Category: Home Modification

Z.P. v. Certas Direct Insurance Company (19-003226)

The claimant suffered a catastrophic impairment and sought entitlement to three treatment plans for home modifications and assistive devices. With respect to a $9,025.30 home modification assessment, the insurer had already paid $2,000 and argued that it was the maximum payable under the SABS. Vice Chair McQuaid agreed that the maximum payable was limited to $2,000 and dismissed the remaining $7,025. With regard to assistive devices, Vice Chair McQuaid concluded that the treatment plan was reasonable and necessary for the claimant’s impairments. For the third treatment plan regarding architectural working drawings, Vice Chair McQuaid found that there was a question as to whether the claimant still wanted to pursue home modifications after the proposal of Adapt-Able was withdrawn. The architectural drawings were therefore not payable.

R.T. v. The Economical Group (17-008069)

The claimant was catastrophically impaired as a result of an accident and sought a determination that she was entitled to receive home modifications and home devices in the amount of $415,334.00. The insurer agree that home renovations were required but disputed the scope and quantum of the proposed benefits. Adjudicator Grieves found that the proposed benefits relating to a rear entrance, deck, intercom system, and security system were reasonable and necessary. Adjudicator Grieves found that the proposed installation of an elevator, bedroom addition with ensuite bathroom, and an addition for a therapy room were not reasonable and necessary. Adjudicator Grieves found that the claimant was only entitled to interest on the portions of the treatment plan for which costs had been incurred.

R.G. v. State Farm Insurance (17-006934)

The claimant sought entitlement to a home modification assessment. The insurer agreed to pay for the assessment up to $2,000. The claimant argued that the cap did not apply to such assessments. Adjudicator Gosio agreed with the insurer and held that home accessibility and housing assessments were subject to the $2,000 cap on assessments.

Applicant v. Motor Vehicle Accident Claims Fund (17-001681)

The claimant suffered a catastrophic impairment following a motorcycle accident which caused a traumatic brain injury. He sought entitlement to NEBs, ACBs, a rehab support worker, home modifications, and a special award. The Fund denied his entitlement to the claimed benefits. It also argued that the claimant did not have a valid licence and was not entitled to NEBs, and that no attendant care services had been incurred. Regarding the exclusion, Adjudicator Hines concluded that it did not apply because the claimant did have a valid driver’s licence (G1) even though it was not the proper licence for operating a motorcycle. She awarded NEBs, concluding that the claimant’s life had changed significantly following the accident. Even though the claimant was receiving ODSP for various disabilities before the accident, the brain injury resulted in significant changes in the claimant’s independent functionality. ACBs were also awarded at the rate of $6,000 per month. Adjudicator Hines concluded that 24 hour care was reasonable based on the claimant’s brain injury and the need for constant supervision. She also held the ACBs to be deemed incurred up to the date of the hearing because the Fund had failed to consider its IEs with a critical eye to ensure that they were medically sound and unbiased. Rehab support worker services were awarded because it was reasonable to teach the claimant skills and strategies to reintegrate into the community. Home modifications were not awarded because the majority of recommended modifications were for someone with severe physical disability rather than a brain injury. Finally, Adjudicator Hines granted a special award in relation to ACBs and the rehab support worker. She concluded that the denials were unreasonable and that the Fund did not critically consider its own IE reports. The Fund also failed to follow the recommendations of its own independent adjustors.

The Applicant v. The Guarantee Company of North America (17-001170)

The claimant sought payment of home renovations. Adjudicator Johal explained that the onus is on the claimant to prove on a balance of probabilities that the renovations were reasonable and necessary. In this case, the renovations would only be reasonable and necessary if they provided the claimant access to areas of the home that were needed for ordinary living. Adjudicator Johal found the disputed treatment plan partially payable. Adjudicator Johal found that it was reasonable and necessary to renovate the primary entry to the home concluding that the pathway needed to be replaced because it was uneven and posed a tripping hazard and the handrail needed to be replaced because the claimant was unsteady on her feet. Adjudicator Johal found that any renovations to make the property wheelchair accessible were not reasonable and necessary, because the claimant could move through her house without any mobility aid and thus did not require a wheelchair. He also found that renovations to enable the use of a four-wheeled walker were not reasonable and necessary in areas of the home that allowed a 48 inch turn radius as this was not a standard set by the Ontario Building Code. Adjudicator Johal concluded that a heated shed was not reasonable and necessary for storing the claimant’s mobility scooter during the winter, because the claimant’s husband and attendant care providers could move the scooter inside for her, and because there was no evidence that the winter weather would impact the scooter’s battery.

D.K.M. v. Motor Vehicle Accident Claims Fund (16-004520)

The claimant sought the remainder of a partially approved home modification treatment plan (which sought the purchase of a new home) in the amount of $119,451.70. The insurer asserted the remaining balance of the treatment plan was not reasonable and necessary and given the claimant’s “Indian” status HST would not apply to the figures originally claimed. It was agreed that a new home was necessary rather than the expense of making repairs to the current residence, which was on an aboriginal reserve and in a state of disrepair. Adjudicator Ian Maedel, on review of the evidence, including estimates for modifications to the existing home, determined that the remaining balance was payable less amounts allocated to HST. It was noted that an insurer would ordinarily have to pay these fees; however, since the claimant was exempt, the invoices would likely be lower than the remaining amount being claimed. Where, however, the claimant still had to pay HST, Adjudicator Maedel indicated the insurer would have to pay the amount as well.

D.M. v. RBC General Insurance Company (16-000080)

The claimant sought home modifications in the form of home repairs. The words “modification” and “repair” were not defined in the SABS. Adjudicator Truong ruled that a “repair” can be a “modification” and held that some of the repairs were payable because such repairs were linked the Applicant’s safety and were needed to assist the claimant’s reintegration into the home.