Category: CAT Assessments

A.L. v. Unica Insurance Inc. (18-008890)

The claimant sought a determination of a catastrophic impairment based on a WPI in excess of 55 percent. He also sought entitlement to ACBs, the denied portion of CAT assessments, and various medical benefits. Adjudicator Lake concluded that the claimant did not suffer a catastrophic impairment. She rejected the claimant’s experts opinions on WPI for mental or behavioural impairments because it relied on opinions from other experts which those experts later retracted. Even if all other WPI were accepted, the claimant would only have a 42 percent WPI. The ACBs claim was dismissed because it was for a period beyond the 104 week mark. Adjudicator Lake agreed with the claimant that CAT assessments were not paid out of the medical benefits limits, and found that six of proposed seven assessments were reasonable. Finally, Adjudicator Lake held that the treatment plans for further physiotherapy were reasonable and necessary, but that the claims for assistive devices, an attendant care assessment, and a two-part neuropsychological examination were not.

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.K. v. Technology Insurance Company Inc. (19-003749)

The claimant sought entitlement to social work services, HST on treatment plans, and the cost of CAT assessments. Adjudicator Chakravarti held that the limitation period applied to the social work services because the denial of the proposed rate was clear and unequivocal. Section 7 of the LAT Act did not apply because the claimant did not provide any details as to why the dispute was brought outside the limitation period. The limitation period did not apply to the HST claim because the insurer provided contradictory reasons in the denial letter. The limitation period did not apply to the CAT assessments either because the denial letter only indicated that the insurer had not made a decision regarding the proposed costs.

F.A. v. Aviva General Insurance (18-0011952)

The claimant sought entitlement to various medical benefits and payment for the cost of examinations. Adjudicator Johal ruled that all disputed plans were not reasonable or necessary based upon the evidence provided. Further, the claimant had not satisfied her onus to prove on a balance of probabilities that the treatment and assistive devices were effective for her recovery. With regards to the cost of the CAT Assessments, Adjudicator Johal found that the assessments were not necessary to determine whether the claimant had a catastrophic impairment. The insurer raised the issues of whether the accident was the cause of the claimant’s injuries. The adjudicator determined that the claimant was not forthright about her pre- and post-accident medical history, her employment history and other traumatic life events. In conclusion, Adjudicator Johal held that the medical evidence suggests that the accident was not a necessary cause of the claimant’s physical complaints nor did the accident exacerbate her injuries.

O.S. v. Certas Home and Auto Insurance Company (18-006633)

The claimant disputed entitlement to three treatment plans for chiropractic services, an orthopaedic assessment, and a neuropsychological assessment, as well as multi-disciplinary CAT assessments. Adjudicator Pinto ruled that all disputed plans were not reasonable or necessary based upon the evidence provided. In her decision, she noted that the disputed treatment plans did not provide medical reasons for the necessity of the services provided in relation to the subject accident. A review of the claimant’s medical records did not show that the claimant’s treating practitioner’s, specifically the family doctor, believed it was reasonably possible that the claimant was catastrophically impaired. All claims were dismissed.

K.H. v. The Personal Insurance Company (18-009077)

The claimant sought entitlement to $26,000 in catastrophic impairment assessments. Adjudicator Ferguson concluded that none of the proposed assessments were reasonable. The claimant had very few visits to his family physician, and very little treatment; he did not use any prescription medications; there were no neurological impairments; he attended the gym; his mood was “okay”; and he functioned “very well.”

A.W.A. v. Certas Home and Auto Insurance (18-007207)

The claimant sought entitlement to IRBs, a series of catastrophic impairment assessments, and further physiotherapy. Adjudicator Gosio awarded IRBs up to the 104 week mark, but denied the remainder of the claims. The claimant worked as a machine operator, and his chronic neck pain inhibited his work. The claimant did not submit any evidence that he met the “complete inability” test. The proposed physiotherapy was not reasonable because it made the claimant’s pain worse. Finally, there was no reasonable basis on which to award the catastrophic impairment assessments. The evidence of psychological impairment was minimal, and he did not meet the criteria for any psychological disorder.

J.A. v. Aviva Insurance Company of Canada (18-002124)

The insurer sought reconsideration of the Tribunal’s decision awarding $10,500 for the cost of catastrophic impairment assessments. Adjudicator Boyce denied the reconsideration request. He concluded that the proposed assessments were not “rebuttal reports” because it was the claimant’s first set of catastrophic impairment assessments (the insurer had conducted earlier IEs, but that did not make the claimant’s proposed assessments “rebuttal reports”). Although the OCF-19 was submitted prior to the claimant’s proposed assessments, the proposed assessments were still “for the purpose” of determining a catastrophic impairment.

Aviva Insurance Company of Canada v. J.A. (2021 ONSC 3185)

The insurer appealed the Tribunal’s decision that it was required to pay for the claimant’s catastrophic impairment assessments even though the assessments were not requested or completed until after submission of the OCF-19 and the catastrophic impairment IEs. The insurer characterized the requested assessments as rebuttal reports, which were not payable under the current version of the SABS. The Court dismissed the appeal, holding that the Tribunal did not make an error of law. The Tribunal made a finding of fact that the claimant had not obtained any earlier assessments, so the requested assessments were not rebuttal assessments. As a matter of law, section 25 was to be interpreted broadly, and the term “preparation” of a catastrophic impairment application did not end when the OCF-19 was submitted. Therefore, section 25 applied and required the insurer to pay for the claimant’s catastrophic impairment assessments.

M.G. v. Aviva Insurance Canada (18-002508)

The insurer sought reconsideration of the Tribunal’s award of the cost of various catastrophic impairment assessments. The insurer argued that because the treatment plans were proposed after the OCF-19 was submitted, the assessments were not being proposed in accordance with section 45, and therefore not payable. Adjudicator Johal rejected the reconsideration. She held that catastrophic impairment assessments were payable under section 25 if necessary for determining whether the claimant suffered a catastrophic impairment, and if the proposed cost was reasonable. Sections 25 and 45 did not require the claimant to submit the proposed assessments before submitting an OCF-19, and submitting an OCF-19 first was not a bar to seeking payment for the assessments under section 25.