Category: Catastrophic Impairment

Lynch v. Intact Insurance Company (20-014497)

The claimant applied to the LAT seeking CAT determination under Criteria 8 and entitlement to post-104 IRBs . Vice-Chair Shapiro applied the “but for” test to the issue of causation. Vice-Chair Shapiro found that the claimant’s current stand-up comedy activities were a “hobby” and not a career that disqualified the claimant from post-104 IRBs. The “hobby” netted the claimant part-time income that was “not nearly commensurate with his pre-accident position.” The claimant was entitled to post-104 IRBs less post-accident income and any applicable deductions, including deductions for CPP disability benefits. The CAT analysis focused on whether the claimant had a Class 4 impairment in ADLs. Vice-Chair Shapiro considered the claimant’s very mild functional limitations on most days as well as his limitations in acute periods and found that overall the clamant had an ADL rating lower than a Class 4. The claimant was found not to be CAT as he did not suffer a Class 4 impairment in 2 of the 4 domains.

Cruz v. Belair Insurance Company (20-014208)

The claimant was involved in a serious motor vehicle accident in September 2017, in which she sustained multiple fractures. She applied to the LAT seeking CAT determination under Criteria 7 and entitlement to post-104 IRBs, medical benefits, and a special award. Vice-Chair Lester decided to exclude two insurer reports that were served after the deadline for productions. The claimant was permitted to call the claims adjuster despite late service of particulars for the claim for a special award. The claimant’s assessors determined the claimant had a WPI rating of 66%. The insurer’s assessors determined the claimant had a WPI rating of 40%. Vice-Chair Lester determined that the WPI ratings of the claimant’s assessors were incorrect for a variety of reasons, including advancing a rating for a future risk. Vice-Chair Lester found that the claimant had a combined WPI rating of 47% and was not catastrophically impaired. The claimant’s pre-accident employment jobs had all been part-time short-term positions in retail, childcare, and a travel agency. Vice-Chair Lester found that the claimant was unable to sit long enough for any sedentary part-time position and was entitled to post-104 IRBs. The claimant was entitled to OT services and physiotherapy. She was not entitled to a SPECT assessment or a special award.

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.

Papadakis v. Wawanesa Mutual Insurance Co. (2022 ONSC 6928)

The claimant appealed the Tribunal’s decision that he did not suffer a catastrophic impairment, and that he was not entitled to IRBs or further physiotherapy. The Divisional Court dismissed the appeal. The only point of law raised in the appeal was whether the Tribunal was correct to exclude a WPI rating for a contingency of future events. The Court agreed that the Tribunal was correct in excluding future contingencies. The authorities support the conclusion that the WPI rating is based on a person’s presentation at the hearing without contingency for future changes. The Court also agreed with the Tribunal’s exclusion of WPI ratings for pre-existing conditions, as the AMA Guides require deducting from the WPI rating the estimated impairment ratings for pre-existing injuries or conditions in order to obtain the net WPI from accident-related impairments. The Court dismissed the remaining grounds of appeal as not raising points of law. The arguments regarding ignoring evidence and rulings on witnesses did not raise appropriate grounds for appeal, and the claimant was not permitted to raise additional issues not contained in the Notice of Appeal.

Crecoukias v. Toronto Transit Commission (19-014590)

The claimant witnessed an individual being struck and killed by a bus. He applied to the LAT for a catastrophic impairment designation, and disputing entitlement to ACBs and various medical benefits. The insurer argued that the claimant’s severe psychological impairments were the result of pre-existing schizophrenia that was already worsening prior to the accident. Adjudicator Neilson agreed with the insurer. Although she accepted that the claimant suffered a psychological injury from witnessing the incident, she found that the schizophrenia and severe psychological impairments demonstrated by the claimant were not a result of the accident, and that it would have developed regardless. The claimant showed a prodromal stage of schizophrenia from a young age, and he was at high risk from developing schizophrenia due to drug use and family history of psychosis. The evidence of the claimant’s mother was rejected as being non-credible as it was contradicted by the medical records of the claimant’s treating psychiatric team. Adjudicator Neilson also noted that she rejected the opinion of the claimant’s catastrophic impairment experts, as it was a chiropractor that provided the AMA ratings following assessment and diagnosis by a psychiatrist. Even using the opinion of the claimant’s psychiatrist, Adjudicator Neilson found that the claimant failed to prove that he suffered a Class 4 marked impairment or Class 5 extreme impairment in any of the four spheres of function as a result of the accident. Adjudicator Neilson did not need to address the claims for ACBs or medical benefits as the claimant had exhausted his medical benefits limits. However, in the event she was overturned with regard to the catastrophic impairment decision, she would have held that the unpaid ACBs related to transportation for the service provider, which was not payable under the SABS. She also found the claimed transportation to be inconsistent with the claimant’s ability to drive himself. Adjudicator Neilson also would have rejected the denied rehabilitation support worker services, as they were duplicative of services the claimant was already receiving at CAMH. Finally, Adjudicator Neilson would have rejected the claims related to the hotel stays, because they were claimed as medical benefits and incurred without a treatment plan. There were also procedural matters addressed at the outset of the hearing. Adjudicator Neilson allowed the insurer’s IE psychiatrist to observe the testimony of the claimant’s psychiatric expert; she allowed a defence medical report completed in the tort matter to be admitted as the insurer had access to the report and it had been provided to other expert witnesses; she allowed the insurer’s IE psychiatrist to testify to matters not contained in the report, while giving the claimant’s expert an opportunity to respond by way of reply evidence; and she restricted the claimant’s catastrophic impairment chiropractor to limiting his testimony to matters pertaining to the spine and musculoskeletal system only.

H.Y.Z. v. Allstate Canada (18-003942)

The insurer initially accepted that the claimant sustained a catastrophic impairment, but reversed its decision upon receipt of ODSP records detailing similar pre-accident impairments. The claimant argued that the treatment plans submitted during the period while she had access to the catastrophic impairment limits ought to be payable. The insurer argued that because the claimant did not truly suffer a catastrophic impairment, she was not entitled to any medical benefits in excess of the standard limits. Vice Chair Lester held that the claimant was entitled to seek medical benefits in excess of the standard limits for the time period the insurer had advised that she was catastrophically impaired. Vice Chair Lester considered each claimed medical benefit under the reasonable and necessary standard, and awarded the treatment plans for psychological treatment (aside from transportation costs). Further physical therapy was mostly denied as there was no evidence to suggest that the claimant received any benefit from the treatment. No submissions were made regarding occupational therapy or an attendant care assessment. Those claims were also denied.

Yevdokymova v. Economical Insurance (21-000502)

The claimant sought a catastrophic impairment designation and entitlement to various medical benefits and attendant care benefits. The insurer argued that the claimant was barred from disputing entitlement because an earlier hearing regarding NEBs already concluded that the claimant did not suffer the majority of the injuries or impairments allegedly sustained in the accident. The insurer also argued that the claim for ACBs was barred due to the claimant’s failure to participate in an IE, as the claimant had put conditions on her attendance, including the presence of her own occupational therapist. In response, the claimant argued that the current dispute was for different benefits, and as such, the earlier decision on NEBs was irrelevant. The claimant also argued that she ought to be permitted to have her own occupational therapist observe the in-home assessment requested by the insurer. Vice Chair Flude agreed with the insurer and held that the claimant’s current application was barred by res judicata. Although the specific benefits and designation at issue were different than the NEB hearing, the findings of fact in the NEB hearing were so closely related that to allow the claimant’s application to proceed would amount to an abuse of process. Vice Chair Flude also held that the claimant could not impose conditions on her attendance and participation in the requested in-home IE. The insurer met all requirements of section 44 when requesting the IE. As such, the claimant’s failure to participate in the format requested by the insurer triggered section 55. Vice Chair Flude dismissed the dispute in relation to a catastrophic impairment, and stayed the dispute in relation to ACBs until the claimant participated in the in-home IE.

Sahadeo v. Pafco Insurance Company (19-006331)

The claimant sought catastrophic impairment designation under Criterion 7 (53% WPI, rounded to 55%) and/or Criterion 8 (marked impairment in Adaptation) of the SABS, as well as entitlement to various medical benefits. Vice Chair Lester found that the claimant was not catastrophically impaired. With respect to Criterion 8, Vice Chair Lester felt that the claimant suffered a moderate (not marked) impairment in Adaptation. The claimant had no issues completing the tasks assigned during either of the OT assessments, and showed no failures to adapt or decompensate in the face of work-like stressors. The claimant also testified that he was able to take his son to daycare every day, showing no reliability issues with attendance. With respect to Criterion 7, Vice Chair Lester accepted the insurer’s lower WPI rating for psychological impairments, given her determination that the claimant suffered a moderate (not marked) impairment in Adaptation, which brought the WPI down to 37%. Vice Chair Lester accepted that three denied treatment plans for physical treatment were reasonable and necessary (up to the remaining policy limits), emphasizing that pain relief is a legitimate goal of treatment. Vice Chair Lester went on to award the claimant costs in the amount of $500 with respect to counsel for the insurer’s conduct in providing an erroneous opinion on the validity of a summons issued to an IE assessor, which resulted in the assessor not attending the hearing on the date he was scheduled to appear.

Ramnarine v. Aviva General Insurance (20-007108)

The claimant sought catastrophic impairment designation under Criterion 8 (marked impairment in Activities of Daily Living, Social Functioning, and Adaptation), as well as entitlement to Non Earner Benefits and various medical benefits. The claimant had a significant pre-accident medical history for chronic pain, Somatic Symptom Disorder, and Major Depressive Disorder. Adjudicator Hines found that the accident was not a necessary cause of the claimant’s physical and psychological impairments, nor did it result in the functional limitations which formed the basis for the claimant’s application for a CAT determination. Notably, psychological status reports prepared both shortly prior to and shortly after the accident noted very similar impairments and limitations. Given that “not much had changed post-accident”, Adjudicator Hines found that the claimant had not sustained a CAT impairment as a result of the accident, nor was he entitled to NEBs. Adjudicator Hines went on to find that a chronic pain program was reasonable and necessary as there was some exacerbation of his pre-existing chronic pain as a result of the accident. She also found an occupational therapy assessment to be reasonable and necessary to investigate the degree that the claimant required attendant care, if any, as a result of his accident-related impairments.

Bernard v. Unica Insurance Inc. (20-007082)

The claimant sought catastrophic impairment designation, as well as entitlement to non earner benefits, attendant care benefits, and housekeeping benefits. The claimant, who had a pre-existing history of ADHD and Asperger’s syndrome, suffered a comminuted fracture of his left tibia/fibula when he was struck by a car while riding his bicycle. The claimant underwent two surgeries, and suffered from ongoing pain and functional impairment. The parties agreed that from a physical perspective, the claimant’s injuries were significant, permanent impairments. The insurer’s IE assessors concluded that the claimant suffered a 44% WPI. The parties disagreed as to whether the claimant suffered impairments from a psychological perspective that met the criteria for a 55% WPI. Based on the 44% WPI, the claimant would require a further 19% WPI in order to meet the threshold established in the Combined Values Chart. Adjudicator Grant found that the evidence fell short of meeting the requirements to establish same. Notably, the family doctor records were largely silent with any notations that would support complaints or recommendations for psychological-based treatment or medication. Adjudicator Grant accepted that the claimant had established entitlement to NEBs, as his physical injuries significantly limited his ability to engage in almost all aspects of his activities of daily living. Adjudicator Grant found that attendant care services were not reasonable and necessary, and that the claimant was not entitled to housekeeping benefits as he was not found CAT.