Category: Attendant Care Benefits

J.D. v. The Dominion of Canada General Insurance Company (16-002745)

The claimant sought entitlement to attendant care, non-earner, and medical benefits. The insurer denied the benefits and had placed the claimant within the MIG. On review of the medical documentation, Adjudicator Nicole Treksler found the claimant was not entitled to any of the benefits claimed. It was noted that non-earner benefits are not automatic upon the submission of a disability certificate; indeed, an OCF-3 is a “a starting point for the [insurer] to investigate whether the applicant is entitled to the claimed benefit.” Adjudicator Treksler also concluded the applicant had not met the onus of demonstrating that his injuries were not minor.

Y.Y. v. Unica Insurance Inc. (16-000552)

The claimant sought entitlement to attendant care benefits. Adjudicator Theoharis did not find the account of the service provider credible as the testimony was vague and did not sound convincing when cross-examined. Additionally, the claimant provided contrary evidence to a statutory declaration. The evidentiary record also contained conflicting accounts as to who provided services, if at all. As a result. Adjudicator Theoharis found that the personal support worker had not provided services and the claim for attendant care benefits was dismissed, under section 3(7)(e)(i).

Applicant v. The Guarantee Company of North America (16-001348)

The claimant sought entitlement to attendant care benefits as well as expenses for an office desk, chair, and for a mattress. Having re-calculated the claimant’s needs when comparing competing Form 1s, Adjudicator Treksler found attendant care payable at a reduced rate, but not payable for a period claimed when the claimant had not received any attendant care. The requested furniture items were said to be needed due of the accident and therefore causation was not a reason for denial. Adjudicator Treksler found the furniture items payable.

T.K. v. Unica Insurance Inc. (16-000372)

The claimant was involved in two accident and sought two years of attendant care benefits. She submitted a Form 1 fifteen months after the second accident. She had also submitted a Form 1 for her first accident in which she claimed similar needs. Adjudicator Shapiro rejected the entire claim for attendant care benefits. First, he did not accept that the claimant’s AC needs arose as a result of the second accident, noting that she had just completed a Form 1 for her 2013 accident claiming similar needs from that accident. Second, Adjudicator Shapiro held that retroactive ACBs were not always warranted following the submission of a late Form 1. He followed FSCO case law which permitted a late Form 1 to support ACBs prior to submission (Kelly and Guarantee). However, he distinguished that case (where the claimant had serious catastrophic injuries and could not complete a Form 1) to this case (where the claimant was slow in providing a Form 1). Third, Adjudicator Shapiro denied the ACBs claimed after the date of the Form 1 based on the claimant’s admissions to an IE doctor that she was independent in self-care. He also found that some of the claimed services were in fact for childcare assistance and housekeeping, rather than personal care for the claimant.

M.P. v. Certas Home and Auto Insurance Company (16-000525)

As a result of the accident, the claimant suffered severe knee injuries. The claimant’s wife was a personal attendant at Seniors for Seniors. She provided attendant care service to the claimant, and the claimant sought entitlement to ACBs. Adjudicator Sewrattan held that the claimant was not entitled to ACBs because the service provider was not a professional, and the service provider had not sustained an economic loss as a result of providing services.

B.U. v. Aviva Canada Inc. (16-000143)

The claimant sought removal from the MIG and entitlement to ACBs and various medical benefits. The claimant was removed from the MIG based on psychological grounds and awarded various assessments and psychological treatment. ACBs were denied. Adjudicator Lester noted that even if the claimant had been found to require personal assistance, the evidence did not satisfy the proof of an incurred expense.