Category: IE Non-Attendance

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.

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.

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.

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.