Category: IE Non-Attendance

The claimant was involved in an accident. She incurred transportation expenses in relation to her hip replacement surgery, and submitted these expenses to her insurer. The insurer denied payment of the transportation expenses as the records did not support that the surgery was required as a result of the accident. The claimant submitted an additional report from her doctor, and the insurer provided notice that the claimant was to attend an IE. The applicant refused to attend, claiming that the insurer had no right to request an examination under s. 44 as a treatment plan was not required for mileage expenses. Adjudicator Kaur held that the insurer has the right to request an IE in respect of transportation services, as they are medical benefits under s. 15(1)(g) of the SABS, and that the insurer may require the claimant to be examined to determine her entitlement to the medical benefit of transportation expenses. However, the insurer’s notice of examination was found to be defective, as it failed to mention the “medical and any other reasons” which formed the basis for the insurer’s decision.

The claimant submitted an application for determination of catastrophic impairment. The insurer scheduled two IEs (psychological and occupational therapy), which the claimant attended. However, Dr. Kiss (psychologist) passed away before he could complete his report, and the insurer determined that the claimant had not meaningfully participated in the situational portion of the OT IE. The insurer issued a second set of notices of examination, which the claimant refused to attend. Vice Chair Logan held that the claimant was non-compliant with s. 44 with respect to the subsequent OT IE situational assessment and stayed the claimant’s application until he complied with the notice of examination. As the claimant was seeking a CAT determination under Criterion 8, Vice Chair Logan held that there was a reasonable nexus between the situational assessment and the claimed impairment, and the insurer would be prejudiced if the situational assessment was not completed. Vice Chair logan held that a second in-person psychology IE was not reasonably necessary, and that a paper review of Dr. Kiss’ assessment and file material would be sufficient. The claimant had already attended one psychology IE, and would be significantly prejudiced if he was required to undertake a new in-person IE, more than 2 years after the initial IE.

The insurer requested that the claimant attend insurer examinations (IE) to assess her claims for various benefits. The claimant only attended one IE, and the insurer sought to bar the claimant’s application for attendant care, non-earner benefits, and treatment plans for her failure to attend IEs. The insurer sent 4 notices of examination to assess the claimant’s entitlement to NEBs, 6 notices of examination to assess the claimant’s application for attendant care, and one notice of examination to assess the claimant’s OCF-3. Adjudicator Kaur held that all of the notices of examination were defective, and the claimant’s application was allowed to proceed. All of the insurer’s notices were found to be vague, as they did not refer to the claimant’s medical condition. In all of the notices of examination, the insurer failed to specifically identify and state what injuries or impairments they believed were not caused by the accident.

The claimant was involved in an accident on November 25, 2015 and sought attendant care benefits. The insurer denied ACBs and the claimant filed a LAT Application. The insurer filed a motion requesting that the claimant’s LAT Application be barred pursuant to s. 55 of the SABS for failure to attend three properly scheduled independent medical examinations to address ACBs. After the insurer filed the motion, the claimant was accepted as CAT and advised the LAT that she wanted to attend the IE in order to move the matter forward. In response, the insurer requested an Order staying the proceedings until the claimant attended the IE. Vice-Chair Flude noted that the claimant had in fact attended numerous other assessments addressing attendant care with both s. 25 and s. 44 providers. The claimant argued that the subject notice was not compliant with the SABS and did not include sufficient medical and other reasons. Vice-Chair Flude disagreed, noting that the letter made specific references to the claimant’s medical records noting an improvement in physical ability, as well as the fact that the disputed Form 1 was over three times the recommended amount, which satisfied the insurer’s obligations. As such, the claimant’s failure to attend the April 18, 2017 IE triggered s. 55. Vice-Chair Flude did not consider the other two failures to attend, as both had been cancelled by the insurer for various reasons. Vice-Chair Flude opined that while the claimant’s failure to attend the IE may be sufficient to strike the claim, she had advanced her claim vigorously since then and had been accepted as CAT. The claimant also expressed a willingness to attend the IE in order to advance the claim. As such, Vice-Chair Flude opted not to issue an Order staying the Application until the claimant attended, but rather issued an Order for the parties to agree on a mutual date for IE attendance within 30 days, and for the IE to take place within 90 days. Should the parties not be able to agree to such dates, they were to submit three proposed each dates to Vice-Chair Flude, who would then decide the date. Should the claimant not attend the IE this time, the insurer would be allowed to request an Order staying the Application.