Category: Attendant Care Benefits

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.

N.N. v. Certas Direct Insurance Company (17-001002)

The claimant sought entitlement to attendant care benefits and two treatment plans. Adjudicator Billeh Hamud reviewed the medical evidence and determined that the claimant was independent with his day to day activities and was functional to the point that attendant care benefits were not reasonable and necessary. In the alternative, Adjudicator Hamud also determined that the claimant did not satisfy that his wife, and reported service provider, suffered an economic loss. Moreover, the claimant failed to provide sufficient evidence to justify payment of the two treatment plans. All of the claimant’s claims were dismissed.

R.P. v. Wawanesa Mutual Insurance Company (16-002947)

The claimant sought entitlement to attendant care benefits and a number of treatment plans. Adjudicator Eleanor White reviewed the claimant’s submissions for attendant care and noted that no evidence was provided showing that attendant care had been incurred. Accordingly, Adjudicator White determined that regardless of a determination regarding the reasonableness and necessity of the claimant’s attendant care claim, it was “without effect as he cannot prove the care was incurred for the period in question.” The treatment plans claimed were also denied as the medical evidence tendered did not support entitlement.

Applicant v. Economical Mutual Insurance Company (17-000846)

The claimant sought entitlement to medical, attendance care, and income replacement benefits. The insurer asserted a MIG position. Adjudicator Nicole Treksler, on review of the evidence, determined that the claimant’s injuries were governed by the MIG and that the claimant failed to establish a substantial inability to perform the essential tasks of employment in the face of evidence that the claimant returned to work. Since the MIG was said to govern, the claimant’s attendant care claim was dismissed summarily pursuant to section 14.

E.D. v. Aviva Insurance Canada (17-002048)

The claimant was an elderly pedestrian knockdown and claimed entitlement to non-earner benefits, attendant care, and a number of medical treatment plans. Adjudicator Christopher Ferguson was critical of the evidence led by the claimant and remarked “The applicant made no submissions in this matter: she advanced no discussion or argument respecting the evidence that she provided, nor did she reply to the respondent’s submissions. Her evidence consisted of her personal affidavit, a chronic pain assessment, and treatment and assessment plans for medical benefits.” It was held that the claimant failed to provide sufficient evidence to justify entitlement to any of the benefits claimed.

Y.D. v. Aviva Insurance Canada (16-001810)

The Tribunal ruled against the claimant’s application for further attendant care benefits on the basis that no expenses had been incurred, and that the Tribunal did not have equitable jurisdiction to order the ongoing payment of attendant care benefits based solely upon earlier payments of the benefit. Executive Chair Lamoureux upheld the earlier decision and noted that even if the Tribunal did have equitable jurisdiction to decide the matter, the pre-requisites for estoppel to apply were not present in this case.

N.R. v. Pembridge Insurance Company (16-003776)

The claimant sought entitlement to NEBs, ACBs, and medical benefits. Adjudicator Hans rejected all of the claims. In terms of NEBs, the adjudicator wrote that the claimant failed to provide evidence of his pre-accident activities and that without such information, entitlement to NEBs could not be proven. In terms of ACBs, the adjudicator wrote that the claimant’s expense forms did not prove that the attendant care services were incurred. In particular, the adjudicator was critical of the lack of specificity or details as to the days or services provided, and the fact that the expense forms were completed months after the services were allegedly provided. Finally, the medical benefits for dental work were denied because the claimant had not proven that he sustained a dental injury in the accident.

J.C.C. v. Echelon General Insurance Company (17-000848)

The claimant was found entitled to attendant care benefits from a medical standpoint, but was denied payment on the basis that his service provider was not a professional. The service provider had her certification as a PSW, but was not working in the field at the time of the claimant’s accident. Adjudicator Go held that the service provider qualified as a professional, noting that there was no requirement that a professional be working in the field at the time of the accident, or that the professional be working exclusively in the field. She also noted that the service provider continued to work as a PSW with other patients after treating the claimant, which supported the conclusion that the service provider was acting in the course of her employment or occupation.