Category: CAT Assessments

Applicant v. Allstate Insurance (18-006253)

The claimant sought entitlement to over $24,000 in catastrophic impairment rebuttal reports. The insurer argued that dispute was statute barred. Adjudicator Grant held that catastrophic impairment assessments are not “benefits” and therefore not subject to the two year limitation period. Adjudicator Grant concluded that the proposed assessments were reasonable and necessary, and were therefore payable. It was not a requirement that the assessments be proposed prior to the OCF-19 submission or prior to the insurer’s IE assessments being completed. A total of $2,000 per assessment was approved, and did not come out of the claimant’s medical benefits limits.

L.G. v. Unifund (18-008089)

The claimant sought entitlement to over $15,000 for multidisciplinary catastrophic impairment assessments. The insurer denied the assessments because the claimant had exhausted her medical benefits limits. Adjudicator Victor held that the cost of catastrophic impairment assessments did not fall within the medical benefits limits. She held that the claimant had to prove that each assessment was reasonable and necessary. Since it was possible that the claimant may have suffered a catastrophic impairment, it was reasonable for her to incur the proposed costs.

D.M. v. Belair Direct Insurance Company (18-005470)

The claimant sought entitlement to over $22,000 for multidisciplinary catastrophic impairment assessments. The insurer had approved a total of $7,000. The claimant disputed entitlement to the remainder. Adjudicator Parish approved entitlement to an executive summary and the cost of the OCF-19, but denied the remainder. She held that the remaining assessments were duplicative of the approved services or in excess of the $2,000 assessment limit.

S.M. v. Federated Insurance Company of Canada (18-004533)

The claimant sought entitlement to $6,000 per month in ACBs from April 2012 onwards, and the cost of two assessments. Adjudicator Lake considered the time period prior to and after the February 1, 2014 changes to the incurred expense definition for non-professional service providers. She held that the claimant failed to prove that her niece suffered an economic loss. No ACBs were payable beyond the 104 week mark because the claimant had not proven a catastrophic impairment. Adjudicator Lake also concluded that the two proposed assessments were not reasonable and necessary. The first was for a Form 1 after the 104 week mark, prior to the claimant submitting an OCF-19. The second was for a clinic file review as part of a catastrophic impairment assessment, which the adjudicator found to be duplicative the services conducted as part of each approved constituent element of the catastrophic impairment assessments.

J.M. v. Aviva General Insurance (17-007215)

The insurer sought reconsideration of the Tribunal’s decision that catastrophic impairment assessments are payable outside of the medical benefits limits. Vice Chair Flude held that the Tribunal’s decision did not contain a significant error of law, and was correct. He concluded that earlier FSCO decisions addressing the same issue were correct, and that catastrophic impairment assessment costs are not to be deducted from the medical benefits limits.

V.K. v. Unica Insurance Inc. (18-007227)

This is a preliminary issue decision on whether the cost of assessments to determine catastrophic impairment falls within the $50,000.00 limit on medical and rehabilitation benefits. Adjudicator Ferguson concurred with previous decisions that CAT assessments are not a benefit, and found that the insurer is obliged to pay the full cost of CAT assessments subject to professional services guidelines, and with the caveat that it remains the claimant’s responsibility to show that any assessment is reasonable and necessary. Adjudicator Ferguson found that the cost of CAT assessments is not subject to the $50,000.00 limit.

Applicant v. The Guarantee Company of North America (17-006956)

The claimant sought reconsideration of the Tribunal’s decision that she was not entitled to payment for catastrophic impairment assessments. Vice Chair Shapiro upheld the decision. He wrote that the Tribunal accurately considered whether there was some objective evidence to suggest that the claimant may suffer a 55 percent WPI. The Tribunal found that further investigation for catastrophic impairment status was not reasonable and necessary.

R.M. v. Unica Insurance Inc. (17-007500)

The claimant exhausted his medical benefits coverage and sought payment of catastrophic impairment assessment outside of the medical benefits limits. He sought a total of $9,718. The insurer argued that it was not required to pay for assessments outside of the medical limits, and in the alternative, that one of the proposed assessments was not necessary. Adjudicator Mazerolle concluded that catastrophic impairment assessments are payable outside of the medical benefits limits. However, he also concluded that the assessments had to be reasonable. A proposed file review appeared duplicative of three other proposed assessments. The insurer was ordered to pay $7,718 for the assessments.

J.M. v. Certas Home and Auto Insurance Company (18-001406)

The claimant was involved in an accident in 1997. She applied for a catastrophic impairment determination in 2007, which found that she did not meet the definition. She did not dispute the determination. In 2016 she submitted a new OCF-19 seeking a catastrophic impairment determination and sought payment for assessments in that regard. The insurer argued that the claimant was not entitled to seek a catastrophic impairment determination and that it was not required to pay for assessments because the 10 year period had expired. Adjudicator Hines concluded that the claimant was permitted to submit a treatment plan for catastrophic assessments, and that such assessments could be payable because such assessments did not fall under the medical/rehabilitation limits. However, she also concluded that the procedure in the 2010 SABS applied rather than the 1996 SABS, meaning that the claimant’s entitlement to such assessments was limited to $2,000 per assessment and that rebuttal reports were not payable by the insurer. Finally, Adjudicator Hines concluded that the insurer was not required to pay for the claimed assessments because they were not reasonable and necessary. The evidence suggested that the claimant remained quite functional and did not demonstrate an ongoing functional limitation that had developed between 2007 and 2017.

Applicant v. Aviva General Insurance (17-007215)

The claimant sought entitlement to over $20,000 for multidisciplinary catastrophic impairment assessments. The insurer argued that the claimant had exhausted her medical benefits limits, that the proposed assessments were not reasonable and necessary, and that the assessment costs were in excess of the $2,000 limit. Adjudicator Grant held that the medical benefits limits did not apply to catastrophic impairment assessments, and that each assessment could cost up to $2,000. In order to be payable though, each proposed assessment had to be reasonable and necessary. He awarded the cost of the neurological, occupational therapy, psychiatry, and orthopaedic assessments. He rejected the claims for a file review and a medical document review, which should fall within the cost of each approved assessment.