Category: CAT Assessments

Grant v TD General Insurance Company (24-009368)

Post author By tgp-admin
Post date April 2, 2026
No Comments on Grant v TD General Insurance Company (24-009368)

The claimant was involved in an automobile accident in July 2021 and sought benefits pursuant to the SABS. The claimant submitted an OCF-18 proposing various s. 25 CAT assessments. The plan also sought funding for interviews with treatment providers and individuals who had knowledge of the claimant pre and post accident ($1,000.00), WPI psychological ratings needed for Criterion 7 ($2,000.00), and CAT file review and imaging review ($2,000.00), which the insurer denied. The claimant argued that the interview and file review components of the disputed plan would enable assessors to contextualize the claimant’s presentation, consider the progression of impairments, and cross-reference historical medical evidence with the claimant’s daily life. The claimant further argued that a denial that severs these foundational components undermines the integrity of the assessment process and reflects an arbitrary and piecemeal approach to adjudication. The Tribunal was of the view that because the file review is so necessary, it should be treated as part of the assessment’s process. It is duplicative, and therefore unreasonable, to bill for a file review in addition to a $2,000 assessment. The claimant made general submissions but did not direct the Tribunal to evidence to support the reasonableness and necessity of the interview component of the disputed OCF-18. The Tribunal found that a separate assessment for Criterion 7, which would be evaluated using the Guides 6th edition and an assessment for Criterion 8, which would be evaluated using the Guides 4th edition, would not be duplicative and that each assessment speaks to different clinical evaluations and therefore reasonable and necessary.

Milanovic v. Intact Insurance Company (21-008566)

Post author By tgp-admin
Post date July 26, 2023
No Comments on Milanovic v. Intact Insurance Company (21-008566)

The insurer argued that pursuant to s. 55 of the SABS the claimant was barred from proceeding with a claim for catastrophic impairment as he did not submit to an IE. The adjudicator concluded that the claimant was not barred. The insurer’s notices were argued to not provide medical and other reasons pursuant to section 44(5) of the Schedule. The notices had stated that the IEs were required, “to determine if the injuries you sustained in the accident resulted in impairments that would meet the catastrophic impairment definition.” The adjudicator found that the notices were non-compliant because they failed to refer to the claimant’s medical condition(s) and as a result it was unclear what the claimant’s medical conditions were. The adjudicator stated that the respondent insurer should have provided some context regarding what the conditions /impairments were. The adjudicator stated that at the very least the insurer’s reasons should include specific details about the claimant’s condition forming the basis for the claimant’s decision or alternatively identify information about the claimant’s condition that the insurer did not have but required.

Wu v. Aviva Insurance Company (20-011618)

Post author By tgp-admin
Post date September 29, 2022
No Comments on Wu v. Aviva Insurance Company (20-011618)

The claimant applied to the LAT disputing the insurer’s partial approval of catastrophic assessments. The dispute centered around the proper reading of s. 25(2)(a) of the SABS which provides a $2,000 limit for as assessment. Adjudicator Shapiro concluded that a plain language reading of the section set a clear total limit of $2,000 which would encompass all components of the assessment including file review, preparation an the written report. A total of $5,000 related to four clinic file reviews; $712 related to transportation; and $2,000 related to a neurological assessment. The file review and transportation costs were not payable under section 25. The neurological assessment was not payable because the claimant did not demonstrate any ongoing neurological impairment in earlier assessments.

Z .R. v. Gore Mutual Insurance Company (18-000017)

Post author By tgp-admin
Post date September 27, 2022
No Comments on Z .R. v. Gore Mutual Insurance Company (18-000017)

The claimant applied to the LAT seeking entitlement to attendant care benefits in the amount of $8,280.86 per month, various medical benefits, and the cost of examinations (including $11,250.00 for CAT assessments). The claimant had been declared catastrophically impaired in a previous LAT decision. As a preliminary issue, the insurer argued that pursuant to s. 56 of the SABS the claimant was barred from proceeding with his application for ACBs for failing to dispute a denial of the benefit within the two-year limitation period. Adjudicator Hines decided that the claimant was not barred from applying for ACBs. While Adjudicator Hines agreed with the insurer that a partial approval of ACBs triggered the limitation clock and the application was made two years after the partial approval, Adjudicator Hines found that the limitation period did not apply based on the guidance outlined in the Ontario Court of Appeal decision in Tomec. With regards to whether the claimed ACBs were reasonable and necessary, Adjudicator Hines held that being catastrophically impaired does not necessarily entitle a claimant to the maximum available under the SABS and found that the claimant did not meet the burden of proving that he required 24/7 supervision. Adjudicator Hines analyzed the various Form 1s and found that the claimant was entitled to reduced amounts for ACBs during two specific time periods. With regards to medical benefits, Adjudicator Hines found that the claimant was entitled to the disputed physiotherapy and psychological treatment as well as a functional abilities assessment. The proposed CAT assessments were partially reasonable and necessary in the amount of $4,200.00. Adjudicator Hines noted that not all the assessments were relied on at the previous hearing, the amount proposed for some assessments was above the $2,000 cap, and the claimant failed to articulate how some of the assessments were reasonable and necessary. The claimant was not entitled to the amount claimed for mileage related to occupational therapy treatment. Adjudicator Hines decided not to address the claimant’s submissions related to housekeeping benefits because entitlement to housekeeping benefits was not listed as an issue in dispute in previous LAT orders scheduling the hearing.

Williams v. Unifund Assurance Company (20-015158)

Post author By tgp-admin
Post date September 19, 2022
No Comments on Williams v. Unifund Assurance Company (20-015158)

The claimant applied to the LAT seeking entitlement to various benefits, including payment for catastrophic assessments. The claimant submitted that the proposed CAT assessments met both the reasonableness and guideline requirements for entitlement to funding. Adjudicator Kaur disagreed with the claimant’s position, noting that she had failed to submit appropriate evidence before the Tribunal in support of the disputed treatment plans. The claimant relied heavily on a neuropsychological report which Adjudicator Kaur found to be fraught with inconsistencies. The onus is on a claimant to prove that the treatment plans are reasonable and necessary and the claimant failed to do so in this case. She did not submit any clinical record from her family physician or other treating professions nor she did she submit any cogent evidence to refute the insurers denial.

Smith v. Certas Direct Insurance Company (20-006605)

Post author By tgp-admin
Post date August 22, 2022
No Comments on Smith v. Certas Direct Insurance Company (20-006605)

The claimant was involved in an accident in 2017. He applied to the LAT seeking CAT determination under Criteria 2,6, 7, and 8, as well as entitlement to NEBs, ACBs, and medical benefits. Causation was a key issue at the hearing. Adjudicator Hines held that the “but for” test was the appropriate test to determine causation. The crux of the dispute was whether the accident led to the progression of pre-existing peripheral arterial disease resulting in the above-knee amputation of the claimant’s right leg in September 2020. Adjudicator Hines found that the claimant was catastrophically impaired under Criteria 2 because the accident was a “but for” cause of the amputation, and entitled to NEBs, ACBs, chiropractic treatment, and the cost of CAT assessments. He was not entitled to the cost of a home exercise program. Adjudicator Hines allowed the insurer to rely on late-served CAT reports as they were responding to a new OCF-19 submitted by the claimant. Adjudicator Hines excluded an insurer addendum report as it was served two-days before the hearing and there was no reason why the causation issue addressed in the addendum report could not have been addressed in the initial report.

Al-Mosawi v TD Insurance Meloche Monnex (20-004916)

Post author By tgp-admin
Post date August 3, 2022
No Comments on Al-Mosawi v TD Insurance Meloche Monnex (20-004916)

The claimant applied to the LAT seeking entitlement to various benefits after being involved in a motor vehicle accident, including catastrophic determination assessments. Vice-Chair Ciriello concluded that none of the disputed treatment plans or assessments were payable due to a lack of supporting evidence, articulating that treatment plans alone do not prove that the proposed treated is reasonable and necessary. There must be corroborating contemporaneous and objective medical evidence put before the tribunal to substantiate the necessity and reasonableness of any proposed treatment.

G.P. v. Wawanesa Mutual Insurance Company (18-010583)

Post author By tgp-admin
Post date May 31, 2022
No Comments on G.P. v. Wawanesa Mutual Insurance Company (18-010583)

The claimant applied to the LAT for a catastrophic impairment designation, post-104 week IRBs, the cost of CAT assessments, and various medical benefits. Vice Chair Lester found that the claimant suffered a catastrophic impairment due to Class 4 Marked Impairments in both adaptation, and concentration, persistence, and pace. The claimant suffered from chronic pain as a result of a minor accident, which deteriorated into somatic symptom disorder with predominant pain and major depressive disorder. The claimant suffered from panic attacks once to twice per week. She was unable to deal with stressful circumstances, had not returned to work as a PSW, and became emotional and overwhelmed by minor things. The claimant was also found to meet the post-104 week IRB test. The only jobs the claimant was suited for were PSW work and an office manager role. The insurer did not have any IEs addressing post-104 week IRBs because it had terminated IRBs within the first 104 weeks. Notably, the insurer’s CAT assessments noted Class 3 Moderate Impairments in social functioning, which was relevant for the claimant’s ability to communicate effectively and ability to get along with others, and found a Class 3 Moderate Impairment in concentration, persistence, and pace, which was relevant to the claimant’s ability to sustain focused attention in a work setting. All of these conclusions supported the determination that the claimant suffered a complete inability to engage in work for which she was suited. The $26,971.50 for CAT assessments, $13,566.81 for a chronic pain program, $2,200 for a chronic pain assessment, and $1,808 for an FAE were awarded due to the insurer’s failure to comply with section 38(8). The denials did not provide adequate medical reasons for the denial, and referred the claimant to read other documents. Vice Chair Lester was critical of the insurer’s reason that something was “excessive” without providing any detail. Finally, Vice Chair Lester granted a special award of 30 percent on the awarded IRBs and treatment plans based on the insurer’s decision to “blindly follow” the IE assessor opinions without considering other evidence. The claimant suffered financial hardships as a result of the denials, including the need to apply for OW, borrow money from her family, and cut back on her diet.

Islam v. Toronto Transit Commission Insurance Company (20-014052)

Post author By tgp-admin
Post date May 30, 2022
No Comments on Islam v. Toronto Transit Commission Insurance Company (20-014052)

The claimant applied to the LAT for a catastrophic impairment designation. Vice Chair Flude concluded that the claimant did not meet the definition, as she did not have a combined physical and mental impairment exceeding 55 percent WPI , and did not suffer at least one Class 4 Marked Impairment. The claimant’s assessor wrote that the claimant had Class 4 Marked Impairments in all four spheres of function and had a combined 53 percent WPI. Vice Chair Flude found that the claimant’s recovery did not support those conclusions. The claimant was able to return to her studies at Humber and graduate three years after the accident with a B average; she had returned to working out at a modified level; she tolerated a long commute from home to school; she started at Ryerson in 2020 just as COVID-19 hit; she worked two summer jobs while in school – one at Tim Horton’s and one as a camp counsellor; and she continued to socialize when her studies allowed it. The claimant’s psychological assessor ignored most of this objective evidence. Vice Chair Flude preferred the IE assessor’s opinion that the claimant suffered (at most) Class 2 Mild Impairments in each of the four spheres of function, which was equivalent to a 10 percent WPI. Regarding physical impairments, Vice Chair Flude did not accept that the claimant suffered neurological impairments, as the immediate post-accident records did not suggest any loss of consciousness, dizziness, blurring, amnesia, or other concussion-type symptoms. The 15 percent WPI assigned by the claimant’s assessor was rejected. The overall WPI accepted by Vice Chair Flude was 10 percent for emotional and behavioural, and 16 percent WPI for physical impairment, which did not combine to 55 percent WPI. The cost of CAT assessments totaling $2,400 was awarded, as it was reasonable for the claimant to investigate whether she suffered a catastrophic impairment. Vice Chair Flude also noted that the denial did not include proper medical reasons, contrary to section 38(8).

Tanner v. Certas Direct (21-000564)

Post author By tgp-admin
Post date May 26, 2022
No Comments on Tanner v. Certas Direct (21-000564)

The claimant applied to the LAT for a catastrophic impairment designation, post-104 week IRBs, and payment of various medical benefits including partially approved CAT assessments. Adjudicator Reilly denied all claims and dismissed the application. With respect to the catastrophic impairment, Adjudicator Reilly found a maximum combined WPI of 32 percent. She found the claimant’s assessors attributed excessive impairment percentages. She found no evidence of right shoulder impairment and found lumbar spine impairment rated too high. She found the claimant’s left wrist and shoulder impairments ought to have been combined before arriving at the total WPI, rather than rating each separately. She found the rating of 18 percent WPI for grip strength to be questionable as OT and FAE assessments found normal grip strength. In terms of neurological ratings, Adjudicator Reilly found no evidence to support a rating for sexual dysfunction or hearing, and the rating for disturbances of consciousness and awareness ought to have been deferred to a psychiatrist. She found a total of 32 percent WPI for orthopaedic and neurological impairment, which did not meet Criterion 6. In terms of mental or behavioural impairment, Adjudicator Reilly did not accept the claimant’s expert’s rating of 20 percent WPI, as the facts described by the assessor were not supported by the evidence (i.e. ability to travel, ability to drive, ability to work part-time). Adjudicator Reilly preferred a maximum WPI of 10 percent for mental and behavioural impairment based on the IE assessor’s opinion. The combined physical and mental impairment did not exceed 55 percent, and the catastrophic impairment designation was dismissed. Adjudicator Reilly concluded that the claimant did not meet the post-104 week IRB test. The claimant had returned to work in a part-time fashion on multiple occasions after the accident. Surveillance showed him with greater physical abilities than reported to his assessors. The claimant’s job was terminated in 2021 because he did not want to return to the office full-time, and the management dismissed him. The claim for further CAT assessments was dismissed, as the claimant did not advance evidence to indicate why the denied amounts were reasonable and necessary. The claim for assistive devices was dismissed because they were not submitted on OCF-18s, and the claimant had exhausted his medical benefits limits.

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