Category: Attendant Care Benefits

C.M. v. Wawanesa Mutual Insurance Company (18-008199)

The claimant sought entitlement to attendant care benefits and a number of treatment plans for occupational therapy and physiotherapy services. Adjudicator Boyce concluded that the claimant was not entitled to attendant care as she had not demonstrated that the services were “incurred” pursuant to section 3(7)(e) of the SABS. The claimant did not provide evidence that the care was provided by a professional service provider, nor that her mother sustained an economic loss. Adjudicator Boyce also concluded that the disputed treatment plans were not reasonable and necessary, noting that aside from the OCF-18s listing her impairments and the retroactive expert reports, the claimant had provided no corroborating records from medical professionals to support the treatment sought nor the injuries claimed. Given the claimant’s failure to produce medical evidence concurrent with the accident, Adjudicator Boyce found no reason to interfere with the insurer’s determinations.

D.K. v. The Guarantee Company of North America (18-007722)

The claimant sought entitlement to attendant care benefits in the amount of $3,022.33 per month, physical treatment proposed in three treatment plans, and the cost of various expenses related to food, prescriptions, assistive devices, and other goods. Vice Chair Lester found that the claimant was entitled to the physical treatment plans and the cost of non-prescription Tylenol. The clamant was not entitled to attendant care benefits based on a finding that the benefits were not reasonable and necessary, and there was no evidence the non-professional service providers sustained an economic loss. The decision refers to a s. 25 Form 1 but it does not indicate that a s. 44 Form 1 was completed. Vice Chair Lester found that the recommendation for $3,022.33 in attendant care services did not coincide with the test results that demonstrated the claimant had the functional ability to complete tasks. Expenses related to fibromyalgia were not payable as this was a pre-existing condition, and the claimant had not submitted medical evidence to show the condition was worsened by the accident.

G.W. v. Coachman Insurance Company (16-003306)

The insurer sought reconsideration of the adjudicator’s decision regarding entitlement to ACBs, interest, and a special award. The claimant sought reconsideration of the adjudicator’s finding of an end date for IRBs and ACBs, and the formula used to calculate the quantum of the special award. Vice-Chair Marzinotto partially granted both the insurer’s and the claimant’s requests. She held that the amount payable for ACBs based on a finding of unreasonably withholding benefits under s. 3(8) of the SABS was limited to the economic loss incurred by the claimant’s wife, which was less than the Form 1 amount. Vice-Chair Marzinotto found that the arbitrator did not err in finding an end date for IRBs and ACBs at the 104-week mark as the hearing took place in the pre-104 week period and there was no evidence submitted on post-104-week entitlement. Vice-Chair Marzinotto held that the formula for calculating the maximum amount available for a Special Award is: 50 percent x (benefits that were unreasonably withheld or delayed + SABS interest on these benefits calculated under the Schedule + compound interest calculated according to s.10 O. Reg.664).

M.R. v. Allstate Insurance Company (17-008969)

The claimant sought reconsideration of the Tribunal’s denial of ACBs and order barring the claim for medical benefits based on IE Non-Attendance; the Tribunal had awarded IRBs. Adjudicator Mazerolle held that the Tribunal denials did not meet the criteria in Rule 18 for reconsideration. However, Adjudicator Mazerolle found that the award of IRBs beyond the 104-week mark was an error and that the claimant had not led evidence to support IRBs on the “complete inability” test.

I.G. v. Security National Insurance Company (19-000292)

The claimant sought entitlement to NEBs, ACBs, and various medical benefits. The insurer argued that the claimant failed to notify it of the circumstances giving rise to the claims, and failed to submit an application in the time prescribed. Adjudicator Boyce permitted the claim to proceed despite the late application. He accepted that the claimant believed her injuries would heal, but instead became progressively worse. He also noted that the insurer had been adjusting the claim for a number of year prior to the LAT application, and to argue that it was prejudiced appeared disingenuous. Adjudicator Boyce did, however, bar the claim for ACBs based on the claimant’s failure to submit a Form 1 during the first 104 weeks of the claim.

G.R. v. Travelers Canada (18-007870)

The claimant sought entitlement to attendant care benefits. Adjudicator Watt dismissed the claim. He held that the claimant had failed to submit a Form 1, that she had not incurred and attendant care expenses, and that she did not require attendant care services from a medical perspective.

G.R. v. Travelers Canada (18-007870)

The claimant sought entitlement to attendant care benefits. Adjudicator Watt dismissed the claim. He held that the claimant had failed to submit a Form 1, that she had not incurred and attendant care expenses, and that she did not require attendant care services from a medical perspective.

Applicant v. Certas Direct Insurance Company (17-008853)

The claimant sought removal from the MIG, and entitlement to ACBs and various medical benefits. The insurer argued that the claimant was barred from proceeding to a hearing due to his failure to attend an IE addressing attendant care benefits. Vice Chair Helt concluded that the claimant was not barred from proceeding with his claim for ACBs because the IE notices contained the wrong address for the IE location. In terms of the claimed benefits, Vice Chair Helt found that the claimant suffered from psychological injuries falling outside of the MIG. She awarded the claimed psychological assessment and therapy, but held that the proposed physical therapy was not reasonable and necessary. Finally, in terms of the ACBs, Vice Chair Helt concluded that the claimant did not require personal care and that he had not incurred any attendant care expenses.

Applicant v. Wawanesa Mutual Insurance Company (18-003314)

The claimant sought reconsideration of the Tribunal’s decision on narrow issue of the quantum of attendant care awarded. The Tribunal awarded the claimant $3,047.27 in monthly attendant care, despite the claimant’s Form 1 listing $6,000 in monthly attendant care and the respondent’s Form 1 listing $3,243.95 in monthly attendant care. The claimant argued that the Tribunal breached the rules of natural justice or procedural fairness in providing relief that was neither sought, nor presented at the hearing. Adjudicator Hines dismissed the claimant’s request for reconsideration, concluding that the Tribunal’s decision provided a careful and detailed analysis for its findings, and compared both parties Form 1’s to establish what was reasonable and necessary based on the facts and the evidence. That the quantum the Tribunal found payable ended up being less than the respondent’s Form 1 was not proper grounds for reconsideration.

S.M. v. Federated Insurance Company of Canada (18-004533)

The claimant sought entitlement to $6,000 per month in ACBs from April 2012 onwards, and the cost of two assessments. Adjudicator Lake considered the time period prior to and after the February 1, 2014 changes to the incurred expense definition for non-professional service providers. She held that the claimant failed to prove that her niece suffered an economic loss. No ACBs were payable beyond the 104 week mark because the claimant had not proven a catastrophic impairment. Adjudicator Lake also concluded that the two proposed assessments were not reasonable and necessary. The first was for a Form 1 after the 104 week mark, prior to the claimant submitting an OCF-19. The second was for a clinic file review as part of a catastrophic impairment assessment, which the adjudicator found to be duplicative the services conducted as part of each approved constituent element of the catastrophic impairment assessments.