. Multiple concurring specialists were decisive in the Security National and Jevco wins. 2. Address causation head-on. State why the accident is the precipitating cause and how pre-accident history shows functionality vs post-accident loss of function. 3. Rebutt the transferable-skills list on function. When the insurer lists light work, respond on endurance, pain-triggered absence, medication side effects, and reliability, not only on strength demands. 4. Do not let "could be accommodated" decide the file. After the 2026 Security National decision, hypothetical future accommodations are not part of the test. Make the insurer prove a concrete, available job. 5. Keep the self-report consistent with the records. Treatment attendance, medication use, and reported limitations must line up. The RBC decision shows the cost of an incongruent narrative. 6. Document the psychological component of pain. Somatic symptom disorder, anxiety, and mood findings turn pain behaviour evidence in the claimant's favour. 7. Use CPP-D as corroboration only. Cite an approval alongside contemporaneous notes, and expect a denial to be used against the claim.

Conclusion

The post-104 test is hard for physical files, but it is not closed. The wins come from objective structural findings, multiple concurring specialists, causation addressed on the record, and the accommodations argument shut down the way the 2026 Security National decision shut it down. The losses come from benign characterizations, inconsistent self-reports, reports that skip the test, and pain files with no psychological documentation.

For assessors and clinics, the workflow is the same one every benefit dispute follows: the burden is the claimant's, and the report is how it gets met, the same prove-it standard the Tribunal applies to billing above guideline rates. Write the structural basis, address causation, rebut the light-work list on function, and document the psych component. Review your last three post-104 physical files against this checklist before the next hearing date.