Category: Attendant Care Benefits

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.

I.S. v. Aviva Insurance Canada (17-001098)

The claimant sought entitlement to attendant care benefits. The insurer requested further information from the service provided pursuant to section 46.2. The insurer asserted that the claimant was barred from proceeding to a hearing given the failure to provide the material outlined under section 46.2. Adjudicator Avvy Go ordered the claimant to provide the requested information within 60 days of the decision.

Y.X.Y. v. The Personal Insurance Company (16-000438)

The primary issue in dispute was whether the claimant sustained a predominantly minor injury as a result of the accident. Adjudicator Neilsen explained that ongoing pain alone was insufficient to remove the claimant from the “minor injury” definition. Rather, she had to prove chronic pain syndrome. The ongoing pain had to be accompanied by some functional impairment. She wrote that a diagnosis of chronic pain without any discussion of the level of pain, its effect on the person’s function, or whether the pain is bearable without treatment will not meet the claimant’s burden to show that the chronic pain is more than mere sequelae of the “minor injury” sustained in the accident. The medical evidence submitted by the claimant was insufficient to prove a non-minor injury, and Adjudicator Neilsen held that the claimant’s pain was mere sequelae of the minor injury. Adjudicator Neilsen also rejected the allegations of psychological injury based on the inconsistencies in the medical report and the claimant’s self-reporting. The only benefit awarded was $215 for a psychological assessment, which is provided for in the Minor Injury Guideline.

A.H. v. Belair Direct Insurance Company (16-001063)

The claimant sought entitlement to a number of treatment plans and attendant care benefits. Adjudicator Lori Marzinotto noted that some of the treatment plans sought were not submitted as evidence, nor specifically addressed in the claimant’s submissions; those plans were denied. Other treatment plans sought mileage beyond the Professional Service Guidelines. Adjudicator Marzinotto highlighted no evidence was tendered to support exceeding the PSG; those previously partially approved plans were accordingly maintained. With respect to attendant care benefits, Adjudicator Marzinotto noted no evidence was provided to satisfy economic loss for much of the period claimed; therefore attendant care benefits were not payable for that time. However, the claimant was entitled to attendant care benefits from February 2016 onwards, as the evidence supported it was reasonable and necessary, and incurred, but that the rate charged by the service provider was in excess of the FSCO Guidelines.