Category: Attendant Care Benefits

M.Z. v. Certas Home and Auto Insurance (19-005344)

Post author By tgp-admin
Post date June 30, 2020
No Comments on M.Z. v. Certas Home and Auto Insurance (19-005344)

The minor claimant suffered serious injuries in an accident. He received attendant care for over one year, but ACBs were terminated thereafter. He sought entitlement to further ACBs and one medical benefit for physiotherapy. Adjudicator Boyce denied the claim for further ACBs, but partially approved the claim for physiotherapy. The medical evidence suggested that the minor claimant had largely healed from his physical injuries within the year. The claimant’s treating surgeons and doctors had noted that the claimant’s injuries had resolved and the claimant was participating in normal activities. Adjudicator Boyce also noted that the claimant’s Form 1 oddly recommended support with activities that his parents were performing before the accident (meal preparation, bathroom cleaning). Further, there was no evidence of attendant care services being incurred.

J.Z. v. Certas Home and Auto Insurance (19-005337)

Post author By tgp-admin
Post date June 30, 2020
No Comments on J.Z. v. Certas Home and Auto Insurance (19-005337)

The minor claimant suffered a broken arm in an accident. He received attendant care for over one year, but ACBs were terminated thereafter. He sought entitlement to further ACBs and one medical benefit for physiotherapy. Adjudicator Boyce denied both claims. The medical evidence suggested that the minor claimant had largely healed from his physical injuries within the year. The claimant’s treating surgeons and doctors had noted that the claimant’s injuries had resolved and the claimant was participating in normal activities. Adjudicator Boyce also noted that there was no evidence of attendant care services being incurred.

R.K. v. Allstate Insurance (19-000502)

Post author By tgp-admin
Post date June 26, 2020
No Comments on R.K. v. Allstate Insurance (19-000502)

The claimant sought entitlement to monthly ACBs and one treatment plan for physiotherapy. Vice Chair Flude concluded that the claimant’s impairments all preceded the accident, and that she did not require attendant care nor further physiotherapy. The claimant’s self-reporting to her experts was contradicted by the medical records and the surveillance.

S.M. v. Unica Insurance Inc. (18-010164)

Post author By tgp-admin
Post date June 25, 2020
No Comments on S.M. v. Unica Insurance Inc. (18-010164)

The Tribunal had found the claimant entitled to (among other things) $6,000 per month in ACBs and granted a 25 percent special award. The insurer sought reconsideration. Adjudicator Boyce granted the reconsideration and reduced the payable ACBs and concluded that no special award was payable on ACBs or an awarded home modification. With regard to the ACBs award, the claimant was only entitled to payment for service incurred but in the amount provided for by the hourly rates set out in the Guidelines (as opposed to the amount actually incurred). The Tribunal erred by awarding the claimant “up to $6,000” for whatever was incurred at whatever rate the service provider charged. With regard to the special award, Adjudicator Boyce held that the Tribunal imposed a greater burden on the insurer than was appropriate. It was unreasonable to expect an adjuster to micromanage the assessments of qualified professionals, and the adjuster was entitled to rely upon their expert opinions.

S.M. v. Unica Insurance Inc. (18-010164)

Post author By tgp-admin
Post date June 25, 2020
No Comments on S.M. v. Unica Insurance Inc. (18-010164)

A.A. v. Aviva Insurance Company (18-011152)

Post author By tgp-admin
Post date June 24, 2020
No Comments on A.A. v. Aviva Insurance Company (18-011152)

The claimant sought entitlement to attendant care benefits of $2,442.67 per month for a seven month period. Adjudicator Boyce concluded that the services identified on the claimant’s Form 1 could not reasonable be associated with the claimant’s accident-related impairments when he continued to work in his pre-accident employment, had not seen his family physician, and was not using any prescription medications. The claimant also failed to prove what services were incurred by his service provider.

A.M. v. Wawanesa Mutual (18-008775)

Post author By tgp-admin
Post date June 19, 2020
No Comments on A.M. v. Wawanesa Mutual (18-008775)

The claimant sought a catastrophic impairment determination, as well as entitlement to NEBs, ACBs, various medical benefits, and the denied portion of catastrophic impairment assessments. The insurer argued that the claimant’s psychological injuries and epilepsy were not accident-related, but resulted from pre-existing conditions. Adjudicator Lake agreed with the insurer and dismissed all claims. She found that the claimant had suffered from various pre-accident impairments (epilepsy, migraines, major depressive episodes related to the death of the claimant’s daughter). Further, surveillance of the claimant showed that she was not credible in her self-reporting. Adjudicator Lake was also critical of the claimant’s experts assigning the maximum WPI when converting psychological impairment. With respect to psychological impairment caused by the accident, Adjudicator Lake found Class 1 and 2 impairments. The claims for NEBs and ACBs were similarly dismissed. The denied portions of the CAT assessments were not reasonable and necessary, and the claimed medical benefits were dismissed.

S.V. v. State Farm Mutual Automobile Insurance Company (18-000605)

Post author By tgp-admin
Post date June 15, 2020
No Comments on S.V. v. State Farm Mutual Automobile Insurance Company (18-000605)

The claimant sought reconsideration of the Tribunal’s decision regarding certain denied ACBs for feeding, bathroom cleaning, and basic supervisory care. She also sought interest on ACBs from the retroactive date of the Form 1, rather than the date the Form 1 was submitted. Adjudicator Parish granted the reconsideration in relation to the quantum payable for feeding, but denied all other aspects of the reconsideration. The error was based on the Tribunal using 90 minutes as opposed to 150 minutes per day for meal preparation. The denial of other aspects of the Form 1 was unchanged as the Tribunal did not make an error in fact or law. The Tribunal also noted that re-integration into the community was not “basic supervisory care” under the Form 1. Finally, the Tribunal re-iterated that interest was not payable prior to submission of the Form 1 because the insurer would not have been aware of the claimant’s need for attendant care prior to the Form 1.

J.V.D.A. v. Aviva General Insurance(19-002631)

Post author By tgp-admin
Post date June 3, 2020
No Comments on J.V.D.A. v. Aviva General Insurance(19-002631)

The claimant sought payment of HST on attendant care services outside of the ACB limit. Aviva had paid a total of $1,829.62 in HST as charged by the AC service provider, but paid it from the ACB limits. The claimant argued that the payable HST was not subject to the ACB limit as set out in section 19 of the SABS. Adjudicator Grant ruled that the payable HST was not subject to the ACB limit and was to be paid separately as a tax and not as a service, citing the Professional Services Guideline, Superintendent’s Guideline No. 03/14, as well as FSCO issued Bulletin No. A-04/15 as both being persuasive in his determination.

A.A. v. Unifund Assurance Company (18-008999)

Post author By tgp-admin
Post date May 21, 2020
No Comments on A.A. v. Unifund Assurance Company (18-008999)

The claimant had previously been deemed catastrophically impaired. She applied to the LAT seeking entitlement to ACBs, medical benefits that had been denied prior to her being deemed catastrophically impaired, and medical benefits that had been denied after she was declared catastrophically impaired. Adjudicator Punyarthi found that the claimant was entitled to ACBs, but based on surveillance and other evidence, determined that the amount payable was less than the amount being claimed. Pursuant to s. 38(2) of the SABS, Adjudicator Punyarthi found that the claimant was not entitled to payment of pre-CAT medical benefits that were incurred prior to the submission of treatment plans. The insurer raised a limitation argument against a claim for pre-CAT medical benefits that were denied more than two years before the claimant’s LAT application. Adjudicator Punyarthi found that the claimant was not barred by virtue of a missed limitation period, based on the Court of Appeal decision in Tomec. Adjudicator Punyarthi found that pelvic floor physiotherapy was not payable as there was insufficient evidence to establish on a balance of probabilities that the impairment was a result of the accident.

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