Category: CAT Assessments

The claimant sought entitlement to four physiotherapy treatment plans and the cost of an impairment assessment, a multi-disciplinary catastrophic assessment, and a neurological assessment. Adjudicator Manigat rejected the opinion of the insurer’s psychiatry assessor that there was no objective evidence of ongoing impairments and that the claimant did not have any functional limitations or physical restrictions, finding instead that the physiotherapy treatment plans were reasonable and necessary to manage the claimant’s chronic pain. The claimant was not entitled to the cost of the impairment assessment because a comprehensive impairment assessment had already been completed; nor was he entitled to the catastrophic assessment or neurological assessment, as his injuries were predominantly physical in nature.

The claimant sought entitlement to physiotherapy and the cost of an occupational therapy assessment conducted as part of a catastrophic impairment assessment. She also argued that HST was not part of the medical benefits limits. Adjudicator Ferguson accepted that HST was payable outside of the medical benefits limits. He concluded that the occupational therapy assessments were not payable because no physician was involved in completion of the OCF-19, and an occupational therapist was not qualified to complete the OCF-19 independently. The disputed medical benefits were also denied.

The claimant sought entitlement to chiropractic treatment and the denied portion of catastrophic impairment assessments. Adjudicator Boyce denied the claims for further chiropractic treatment because the claimant failed to prove the treatment was reasonable and necessary. He awarded the FAE component of the catastrophic impairment assessments, as well as the cost of the OCF-19 completion, but denied the remainder. He wrote that the denied psychiatric assessment and neuropsychological assessment were just attempts to garner two payments for an already approved assessment. The proposed biopsychosocial assessment was not reasonable and necessary.

The claimant sought entitlement to two medical benefits, and a series of catastrophic impairment assessments. Adjudicator Reilly rejected all of the claims. She held that the proposed benefits were not reasonable and necessary. The medical records from the family physician shows no ongoing accident-related impairments.

The claimant sought entitlement to nine assessments in relation to a catastrophic impairment determination. The insurer approved four (an orthopaedic assessment, an occupational therapy assessment, a psychiatry assessment, and a WPI rating); it denied five other assessments. Adjudicator Boyce accepted that each assessment had to be reasonable and necessary for the completion of the OCF-19 in order to be payable. He found only one further assessment – a functional review evaluation – to be reasonable and necessary. The remaining four assessments were largely duplicative and not essential for the completion of a catastrophic impairment determination.

The claimant sought reconsideration of the Tribunal’s denial of the cost of catastrophic impairment assessments. Adjudicator Lester held that section 25(1)(5) only obligates an insurer to pay the reasonable fees charged in connection with filling out the application for the catastrophic determination rather than the assessments themselves. She also agreed that the reasonable and necessary standard applies to the determination of whether catastrophic impairment assessments would be payable by the insurer.