The claimant appealed the Tribunal’s decision that she was failed to attend an IE in relation to a claimed prescription expense. The claimant argued that the SABS does not permit an IE in relation to prescriptions. The Divisional Court granted the appeal, holding that only items required to be submitted on a treatment plan could be referred to IE. Items permitted to be submitted by way of OCF-6 could not be assessed at an IE. The Court also held that the $250 threshold referred to in section 38(2) did not apply to prescription. Rather, it only applied to “goods with a cost of $250 or less per item.” The Court wrote that the adjudicator ought to have followed the FSCO decision in Ward v. State Farm, which was persuasive authority for the claimant’s position.
Two claimants sought judicial review of the Tribunal Orders staying their applications while ordering the claimants to attend IEs prior to hearings on catastrophic impairment disputes. The Court held that the judicial review was premature and should not be heard. The cases did not raise exceptional circumstances, absent which the Court would not consider review or appeal of interlocutory matters.
The claimant appealed and sought judicial review of the Tribunal’s decision to dismiss her application due to non-attendance at an IE. The Court dismissed the appeal and judicial review, holding that the Tribunal properly considered the SABS and the materials before it, and the result was a reasonable outcome available to the Tribunal under the SABS. The claimant failed to prove that she was not afforded procedural fairness in the hearing.
The insurer raised a preliminary issue and argued that the claimant was barred from applying to the LAT for failure under s. 55 and s.44 of the SABS to cooperate with an IE assessor. Secondly, the insurer argued that the claimant did not suffer a complete inability to carry on a normal life. The claimant argued that she “became ill or unwell” during the assessment and was unable to participate, and that she did suffer a complete inability to carry on a normal life. The insurer had arranged for an occupational therapy IE to address NEBs. When the OT arrived at the claimant’s resident, she was informed that the claimant was not home. After several unsuccessful attempts to ascertain where the claimant was, the OT was able to speak to the claimant by cell phone and was informed that the claimant and her husband “were driving back from Wasaga Beach and stuck in traffic”. The assessment proceeded, although later than scheduled and was modified to a joint assessment with the claimant and her husband, rather than the back-to-back assessments originally scheduled. After around two hours, the claimant stated she was feeling unwell and requested that the balance of the assessment be rescheduled. The insurer agreed to reschedule the assessment and it was continued on June 27, 2018. The assessor noted that “Ms. Ruchlemer reported she felt unwell and was experiencing severe back pack pain and headaches, and again requested the assessment be rescheduled.” The assessor also reported that the claimant refused to participate in the functional portion of the assessment. Vice-Chair Flude noted a previous insurer’s report from two months prior, in which the assessor noted that the claimant performed tasks, albeit with both pain and difficulty. Based on the evidence, Vice-Chair Flude opined that it was reasonable for the claimant to refuse a physical exam that may cause her pain, and that a refusal to participate in those circumstances did not amount to a refusal to cooperate entirely with the assessment. The preliminary issue was dismissed. In terms of NEBs, Vice-Chair Flude opined that the claimant did not meet the complete inability test as she still traveled out of town to visit relatives, traveled internationally, went to restaurants and socialized, and the extent that she reported a decline in these activities would not amount to a complete inability to carry on a normal life as defined in the SABS.
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.
The insurer brought a preliminary issue motion to bar the claimant’s claim for non-attendance at IEs. Although he had attended the IE clinic at the appropriate time, he had become aggressive and refused to proceed until the clinic agreed to use the consent form he had personally prepared. At the motion hearing, the claimant argued that s. 44 provided him the right to require his IE assessors to have expertise in Platelet-Rich Plasma therapy (the treatment modality that was being proposed in the disputed treatment plans that had triggered the IE). He also submitted that s. 44 required an assessment to be “reasonably necessary”, which included providing information regarding the medical specialization of the assessors. Adjudicator Flude rejected the claimant’s position and stated that the terms “reasonably necessary” in s. 44(1) were written to prevent insurers from attempting to wear out a claimant by requiring them to attend multiple IEs for the same matter. Adjudicator Flude noted that the claimant had unsuccessfully raised the same argument before the LAT regarding s. 44 and his IE assessors’ expertise on a previous occasion. He noted that the claimant’s reassertion of the same argument appeared to be an abuse of process. He found that the claimant had not identified the elements of his IE clinic’s consent form that were problematic, and as a result, that it appeared to be an excuse to refuse to attend IE assessments. Adjudicator Flude held that the claimant was barred from proceeding under s. 55(1), and that the circumstances did not warrant an exercise of the LAT’s discretion under s. 55(2) and (3).
This motion was brought by the claimant for a declaration that she was not barred from proceeding to a hearing due to non-attendance at a psychological IE. The claimant argued that the Notice of Examination for the IE did not satisfy the requirements in s. 44, and that s. 55(1) was not triggered because the IE had been requested after she had filed her LAT application. Adjudicator Mazerolle found that the Notice of Examination satisfied the requirements under s. 44 as it provided sufficient medical and other reasons for the assessment. Although it was concerning that the insurer had served the Notice of Examination in September 2021, despite the disputed treatment plan having been submitted on March 23, 2021, Adjudicator Mazerolle found that the insurer had requested medical records from the claimant on March 29, 2021, one week after the disputed treatment plan had been submitted, and had not received these records until August 21, 2021. He reasoned that the insurer had waited to receive these records before setting up the IE and had requested the IE with the intention of properly adjusting the claim. The adjudicator rejected the claimant’s argument that s. 55(1) would only be triggered if the IE was requested before a LAT application was filed, as this would impair the insurer’s ability to seek assessments under s. 44 and because it went against the principle that an insurer’s duty to adjust a claim in good faith did not end when litigation began. However, Adjudicator Mazerolle exercised the discretion granted under s. 55(2) and permitted the application to proceed because there remained ample time for the IE to be completed before the hearing.
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.
The insurer brought a motion requesting that the claimant’s application for IRBs be barred under s. 55(1) due to IE non-attendance. The claimant had failed to attend a post 104-week physiatry IE on four occasions. Adjudicator Mazerolle found that the Notice of Examination provided sufficient medical and other reasons for the examination under s. 44. Nonetheless, he exercised his discretion permitted under s. 55(2) to allow the IRB claim to continue. He found that the claimant had participated in other IEs, which demonstrated her interest to pursue the claim. He noted that two of the missed four IEs had been postponed due to COVID-related concerns, and that the claimant had been ill for the most recently rescheduled IE. Above all, Adjudicator Mazerolle found that the parties had enough time before the hearing to reschedule and complete the IE and ordered that the IRB claim proceed.
The claimant appealed the Tribunal’s decision dismissing his application due to repeated non-attendance at IEs. The Court dismissed the appeal, holding that the LAT had the legal authority to dismiss the application. The claimant’s failure to cooperate in obtaining IEs interfered with the insurer’s ability to participate in the process before the Tribunal, and caused delay in the timely determination of the matter before the Tribunal. The Tribunal was justified in concluding that the claimant’s behaviour amounted to abuse of process. The Court also rejected the claimant’s argument that the Tribunal did not have the power to require that he sign a consent as part of the IE process. The Court affirmed that the Tribunal does have such power as part of its power to require the claimant to cooperate in the IE process.