Category: Accounting Report

Ramkelawan v Aviva Insurance Company (20-006937)

The claimant retained an expert accountant to calculate their quantum of IRBs as a result of the subject accident. The insurer denied payment of the report. The matter eventually proceeded to a Case Conference and several issues were settled between the parties, the only remaining issue was the cost of the accounting report. The claimant’s report covered the period of July 8 to August 15, 2018 and noted that the claimant was entitled to $0.00 in IRBs for that period. The claimant argued that the report was necessary as it showed income loss and included copies of supporting documentation, such as tax forms, bank statements and pay stubs. Furthermore, she argued that she had two employers at the time of the accident and was on modified duties, and that the report was necessary to determine her eligibility for any other income assistance or whether she was entitled to collateral benefits and noted that her medical issues “could have” led to her stop working at any time. The insurer argued that the report was neither reasonable or necessary as the claimant was a salaried T4 employee, and an IRB calculation was straightforward. The insurer also noted that the claimant was not entitled to IRBs as 70 percent of her post-accident income exceeded the policy maximum of $400 per week. Adjudicator Goulet noted that the calculation of IRBs in this case was not a complex matter and queried why the claimant simply did not submit the financial documents directly to the insurer. Furthermore, the claimant retained the accountant only two weeks after she submitted her OCF-1, one day after submitting her OCF-3, and prior to submitting an OCF-10. Adjudicator Goulet noted M.G. v Intact in her reasoning, noting that the claimant retaining an accountant prior to there being an IRB quantum in dispute was premature. The accounting report was found not payable.

A. G.-B. v. Unica Insurance Inc. (19-003153)

The claimant sought payment for accounting invoices related to calculating IRBs. The insurer argued that the accounting report was not reasonable or necessary for calculating IRBs. Vice Chair McGee found the accounting report costs were not payable. The claimant had only one source of income, and the IRB calculation required a simple deduction for short-term disability payments. No expertise was required to interpret the documentation. Obtaining the accounting report was not reasonable or necessary in the circumstances.

S.A. v. Aviva Insurance Canada (18-004334)

The claimant sought entitlement to IRBs in the amount of $195.81 per week, the cost of an IRB calculation report, interest and a special award. The claimant submitted that from March 9, 2016 to April 30, 2016, he suffered a substantial inability to perform the essential tasks of his pre-accident employment as a floor installer due to the physical and psychological impairments he sustained. The claimant was working approximately 10 hours per day as a floor installer and was also employed as a server. The claimant began to receive chiropractic treatment a few weeks post-accident. According to the OCF-3, the claimant was said to be unable to perform the essential tasks of his employment, but was able to return on modified duties and specifically, “the applicant reports returning to work despite medical advice to refrain from work”. The insurer received a second copy of the OCF-3, one day prior to the claimant’s return to work, but the OCF-3 was altered to remove the information that the claimant had returned to work post-accident and modified duties were no longer listed as being available. Adjudicator Gosio concluded that the claimant was not entitled to the IRB as the claimant only saw his family physician once for accident related issues, he had returned to his pre-accident employment with modifications, and the medical evidence suggested that he was dealing with primarily soft tissue injuries that were successfully managed through treatment modalities. There was no evidence or submissions which indicated that the claimant was suffering from anxiety. With regards to the IRB calculation report, Adjudicator Gosio found that the report was reasonable and necessary as the claimant was self employed, which could complicate the calculation and having a member of a designated body prepare the report was acceptable in the circumstances.

M.G. v. Intact Insurance Company (17-008078)

The claimant sought entitlement to the cost of an accounting report related to IRBs. Adjudicator Parish dismissed the dispute. She found that the delays which occurred with the file while the insurer was conducting an investigation regarding the accident did not establish that the accounting report was reasonable and necessary. Further, she found that the accounting report was commissioned prematurely at a time when there was no quantum dispute with respect to the IRB, and that the IRB calculation was straightforward based on two income sources and did not necessitate retaining an accountant.

M.G. v. Intact Insurance Company (17-008078)

The claimant sought entitlement to the cost of an accounting report related to IRBs. Adjudicator Parish dismissed the dispute. She found that the delays which occurred with the file while the insurer was conducting an investigation regarding the accident did not establish that the accounting report was reasonable and necessary. Further, she found that the accounting report was commissioned prematurely at a time when there was no quantum dispute with respect to the IRB, and that the IRB calculation was straightforward based on two income sources and did not necessitate retaining an accountant.

M.M. v. Aviva Insurance Canada (17-006475)

The claimant sought entitlement to IRBs, various medical benefits, educational expenses, and an accounting report. Adjudicator Boyce found that the claimant was not entitled to payment of IRBs as claimed as she did not demonstrate a substantial inability to perform the essential tasks of her pre-accident employment for the period in dispute. Adjudicator Boyce had noted inconsistencies in the claimant’s IRB claim about her ability to complete her essential pre-accident employment tasks and that the claimant was able to return to work. The surveillance evidence was found to show the claimant doing many routine work tasks that contradicted her claim she was unable to work. She also claimed the cost of the accounting report she completed to calculate her IRB quantum, which was determined to be not payable because it was not an identified issue in dispute. The claimant was found to be entitled to payment for physiotherapy treatment and dental expenses including interest as they were considered to be reasonable and necessary. Further, the claimant was not entitled to the education expenses claimed as there was no evidence to support that she was unable to complete her course as a result of the accident. No special award was granted as there was no indication that Aviva unreasonably withheld or delayed payment of benefits where there was also a genuine dispute over entitlement.

S.M. v. Aviva General Insurance Company (18-010116)

The claimant sought entitlement to the cost of an accounting report related to IRBs. Adjudicator Boyce dismissed the dispute. He held that it was not reasonable and necessary for the claimant to procure an accounting report. The claimant had a single source of income, and was not self-employed. The existence of short-term disability payments did not justify retaining an accountant. The insurer’s use of an accountant was completed in the scope of properly adjusting the claim, and to address the missing OCF-2 that the claimant’s accountant had not considered.

S.G. v. Wawanesa Mutual Insurance Company (18-001861)

The claimant sought reconsideration of the Tribunal’s denial of IRBs and the cost of an accounting report. Adjudicator Parish concluded that the Tribunal had not made a significant error or law or fact such that it likely would have reached a different conclusion. Most of the arguments made by the claimant were, in essence, an effort to re-argue the case.

P.M. v. Aviva Insurance Canada (17-005419)

The claimant sought entitlement to IRBs and medical benefits. She also sought entitlement to an accounting report. Adjudicator Watt denied the claim for IRBs, as the claimant had been paid IRBs up to the date she returned to work on a modified basis. He found the treatment plans not reasonable and necessary. Finally, he held that the cost of the accounting report was not payable because it was the claimant’s behaviour which resulted in difficulties calculating the IRB. She withheld information regarding disability benefits and her return to work. Furthermore, she was not a self-employed person.

B.H. v. Certas Home and Auto Insurance Company (17-006692)

The claimant sought entitlement to the cost of an accounting report and interest on IRBs. The insurer had paid IRBs at a lower rate and then increased the weekly IRB payment upon receipt of further information. Adjudicator Ferguson held that the insurer was not required to pay for the accounting report because the claimant was an employed individual and the IRB calculation was very simple. It was not reasonable to retain an accountant. In terms of interest, Adjudicator Ferguson ordered the insurer to pay interest on the increased IRBs even though the claimant was late in submitting documents.