This is a reconsideration decision of Adjudicator Shapiro. The insurer requested reconsideration of Adjudicator Shapiro’s initial decision wherein he found the claimant entitled to retroactive ACBs with interest. The facts of this case were unusual. The claimant was a pedestrian struck by a vehicle. She did not have her own insurance. The driver of the insured vehicle did not advise his insurer of the accident. The insurer first learned of the accident when the claimant initiated a tort claim two years after the accident. The claimant was catastrophically impaired as a result of the accident. The insurer took an off-coverage position in the tort claim. Therefore, for a significant period of time, the claimant did not seek attendant care benefits nor was she aware of her ability to claim accident benefits. Adjudicator Shapiro found that there was a reasonable excuse for the claimant’s delay in applying for benefits given the insurer’s coverage position. Adjudicator Shapiro held that the claimant actively investigated coverage issues and then filed her accident benefits claim as soon as the only possible insurer reversed its coverage position and acknowledged it insured the vehicle that hit her. Therefore, Adjudicator Shapiro dismissed the reconsideration application concluding that the claimant was entitled to retroactive ACBs and interest was payable. Adjudicator Shapiro also reminded the insurer that interest was compensatory and not punitive.
The claimant was involved in a serious accident. He was skateboarding and was hit by a vehicle and suffered nasal, left elbow, pelvic, and sacral fractures, and psychological injuries. The claimant applied to the LAT disputing entitlement to NEBs, ACBs, and the full cost of partially approved medical benefits. Adjudicator Farlam dismissed the claimant’s dispute in its entirety. With respect to NEBs, Adjudicator Farlam noted that the claimant travelled post-accident, resumed full-time education, and resumed his participation in sports including judo and wrestling. Adjudicator Farlam held that while the claimant required help with some self-care tasks and had ongoing physical and psychological limitations, he did not meet the NEBs disability test. With respect to ACBs, Adjudicator Farlam noted that the claimant reported that his family cared from him. However, the claimant did not submit proof of incurred expenses nor economic loss. Adjudicator Farlam noted that the claimant did not submit OCF-6s, receipts, invoices, or any other proof of incurred benefits. Adjudicator Farlam dismissed the claimant’s submissions that ACBs be “deemed incurred” as he did not believe that ACBs were reasonable and necessary in light of the 8 month delay in submitting a Form 1. With respect to the disputed medical benefits, Adjudicator Farlam opined that the claimant had not proven that the balance of the treatment plans were reasonable or necessary.
The claimant applied to the LAT seeking entitlement to medical benefits, IRBs, and ACBs. Prior to the accident, the claimant worked full-time at a restaurant. After the accident, she was off work for several months before starting a volunteer position at a residence for assisted living that transitioned into a part-time job. She continued to work in the new part-time position into the post-104 week period. Her previous employment was no longer available to her. Adjudicator Victor found that the post-104 part-time position was substantially different from the claimant’s pre-accident position in nature, status, and remuneration. Adjudicator Victor stated: “I have difficulty finding that [the claimant] is suited to the part-time job she is undertaking, let alone the high paced, full-time job she previously held.” Adjudicator Victor found that the claimant was entitled to IRBs to date (i.e., into the post-104 period). She was not entitled to ACBs or the in-dispute occupational therapy services.
The claimant sought attendant care and medical benefits for chiropractic treatment and a psychological assessment plus interest. The insurer had paid various medical and rehab benefits as well as ACBs. It denied the ACBs after the 104 week mark as the claimant was not deemed catastrophically impaired. The insurer also denied the chiropractic treatment and psychological assessment based on IEs that determined they were not reasonable or necessary. The claimant argued that the insurer was required to resume payment of ACBs because she had made a catastrophic impairment application. In regard to ongoing ACBs, Adjudicator Boyce found while an OCF-19 had been submitted and CAT assessments had been scheduled, there was no dispute between the parties that the claimant had not yet been found catastrophically impaired and as submitted by the insurer, that issue was not before the Tribunal at this time. Adjudicator Boyce also found the insurer’s denial notice of ACBs clearly indicated the insurer’s position and since there was no dispute the claimant was not yet deemed catastrophically impaired, the exception under section 20(3) of the SABS was not triggered. It, therefore, followed that the claimant was not entitled to ongoing ACBs for the period in dispute that fell outside the two year mark by section 20(2) of the SABS. With respect to the disputed chiropractic treatment, Adjudicator Boyce agreed with the IE opinions based on the medical evidence. Adjudicator Boyce found the claimant did not satisfy her burden to show why another psychological assessment was reasonable and necessary or why the assessment was not a duplication of assessments already conducted in the same year and to date.
The claimant sought entitlement to ACBs, the balance of a partially approved social work assessment (seeking a higher hourly rate), and the cost of catastrophic impairment assessments. The insurer had denied ACBs on the basis that the claimant had not received the claims services and that insufficient information was provided regarding the services allegedly provided. The insurer denied the catastrophic impairment assessments because the claimant proposed them only one year after the accident. Adjudicator Grieves concluded that the claimant was entitled to ACBs of $3,000 per month, subject to the claimant proving that the services had been incurred. She accepted that the claimant required personal care services due to post-accident ankle surgery and knee surgery. She rejected the insurer’s position that surveillance suggested that the claimant was not receiving the services claimed, as the claimant and her family members were able to explain why the claimant and personal care workers were not seen at her house on certain days. Adjudicator Grieves also rejected the insurer’s argument that the payable ACB was calculated based on the specific service provided multiplied by the hourly rate for that service set out in the Professional Services Guideline. She held that the purpose of the hourly rates was to calculate the maximum ACB payable, and that the amount payable by the insurer was based on the rate charged by the service provider (provided that it was reasonable and not excessive) for whichever services were provided, subject to the statutory maximum and/or the Form 1 total. The denied portion of the social work assessment was also awarded. Adjudicator Grieves held that $135 per hour was a reasonable rate for a social worker, rather than the $100 approved by the insurer. Finally, the catastrophic impairment assessments were denied as being not reasonable. Although the claimant was approaching her combined medical and ACBs limit, she could not apply for a catastrophic impairment until the two year mark unless her condition was unlikely to improve. The medical evidence suggested that the claimant continued to show medical improvement. Additionally, the assessors proposing the catastrophic assessments did not explain why each of the proposed assessments was reasonable or necessary.
The claimant sought entitlement to ACBs and various medical benefits for occupational therapy services, assistive devices, and chiropractic services. Adjudicator Paluch rejected the claim for ACBs and most of the medical benefits, but allowed the claims for assistive devices and one of the occupational therapy services. Regarding the ACBs claim, the claimant failed to prove that any services were incurred. The claimant’s affidavit submitted in support of the claim was vague and unhelpful as it did not provide specific details of services, times, duration, level of care, and no exhibits were provided from care providers detailing this information either. Adjudicator Paluch also questioned how the claimant could require 10 hours of supervisory care when the medical evidence was clear that the claimant could respond to an emergency independently. The adjudicator declined to deem the expenses incurred under section 3(8) as the claimant failed to advance any arguments, analysis, or evidence how the insurer unreasonably withheld or delayed payment, other than stating in a general way that the benefits were wrongfully denied. Adjudicator Paluch awarded the claim for a new mattress because there was evidence that the claimant had poor sleep as a result of her injuries and the new mattress did provide improved sleep. A portion of claimed occupational therapy sessions were also awarded because the insurer’s denial did not comply with section 38(8) (no medical reason was provided as to why the proposed treatment was “quite excessive”). Adjudicator Paluch was critical of the claimant’s failure to provide documentation as ordered in the Case Conference Order. Claimant’s counsel insisted on payment for records before production of same, despite the Order not requiring the insurer to pay for the records. Once the records were in the claimant’s possession, she should have provided them. Her failure to do so prevented the Tribunal from having the ability to review the complete clinical notes and records.
The claimant applied to the LAT seeking entitlement to ACBs in the amount of $2,479 per month and various medical benefits for physical treatment, psychological treatment, occupational therapy services, an orthopaedic mattress, the cost of clothing and personal expenses, and transportation expenses. The claimant was a pedestrian injured in a motor vehicle accident in a parking lot. The insurer’s Form 1 initially recommended ACBs in the amount of $297.76 per month. A subsequent insurer’s Form 1 recommended $0.00 for ACBs. The assessor opined that the provision of unnecessary support for self care tasks would promote unnecessary dependency on external supports which is not required in the course of rehabilitation. Adjudicator Gosio found that there was no objective evidence of ongoing physical impairments in the left upper extremities, and the insurer’s Form 1s were reasonable. The claimant was entitled to chiropractic and physiotherapy treatment, and ACBs in the amount of $297.76 per month for 10 months. Adjudicator Gosio found that the claimant failed to establish that 90-minute sessions of psychotherapy, as opposed to the approved 60-minute sessions, were reasonable and necessary. Pursuant to section 55 of the SABS, the claimant was barred from disputing entitlement to the orthopaedic mattress as she had failed to attend an IE assessment.
The claimant sought reconsideration of the LAT’s denial of retroactive ACBs and the decision regarding the amount of ACBs that were found payable. The accident occurred prior to September 1, 2010. Interpretation of the transitional provisions in the 2010 SABS and 1996 SABS was an issue in dispute, including interpretation of provisions relating to interest and the applicability of the requirement for benefits to be incurred before they are payable. The request for reconsideration was denied. Adjudicator Johal found that there was no error in law in the determination that there is no strict bar against filing an application for retroactive attendant care benefits, but the burden is on the claimant to “explain the urgency, impossibility or impracticability of compliance with s. 42(5) of the Schedule.” Adjudicator Johal found that there was no error in law in determining that the “incurred” definition applied to this claim, even though the accident occurred before September 1, 2010. Adjudicator Johal held that “rights are based on what is set out in the Insurance Act and regulations at the time of a claim rather than the date of the accident.” Adjudicator Johal found that there was no error in law in the finding that the applicable interest rate was 1%, in accordance with the 2010 SABS.
The insurer and claimant sought reconsideration of Adjudicator Johal’s decision that: (1) the claimant was only entitled to 120 minutes of ACBs per day and 60 minutes of ACBs per week, and (2) the claimant was not entitled to retroactive ACBs. Adjudicator Johal dismissed the reconsideration and noted that she properly applied the law to her original decision – retroactive benefits were not payable because the claimant did not establish that there was a valid reason for his delay in filing a retroactive Form 1 (urgency, impossibility or impracticability in accordance with section 42(5) of the SABS.) With respect to the amount of ACBs, Adjudicator Johal noted that she weighed the evidence and the testimony of the witnesses and that her original decision provided sufficient reasons and explanations for her conclusion.
The claimant disputed entitlement to numerous treatments plans and ACBs in the amount of $6,142.59 per month from November 29, 2018 and ongoing. The claimant was diagnosed with Parkinson’s Disease and Dementia pre-accident, as well as headaches and ear pain. The insurer argued that the benefits claimed were for the claimant’s pre-existing conditions, and that he had only sustained minor soft tissues injuries as a direct result of the subject accident, and were therefore not reasonable or necessary. Adjudicator Watt noted that a review of the pre-accident medical records showed that the claimant was suffering from all of the alleged accident-related complaints long before the subject accident, that the claimant’s own expert reports were often contradictory and lacked compelling arguments as to why the proposed treatments were reasonable and necessary as a result of the accident. further, some of the disputed benefits were available to the claimant through OHIP. The claimant’s own statement’s that he was independent with personal care, along with a lack of evidence that any proposed ACBs would be as a result of the accident, and not his pre-existing conditions, resulted in the claim for attendant care being dismissed along with the rest of the Application.