Category: Attendant Care Benefits

Applicant v. Certas Direct Insurance Company (16-003108)

The claimant sought entitlement to NEBs, ACBs, and a chronic pain assessment. The insurer argued that the claimant was barred from seeking the chronic pain assessment for failure to attend an IE assessment. Adjudicator Anwar found that the claimant was barred from pursuing the cost of the chronic pain assessment due to her nonattendance at a s. 44 assessment and because the LAT application was filed prior to the insurer providing a response to the proposed treatment. The adjudicator found that the claimant failed to prove that she sustained a complete inability to carry on a normal life as a result of the accident. In coming to this conclusion, Adjudicator Anwar noted that he found the records of the claimant’s family doctor more persuasive that the IEs and s. 25 medicolegal reports, the evidence of the claimant and her son, and the report of the family doctor prepared for the hearing.  The claimant was also not to be entitled to ACBs.

V.K. v. Allstate Insurance Company (16-004273)

The claimant sought entitlement to attendant care benefits and medical benefits for vision-related expenses and transportation expenses. Adjudicator Truong held that the claimant was not entitled to any of the benefits or expenses at issue. The claimant’s mother provided her with attendant care; however on the limited and unreliable evidence before the adjudicator, the claimant did not meet her onus of proving that the mother sustained economic loss. Therefore, the claim for attendant care benefits did not meet the definition of “incurred” under to the SABS. The claims for prescription eyewear and an eye exam were not reasonable and necessary, and the transportation expenses submitted were not authorized transportation expenses within the meaning of the FSCO Superintendent’s Guideline No. 04/16. The claimant was not entitled to laser eye treatment expenses because no treatment plan was submitted.

I.A. v. Allstate Insurance (17-006850)

The claimant sought entitlement to attendant care benefits as well as the benefits proposed in four treatment plans. Adjudicator Watt found that none of the benefits in dispute were reasonable and necessary as a result of the accident. Adjudicator Watt further noted that the claimant had not submitted a Form 1 or attendant care assessment in support of entitlement to attendant care benefits. The application was dismissed.

Applicant v. Aviva Insurance Canada (17-002957)

The claimant sought entitlement to treatment outside of the MIG, attendant care benefits, medical benefits, the costs of three examinations, and a special award. After a review of the medical evidence, Adjudicator Anwar preferred the reports of the claimant’s specialists and held that the claimant’s injuries warranted treatment outside of the MIG. Adjudicator Anwar further concluded that the claimant was entitled to the medical benefits sought, as they were reasonable and necessary, but that attendant care benefits were not warranted nor were any expenses incurred.  Moreover, Adjudicator Anwar held that the insurer did not unreasonably withhold payments from the claimant to necessitate a special award.

Applicant v. Aviva Insurance Canada (17-002213)

The claimant sought entitlement to two medical treatment plans and attendant care benefits. Adjudicator Brian Norris reviewed the chronology of Form 1s and denial letters and determined that the insurer had paid all payable attendant care and no further benefits were owed. On review of the medical evidence, Adjudicator Norris determined that one of the two treatment plans was reasonable and necessary. Accordingly, the one treatment plan was found payable, while the remaining claims were dismissed.

Applicant v. Certas Direct Insurance Company (17-001627)

The claimant sought entitlement to 15 treatment plans, non-earner and attendant care benefits. The insurer paid the non-earner and attendant care benefits for two years, before stopping both with IE reports. The insurer, in its written submissions, reversed its position on medical benefits, and ultimately approved the disputed treatment plans. However, Adjudicator Susan Sapin determined the withholding of the treatment amounted to a special award and awarded five percent of the disputed quantum, plus special award interest. On review of the medical documentation, as well as an analysis of the claimant’s pre- and post-MVA lifestyle, along with finding favour in the claimant’s subjective reports, it was held that the claimant suffered a complete inability to carry on a normal life and was therefore entitled to ongoing NEBs. As it pertained to the claim for attendant care benefits, Adjudicator Sapin determined that the claimant was entitled to a reduced Form 1 quantum, as the claimant failed to demonstrate proof of incurred expense necessary to claim the full amount. Although the insurer sought to quash the claimant’s ongoing attendant care benefits as premature, Adjudicator Sapin held that the claimant needed to dispute the denial of attendant care within the 104 week period, or else forfeit the claim beyond the 104 week due to a possible limitations deadline. On review, it was determined the claimant was entitled to an increased quantum beyond the 104 week cut-off; however, the claimant would first need to apply for, and be designated, catastrophically impaired. Interest on all payable benefits was also awarded.

Applicant v. Allstate Insurance Company of Canada (17-001523)

The claimant sought entitlement to a number of medical benefits, as well as attendant care benefits. The insurer denied the medical treatment asserting the claims were not reasonable and necessary. The insurer also denied the claimant’s attendant care claim and cited a lower attendant care rate commissioned by an IE assessor. Adjudicator Billeh Hamud reviewed the medical evidence and preferred the evidence of the insurer’s attendant care assessor, which was not rebutted. Accordingly, attendant care benefits were awarded at the rate of the insurer. Moreover, because only one of the attendant care providers was qualified, the award for attendant care was confined to the expenses of the one PSW. As it pertained to the medical benefits claimed, Adjudicator Hamud determined that fees attached to the submission of treatment plans were compliant with Superintendent Guideline No. 03/14 and therefore payable. The substantive treatment sought, with the exception of a progress report, was considered not reasonable and necessary on review of the medical evidence.

Applicant v. Unifund Assurance Company (16-003709)

The claimant sought entitlement to IRBs and ACBs. The insurer sought repayment of IRBs paid for a period that the claimant was working. Adjudicator Bickley denied entitlement to both IRBs and ACBs. She held that the claimant’s return to work shortly after the accident and frequency gym attendances suggested that the claimant did not suffer a substantial inability to engage in her employment, and that she did not require assistance with personal care. Adjudicator Bickley also held that the claimed attendant care expenses were not incurred because the claimant’s daughter had not submitted any evidence of an economic loss. In terms of the claim for repayment, Adjudicator Bickley allowed the repayment issue to be added as an issue at the beginning of the hearing. The claimant’s representative acknowledged an overpayment for the period which the claimant had returned to work after the accident. The claimant was ordered to repay $2,984.59 in IRBs plus interest.

Applicant v. Wawanesa Mutual Insurance Company (17-002337)

The claimant sought entitlement to a number of medical benefits, as well as income replacement and attendant care benefits. The insurer denied entitlement and also asserted a MIG position. Adjudicator Christopher Ferguson reviewed the medical evidence and determined that no compelling evidence was tendered by the claimant to support entitlement to any of the benefits claimed. The MIG was said to govern the claimant’s impairments and the matter dismissed.

J.A. v. Aviva Insurance (17-001494)

The claimant sought entitlement to IRBs and attendant care benefits. Adjudicator Hamud concluded that the claimant was entitled to IRBs, as he suffered a substantial inability to perform the essential tasks of his employment. An essential task of the claimant’s employment as a construction worker required him to lift over 50 pounds, but the claimant was only able to lift 10 pounds. The claimant was also entitled to attendant care benefits, but in the amount indicated on the Form 1 rather than on the invoices submitted. The invoices were based on rates which exceeded the maximum rates noted in the Guideline, and were thus inappropriate.