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.
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.
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.
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.
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.
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.
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.
The claimant sought entitlement to ACBs, transportation expenses, and interest. Adjudicator Grant concluded that the claimant was entitled to attendant care benefits from February 22, 2016 to August 11, 2017 in diminishing amounts over that period. He found it unreasonable for the attendant care need to increase over time, and rejected the claimant’s Form 1s that increased over time. He also awarded the cost of transportation expenses in accordance with the Transportation Expense Guideline because the claimant suffered driving anxiety and was prohibited from driving while on pain medications. The awarded amounts were the amounts set out in the treatment plans, rather than the totals claimed by the claimant.
This preliminary issue addressed the limitation period in the context of a claim for IRBs and ACBs. The insurer denied the benefits more than two years prior to the LAT application. The claimant was found in June 2016 to lack capacity to instruct counsel and to require the assistance of a litigation guardian. Adjudicator Punyarthi held that the provisions suspending the Limitations Act did not apply to the Tribunal’s proceedings. However, Adjudicator Punyarthi concluded that section 7 of the LAT Act permitted the extension of the limitation period until the time his LAT application was filed. The adjudicator wrote that the reason for the delay was explained and that there was a bona fide intention to apply to the LAT within the two-year time period. There was also no prejudice to the insurer and there was potential merit to the claims.
The insurer sought reconsideration of the Tribunal’s decision that the limitation period did not bar the claims for attendant care benefits and medical benefits. Associate Chair Batty granted the reconsideration, reasoning that the denials were “clear and unequivocal.” The denials were based on the claimant having exhausted her non-catastrophic medical benefits limits.
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416.507.1850
© 2020 Thomas Gold Pettingill LLP