Category: IE Non-Attendance

Applicant v. CAA Insurance (17-001138)

The Tribunal was asked to determine whether the claimant was barred from proceeding with his appeal of the insurer’s denial of medical benefits owing to his failure to attend scheduled examinations, in contravention of section 44.  The claimant had sought a determination of catastrophic impairment. The insurer indicated that further IEs were required to make such a determination, and sent three letters advising the claimant of this. Adjudicator Goela held that the claimant was required to attend the IEs before the matter could proceed to a hearing. Adjudicator Goela noted that the insurer had provided proper notice of the scheduled examinations, and that any prejudice to the claimant could be minimized by rescheduling the examinations promptly.

Applicant v. Economical Mutual Insurance Company (17-004358)

The claimant sought entitlement to NEBs, ACBs, and medical benefits. The insurer argued that the claimant failed to attend IEs; the claimant responded that the IEs were not reasonably required and several were requested after the LAT application. Adjudicator Mazerolle agreed with the insurer. He held that the IE notices provided the medical reason for the assessments – namely, that the insurer had received section 25 assessments with new information which required updated medical opinions. He also held the timing of the requests was appropriate based on the timing of the section 25 assessments. However, he held that an IE was not needed to determine if prescription expenses were reasonable and necessary because there was prejudice to the claimant if the psychiatric medications were not paid for.

T.F. v. Peel Mutual Insurance Company (16-003316)

The claimant sought reconsideration of the Tribunal’s decision that she was barred from seeking entitlement to two treatment plans, arguing that the insurer’s denials did not provider the requisite medical reasons. Executive Chair Lamoureux agreed with the claimant and overturned the decision. She held that the insurer’s medical reasons had to engage the specific details about the claimant’s condition, and should be adequate enough to allow an unsophisticated person to understand them and make an informed decision. She reasoned that the insurer’s denials in this case failed to cite the specific documentation upon which the insurer was relying in denying the proposed benefits.

T.F. v. Peel Mutual Insurance Company (16-003316)

The claimant sought reconsideration of the Tribunal’s decision that she was barred from seeking entitlement to two treatment plans, arguing that the insurer’s denials did not provider the requisite medical reasons. Executive Chair Lamoureux agreed with the claimant and overturned the decision. She held that the insurer’s medical reasons had to engage the specific details about the claimant’s condition, and should be adequate enough to allow an unsophisticated person to understand them and make an informed decision. She reasoned that the insurer’s denials in this case failed to cite the specific documentation upon which the insurer was relying in denying the proposed benefits.

Applicant v. Travelers Canada (17-005291)

The insurer requested the claimant’s attendance at an IE shortly before the LAT hearing. The claimant refused to attend. The insurer argued that the claimant could not proceed with the hearing. Adjudicator Paluch held that the insurer’s request for an IE was not reasonably necessary, and that the claimant could therefore proceed with the hearing. In coming to his conclusion, the adjudicator noted that the insurer had already conducted similar IEs, and that no new information was given to the insurer to warrant IEs at the time requested.

R.W. v. The Co-operators (17-005447)

The claimant sought entitlement to IRBs for a four month period of IE non-attendance. Adjudicator Ferguson held that the claimant had a reasonable excuse for not attending the IE – namely, that he suffered anxiety, which was exacerbated at the beginning of the initial IE assessment. The claimant was entitled to receive the four months of withheld IRBs.

Applicant v. RBC General Insurance Company (16-002963)

This is a preliminary issue decision on whether the applicant was precluded from proceeding with the LAT application until she attended requested IE assessments. With reference to Augustin v. Unifund, Adjudicator Daoud found that the insurer’s Notice of Examination complied with section 44 of the SABS and held that the applicant was precluded from proceeding with the application until she attended the assessments, pursuant to section 55 of the SABS.

A.L. v. The Personal Insurance Company (17-002582)

The Tribunal initially decided that the claimant was precluded from applying to the LAT in light of his non-attendance at multiple insurer examinations. Associate Chair Batty initiated a reconsideration on his own initiative to remedy a breach of procedural fairness in the preliminary issue hearing. In its reasons, the LAT had described how the respondent’s submissions relied upon affidavit evidence which had not been filed. Counsel for the respondent subsequently provided proof that the affidavit in question had been filed. It was not provided to the adjudicator as a result of an administrative error. Associate Chair Batty held that the respondent had been denied procedural fairness and remitted the matter to be reheard on the LAT’s full record.

A.L. v. The Personal Insurance Company (17-002582)

The Tribunal initially decided that the claimant was precluded from applying to the LAT in light of his non-attendance at multiple insurer examinations. Associate Chair Batty initiated a reconsideration on his own initiative to remedy a breach of procedural fairness in the preliminary issue hearing. In its reasons, the LAT had described how the respondent’s submissions relied upon affidavit evidence which had not been filed. Counsel for the respondent subsequently provided proof that the affidavit in question had been filed. It was not provided to the adjudicator as a result of an administrative error. Associate Chair Batty held that the respondent had been denied procedural fairness and remitted the matter to be reheard on the LAT’s full record.

I.K. v. Primmum Insurance Company (16-001652)

The claimant sought entitlement to a number of medical benefits as well as attendant care benefits. The insurer argued the claimant was barred from proceeding with a LAT application for failing to attend a number of IEs, pursuant to section 55. The LAT agreed and dismissed the matter. On reconsideration, Executive Chair Linda Lamoureux upheld the decision. It was noted that IEs are an important tool for medical management. In this instance, the insurer’s requests were reasonable. The claimant raised an argument that section 55 should operate to bar a proceeding only for the benefits the IE is reviewing and allow all other claims to proceed. Executive Chair Lamoureux noted this argument was new and should have been raised at the Tribunal level and declined to exercise the discretion to hear fresh arguments at the reconsideration level.