Category: Attendant Care Benefits

J.B. v Motor Vehicle Accident Fund (19-003638)

The claimant disputed her entitlement to attendant care benefits and various medical benefits. Adjudicator Paluch found that the claimant was not entitlement to attendant care for the period in dispute because she did not submit a Form 1 in accordance with the SABS nor did she demonstrate that her expenses were incurred. However, Adjudicator Paluch determined that the remaining amounts for two partially approved physiotherapy treatment plans as the respondent failed to provide medical reasons and comply with section 38(8) of the SABS. The insurer simply advised that the treatment “appeared excessive”, without providing any details or particulars of what part of the services was excessive and why.

J.P. v. Aviva General Insurance (19-004854)

The claimant sought attendant care benefits for two separate periods post-accident, a special award and interest on overdue payments. The insurer argued that the claimant failed to provide proof of expenses incurred for the periods claimed and his wife, who was a retired nurse at the time that she provided care to the claimant, failed to provide evidence of economic loss. Adjudicator Boyce held that the claimant was not entitled to attendant care for either period in dispute as the claimant had not shown that the service provider met the definition under the SABS or that the provider sustained an economic loss. Adjudicator Boyce also denied the claim for an award as he found no evidence of bad faith.

R.T. v Coseco Insurance Company (18-004783)

The claimant filed a motion to withdraw some of the issues listed for an upcoming LAT hearing on a without-prejudice basis. The insurer submitted that the issues not identified for withdrawal (namely attendant care benefits) were still in dispute, while the claimant submitted that the issue of attendant care benefits was previously determined in a preliminary issue decision that was upheld on reconsideration. Adjudicator Punyarthi concluded that the claimant was permitted to withdraw issues without prejudice, noting that there was no basis for imposing a generalized “with prejudice” withdrawal of issues in this case. If an issue is brought back, the claimant would have a right to have that issue considered and decided on the merits. Adjudicator Punyarthi also determined that attendant care benefits were not an issue in dispute because the issue had already been decided and upheld on reconsideration, and the Tribunal could not re-hear the issue at this stage.

Z.S. v Intact Insurance Company (19-000175)

The claimant was deemed catastrophically impaired, and sought entitlement to attendant care benefits which were denied by the insurer on the basis that the claimant’s alleged service provider, his wife, did not meet the requirements for a provider under the SABS and did not incur an economic loss. The claimant’s wife was laid off by her employer as a result of the company’s bankruptcy prior to the accident. The claimant argued that but for the accident, his wife would have returned to work but could not due to her having to provide attendant care to the claimant. Adjudicator Boyce found that the claimant was not entitled to attendant care benefits for the period in dispute. The 39 invoices provided in support of the claim were identical and void of details of the expenses allegedly incurred in providing care, with no mention of how many hours of attendant care the claimant’s wife provided on a daily, weekly, or monthly basis. Adjudicator Boyce stated that without this information, it was difficult to analyze what the claimant’s wife did, for how long she did it, and what economic loss she incurred as a result.

J.N. v Co-Operators General Insurance Company (18-012227)

The claimant submitted a LAT Application in August 2017 disputing attendant care benefits, among other benefits. The parties resolved the issues in dispute and entered into a partial settlement agreement. In 2018, the claimant filed a second LAT Application disputing entitlement to attendant care benefits. The insurer brought this preliminary issue hearing, arguing that the claimant was barred from pursuing his claim for attendant care benefits in this 2018 Application as a result of the release and partial settlement disclosure notice arising from the 2017 Application. The claimant argued that he did not settle his entitlement to attendant care benefits beyond two years from the date of the accident, and thus, the settlement following the 2017 Application did not preclude him from proceeding with the 2018 Application. Vice Chair Marzinotto did not accept the claimant’s argument, noting that the 2017 Application indicated that the claimant was claiming attendant care benefits on an “ongoing” basis and that the settlement documents clearly referred to “any and all claims for attendant care benefits from July 5, 2016 to date and ongoing”. As such, Vice Chair Marzinotto dismissed the application.

M.Y. v Wawanesa Mutual Insurance Company (19-003973)

The insurer brought this preliminary issue hearing arguing that the claimant was barred from disputing her entitlement to medical/rehabilitation benefits beyond the MIG and attendant care benefits on the grounds that she failed to attend two section 44 IEs. The claimant took the position that she was not required to attend the IEs because the first IE was for the purposes of determining the applicability of the MIG, which is not permitted, and the second IE was scheduled as a substitute for the submitted Form 1. With respect to the first IE, Vice Chair Farlam held that scheduling an IE to address doubt about whether the claimant’s injuries fall outside the MIG does not violate the SABS. With respect to the second IE, Vice Chair Farlam found that the insurer was merely exercising its right under the SABS to assess the claimant as part of determining whether the claimant was entitled to attendant care benefits. As such, Vice Chair Farlam concluded that the claimant was barred from proceeding with her application, noting that counsel’s position that the claimant was not obligated to attend either IE was incorrect and that an erroneous legal position was not a reasonable explanation for non-attendance at IEs.

Y.K. v. Aviva General Insurance Company (18-003926)

The claimant suffered a brain injury and was deemed catastrophically impaired as a result of a 2011 accident. He received personal care from his brother, who left multiple part-time jobs to care for him. The Form 1 supported $6,000 per month in ACBs, but the claimant’s brother suffered an economic loss of $2,100 per month based on his income in the year prior to the accident; however, following the 2014 amendments to the SABS, the insurer paid $1,528.91 per month based on the average income earned by the brother in the three years prior to the accident. In 2018, the claimant hired a professional service provided in order to utilize the full $6,000 per month Form 1. The insurer received an invoice, but never paid it. The claimant sought entitlement to the full Form 1 amount, arguing that it was “deemed incurred” or that the 2014 amendments to the SABS did not apply. He also sought entitlement to HK expenses and a special award. Adjudicator Lester concluded that the 2014 amendments to the SABS applied and that the claimant was only entitled to the economic loss suffered by his brother. However, she accepted that lost opportunities and “fringe benefits” (IE, CPP, extended health care benefits) could form the basis of an economic loss, but required a sufficient evidentiary basis. The claimant did not have sufficient evidence to prove the projected scenarios he put before the Tribunal, so his economic loss was limited to his foregone wages. Adjudicator Lester also found services by the professional to be deemed incurred for a period of 10 months (the time between submission of the invoice up to the payment of the invoice). Adjudicator Lester awarded HK expenses, finding that the claimant was responsible for cleaning tasks prior to the accident and that he could no longer perform such tasks. Further, services were incurred because the claimant’s brother had given up his work. Finally, the adjudicator held that the insurer improperly withheld ACBs by paying only $1,528.91 per month. A special award of 50 percent based on the shortfall of $571.09 per month was granted for services provided by his brother, all amounts provided by the professional service provider which were deemed incurred, and all awarded HK expenses.

J.W. v. Security National Insurance Company (18-008988)

The claimant sought entitlement to ACBs. Adjudicator Norris found that the claimant was entitled to attendant care benefits, even though the claimant had returned to an intellectually challenging vocation (litigation lawyer) which required long work days. Since the evidence indicated that the claimant suffered ongoing fatigue as a result of a traumatic brain injury and other serious physical injuries, the claimant would require assistance with fatigue, memory loss, and irritability. However, Adjudicator Norris found that the claimant was not entitled to payment for any expenses to-date because expenses did not meet the definition of an “incurred expense”. Adjudicator Norris explained that neither service provider (his wife and his “house helper”) was doing so within the course of their employment, occupation, or profession.

T.N. v. TD Insurance Company (19-005638)

The claimant sought entitlement to ACBs in excess of the total approved by the insurer. The insurer raised a preliminary issue that the Tribunal did not have jurisdiction to hear the matter because the claimant had not actually incurrent any attendant care expenses. Adjudicator Lester found that there was a dispute between the parties since the respondent only partially approved the request amount in Form 1, regardless of whether expenses had been incurred. Adjudicator Lester ultimately concluded that the claimant was entitled to ACBs in excess of the amount approved by the insurer, totalling 8 hours per day. With regard to cueing, Adjudicator Lester held that the time should be considered under the specific Form 1 activity, rather than as a supervisory function.

J.M. v. Wawanesa Mutual Insurance Company (18-006148)

The insurer sought reconsideration of the Tribunal’s award of $6,000 per month in ACBs. The claimant was involved in an accident in 2015 and deemed catastrophically impaired three years later. The claimant’s Form 1 recommended $8,467.65 worth of ACBs per month; the insurer’s Form 1 supported $1,583.45 in ACBs per month. The insurer argued that the Tribunal erred in its decision, and that the evidence showed that the claimant was largely independent at the time the Form 1 was submitted, that the Tribunal did not properly apply the “but for” test, that the Tribunal incorrectly admitted late evidence, and failed to apply the proper law in relation to ACBs. Adjudicator Lester reiterated the exhaustive list of reasons why such a high quantum of ACBs were warranted and rejected the reconsideration request. She further commented that, although the claimant’s Form 1 was not included in the evidence brief prior to the hearing, the insurer had a chance to object to it being admitted into evidence at the hearing and did not, it was also a key piece of evidence that caused no prejudice to the insurer as it was aware of it prior to the hearing. Although the claimant and her treating therapists did not specifically elaborate on a precise breakdown of each line of the Form 1 in dispute, Adjudicator Lester was satisfied that it was reasonable on the grounds of the claimant’s psychological injuries requiring a higher level of assistance, such as cueing.