Category: IE Non-Attendance

Applicant v. Aviva General Insurance (17-006537)

Post author By tgp-admin
Post date October 10, 2018
No Comments on Applicant v. Aviva General Insurance (17-006537)

The claimant sought entitlement to various treatment plans, IRBs and dental treatment. The insurer raised section 33 and 55 defences due to the claimant’s failure to provide requested information and attend IEs. Adjudicator Ferguson held that the claimant was barred from seeking IRBs and dental treatment for failing to provide dental records, invoices, an OCF-10, income tax returns, and post-accident income information requested per section 33. The adjudicator held that there was no legal basis for the claimant’s argument that as long as best efforts are made under s. 33, the claim moves forward. The adjudicator also held that the claimant’s appeal for other goods and services of a medical nature was barred per section 55. The claimant’s reason for non-attendance was that her psychological and pain-related impairments prevented her from leaving her house, which was not supported with any evidence and the insurer had surveillance showing her participating in various ADLs outside of her house. The adjudicator denied various treatment plans due to lack of medical evidence, but found the balance of a chiropractic treatment plan payable as the insurer only denied the treatment plan based on the MIG, and was not allowed to rely on the MIG position after covering psychological treatment.

D.M. v. RBC Insurance (17-006781)

Post author By tgp-admin
Post date October 10, 2018
No Comments on D.M. v. RBC Insurance (17-006781)

The claimant sought entitlement to an ADL assessment and orthopedic assessment. The insurer argued that the claimant was statute-barred from disputing the denials. Adjudicator Norris held that the claimant was not entitled to the ADL assessment, but was entitled to the cost of the orthopedic assessment plus interest. The claimant claimed to have not received denial letters from the insurer. The adjudicator held that the claimant was barred from adjudicating the ADL assessment as the claimant received an unequivocal denial on June 4, 2015, over 2 years before the LAT Application. However, the adjudicator held that there was no clear and unequivocal denial of the orthopedic assessment. The first “denial” letter noted that the insurer would not fund the treatment plan “at this time” and a second letter only referenced the assessment plans by HCAI number, which the adjudicator found made it too difficult for the claimant to determine which plans were in dispute. The claimant incurred the cost of the disputed orthopedic plan after the 10th business day after the plan was proposed and prior to receipt of a clear and unequivocal denial. The insurer argued that the claimant was barred per section 55 from adjudicating entitlement to the orthopedic assessment for failure to attend a section 44 IE. The adjudicator held that the claimant was not barred as the insurer requested an assessment more often than reasonably necessary. The claimant attended a section 44 orthopedic assessment, but the insurer had failed to have the assessor assess the claimant’s entitlement to the disputed orthopedic assessment. Adjudicator Norris held that it was unreasonable to subject the claimant to another in-person assessment so soon after the first assessment simply because the insurer failed to address the issue during the previous IE.

B.H. v. Aviva Canada Inc. (17-003774)

Post author By tgp-admin
Post date September 6, 2018
No Comments on B.H. v. Aviva Canada Inc. (17-003774)

The claimant sought reconsideration of the Tribunal’s decision that he could not proceed with his application due to failure to attend an IE. Executive Chair Lamoureux held that the insurer’s denial of medication benefits and subsequent request for an IE did not comply with sections 38 and 44 of the SABS. She wrote that the insurer’s denial did not refer to the medical information Aviva relied upon to make its determination or explain why it could not determine whether the treatment recommendations were not reasonable. Executive Chair Lamoureux held that improper denial resulted in the disputed medical benefits being payable.

Applicant v. Aviva Insurance (18-000467)

Post author By tgp-admin
Post date September 6, 2018
No Comments on Applicant v. Aviva Insurance (18-000467)

The claimant sought entitlement to a mental health assessment. The insurer had requested the claimant’s attendance at an IE to address. The claimant attended the IE but it did not proceed because the claimant wishes to record the IE. The insurer argued that section 55 barred the claimant from seeking entitlement at the LAT. Adjudicator Kershaw held that the insurer’s IE notice was deficient because it did not provide specific details about the claimant’s condition that formed the basis of the insurer’s decision, and when the claimant sought clarification, the insurer said it was simply asking the claimant to comply with the SABS.

Applicant v Unifund Insurance Company (17-009004)

Post author By tgp-admin
Post date August 24, 2018
No Comments on Applicant v Unifund Insurance Company (17-009004)

The insurer requested reconsideration of part of a decision made by external counsel for the Tribunal during a case conference. At the case conference, the insurer requested the determination of the preliminary issue of whether the claimant was precluded from proceeding with his application to the LAT because he failed to attend IEs. External counsel directed that this preliminary issue would be heard with the issues in dispute at an in-person hearing. Adjudicator Jovanovic granted the request for reconsideration and held that the insurer was not afforded procedural fairness when its request for a determination of the preliminary issue was denied without reasons. Both parties should have the benefit of a decision on the preliminary issue before incurring the expenses of a full hearing. Adjudicator Jovanovic held that the preliminary issue would be determined first, and the balance of the hearing would be adjourned pending the release of a decision on the preliminary issue.

Applicant v. Aviva Insurance Company of Canada (17-004147)

Post author By tgp-admin
Post date June 14, 2018
No Comments on Applicant v. Aviva Insurance Company of Canada (17-004147)

The claimant sought removal from the MIG and entitlement to IRBs and various medical benefits. The insurer argued that the claimant failed to attend an IE, which barred payment of further IRBs. Adjudicator Norris concluded that the claimant did not suffer pre-existing conditions that would prevent recovery under the MIG and that the claimant did not suffer psychological injuries in the accident. He also held that the claimant was not entitled to further IRBs, and that the claimant’s non-attendance at an IE without reasonable explanation barred payment of IRBs for the period of non-compliance.

I.K. v. Coseco Insurance Company (17-004897)

Post author By tgp-admin
Post date June 7, 2018
No Comments on I.K. v. Coseco Insurance Company (17-004897)

The claimant sought a determination that his impairments were outside of the MIG and entitlement to medical benefits proposed in five treatment plans. The claimant argued that he should be removed from the MIG due to psychological impairments, chronic pain, and pre-existing migraines and left wrist/arm pain. Adjudicator Boyce found that pursuant to s. 55(1)2 of the SABS the claimant was statute barred from claiming entitlement to a s. 25 psychological assessment for failure to attend an IE assessment. Adjudicator Boyce found that claimant’s impairments were within the MIG and dismissed the application.

Applicant v. Aviva Insurance Canada (17-007036)

Post author By tgp-admin
Post date June 7, 2018
No Comments on Applicant v. Aviva Insurance Canada (17-007036)

The claimant sought entitlement to IRBs, occupational therapy treatment, the cost of an in-home occupational therapy assessment, and a special award. The respondent submitted that the claimant was barred from filing a LAT application due to failure to attend a s. 44 assessment, pursuant to s. 55 of the SABS. The s. 44 assessment had been arranged to address entitlement to IRBs and the in-home occupational therapy treatment. Adjudicator Boyce found that the claimant was statute-barred from applying to the LAT for failure to attend a properly scheduled s. 44 IE.

Applicant v. Aviva Insurance Canada (17-007683)

Post author By tgp-admin
Post date May 24, 2018
No Comments on Applicant v. Aviva Insurance Canada (17-007683)

The claimant sought payment for IRBs. The respondent brought a preliminary issue motion seeking to bar the claimant from commencing her application because she failed to attend IE assessments. Adjudicator Ferguson concluded that the insurer’s IE notices were compliant with s. 44 of the SABS. Adjudicator Ferguson concluded that the claimant’s application was not allowed to proceed until she attended IEs requested by the insurer to assess the claimant’s claim for IRBs.

D.C. v. Aviva Insurance Company (17-002921)

Post author By tgp-admin
Post date May 2, 2018
No Comments on D.C. v. Aviva Insurance Company (17-002921)

The claimant sought entitlement to NEBs, medical benefits, and the cost of various examinations. The insurer raised s. 55 and s. 33 defences. Pursuant to s. 55, Adjudicator Ferguson held that the claimant was barred from commencing part of the application as a result of his failure to attend IE assessments. He was only barred from pursuing the issues in dispute that were relevant to the IE assessments. Adjudicator Ferguson held that the claimant was entitled to NEBs for an initial period based on the insufficiency of the insurer’s s. 35(1) notice; however, the insurer was entitled to withhold payment of NEBs during the period in which the claimant was not in compliance with s. 33 requests.

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