Category: CAT 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.

N.K. v. Intact Insurance Company (19-003405)

The claimant sought entitlement to the costs of examinations in two treatment plans that were performed as part of catastrophic impairment assessments. Adjudicator Norris found that although a psychiatric assessment was performed instead of an approved psychological assessment, the psychiatric assessment was reasonable and necessary in light of the claimant’s post-concussion mental condition. The claimant was only entitled to $2,000 for the cost of the psychiatric assessment, however, as the fact that the assessment formed the basis of the catastrophic impairment determination did not entitle him to funding above the $2,000 limit on assessment costs per section 25(5)(a) of the SABS. Adjudicator Norris also found the claimant entitled to the costs of two occupational therapy assessments. Interest was found payable on both disputed treatment plans.

D.Y. v. Aviva General Insurance Company (18-011171)

The claimant sought entitlement to NEBs, medical treatment, various assessments, and a special award. In addition, the claimant sought entitlement to the balance of proposed catastrophic impairment assessments, which had been proposed in the amount of $26,400.00 and approved up to $12,400.00. The claimant was found entitled to NEBs, chiropractic and physiotherapy treatment, concussion management, and various s. 25 assessments up to $2,000.00 limit. Adjudicator Conway approved a second portion of a neuropsychological assessment, but denied the claim for additional CAT assessments because they were duplicative or for review of medical records (which is included in the $2,000 limit). The claimant was found entitled to interest if the cost of treatment had been incurred. Interest was found payable from the date payment was made by the applicant until the date of payment by the insurer. A special award of 33 percent was made due to the insurer not approving medical benefits when it had sufficient evidence that the claimant suffered from chronic pain and psychological injuries.

K.Y.C. v. Unica Insurance Inc. (19-000494)

The claimant sought entitlement to a series of catastrophic impairment assessments. The insurer argued that the medical benefits available to the claimant had been exhausted and that the assessments were therefore not payable. Adjudicator Grant disagreed with the insurer and held that the medical benefits limits did not apply to catastrophic impairment assessments because such assessments were not medical benefits. In terms of the various assessments, Adjudicator Grant approved the physiatry assessment, psychological assessment, two occupational therapy assessments, and a final AMA ratings assessment, he declined to award the file review assessment because a file review was to be performed as part of each approved assessment.

H.S.H. v. Aviva Insurance Company of Canada (18-002204)

The claimant sought reconsideration of the Tribunal’s denial of the cost of a catastrophic impairment assessment, arguing that the burden should not be on the claimant and that the “reasonable and necessary” test did not apply to section 25. Adjudicator Reilly dismissed the reconsideration request, holding that the “reasonable and necessary” test applied to each catastrophic impairment assessment, and that the burden was on the claimant to prove that the test was satisfied.

R.B. v. RSA Insurance (19-002329)

The claimant sought entitlement to four treatment plans for medical rehabilitation and cost of examinations, including a catastrophic impairment assessment and medications. The insurer denied the benefits in dispute on the basis that the claimant’s medical limits had been exhausted. Adjudicator Kaur concluded that that cost of examination for a catastrophic assessment are not subject to the medical benefits limitation. The claimant was entitled to the catastrophic impairment assessments, but the remainder of the medical benefits were denied as there was no evidence on a balance of probabilities that the expenses were reasonable or necessary.

S.L. v. Aviva Insurance Company of Canada (19-002783)

The claimant sought entitlement to income replacement benefits and to medical benefits proposed in eight treatment plans, and the cost of $26,400 for catastrophic impairment assessments. The claimant argued that he suffered from pre-existing lower back pain which was exacerbated as a result of the accident and would prevent him from reaching maximum recovery under the MIG. Adjudicator Lester found that the claimant’s pre-existing strains did not remove him from the MIG and the claimant did not have a chronic pain disorder, therefore, the MIG limits applied. Adjudicator Lester concluded that the claimant exhausted all funding under the MIG and he was not entitled to any of the treatment plans in dispute. Adjudicator Lester found that the claimant suffered a substantial inability to perform the essential tasks of his employment and was entitled to IRB for a period of four months. Adjudicator Lester noted that the claimant was also entitled to interest for the IRB.

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

The claimant sought a catastrophic impairment determination, entitlement to attendant care benefits, and the cost of various assessments. The claimant suffered from chronic pain, had not worked in the 10 years since the accident, and had been diagnosed with major depressive disorder. Pain prevented the claimant’s participation in home-based activities, and she rarely left the house. Adjudicator Parish found that the claimant suffered a Class 4 marked impairment in activities of daily living (no other spheres of function were found to be Class 4). In terms of the WPI, Adjudicator Parish would have assigned 40 percent for the psychological impairment and 7 percent for physical impairment, meaning that the claimant did not have a 55 percent WPI. Adjudicator Parish awarded retroactive ACBs of $507.03 per month for assistance with meal preparation. She rejected the claims for grooming (the claimant was capable of independent hair care), bathroom cleaning (which was found to be housekeeping, not attendant care); and basic supervisory care (the Form 1 category was for emergency assistance, but the claimant did not lack the capacity to respond to an emergency; emotional care was not an appropriate attendant care service). Adjudicator Parish also awarded the cost of an OT situational assessment related to the catastrophic impairment application. She also awarded the cost of the in-home assessment to complete the Form 1. Adjudicator Parish also held that the claimant was not required to meet the strict “incurred” definition for payment of ACBs, because the accident occurred in 2009. Interest was awarded on ACBs, but only from the date the Form 1s were submitted.

Applicant v. Unifund Assurance Company (18-008089)

The insurer filed a request for reconsideration arising from a decision in which the Tribunal found that CAT Assessments were not a medical benefit and therefore their funding did not fall within the $50,000 limit under section 18 of the SABS. Adjudicator Victor dismissed the insurer’s request for reconsideration and granted the claimant’s request for costs in the amount of $100, noting that the insurer had only raised the same arguments it made at the hearing and was essentially trying to re-litigate the decision based on the same arguments.

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

The claimant sought entitlement to $16,320 for various catastrophic impairment assessments more than 10 years after his accident had occurred (and his medical benefits coverage had lapsed). The assessments were proposed after an OCF-19 had been submitted and IEs had taken place showing that the claimant did not suffer a catastrophic impairment. The insurer argued that the proposed assessments were rebuttal reports, and that the SABS did not provide coverage for such reports. Adjudicator Boyce held that the claimant did not have a vested right to pre-2010 SABS rebuttal reports, but that the proposed assessments were nevertheless payable. The assessments were not rebuttal reports, but rather first assessments which were necessary for the claimant to attempt to prove his claim. Adjudicator Boyce considered each proposed assessment and concluded that $2,000 per assessment was payable. He denied entitlement to the Essential Clinical Tasks fee and Medical File Review fee, as they were not reasonable and necessary.