Category: IE Non-Attendance

N.A. v. Aviva General Insurance (19-003283)

Post author By tgp-admin
Post date October 21, 2020
No Comments on N.A. v. Aviva General Insurance (19-003283)

The claimant applied to the LAT for NEBs, ACBs, and various medical benefits. The insurer argued that the claimant failed to attend IEs and was not permitted to proceed with the LAT dispute until attending. Adjudicator Hines held that the claimant could not proceed with her claims for ACBs, an in home-assessment, or on treatment plan for chiropractic services. The IE notices for those benefits contained all information required by section 44. The medical reasons indicated that the claimant’s injuries fell within the MIG (among other things). The claimant was permitted to proceed with the other aspects of her claim as the IE notices did not set out sufficient medical reasons. In particular, the insurer wrote in the deficient IE requests “the disability period appears to be inconsistent with the diagnosis or mechanism of the injury.” This wording was found to be insufficient as it was not specific to the claim’s injuries and would not be understood by a lay person.

M.E.R v. Aviva General Insurance Company (17-008924)

Post author By tgp-admin
Post date September 23, 2020
No Comments on M.E.R v. Aviva General Insurance Company (17-008924)

The claimant applied to the LAT seeking entitlement to ACBs in the amount of $2,479 per month and various medical benefits for physical treatment, psychological treatment, occupational therapy services, an orthopaedic mattress, the cost of clothing and personal expenses, and transportation expenses. The claimant was a pedestrian injured in a motor vehicle accident in a parking lot. The insurer’s Form 1 initially recommended ACBs in the amount of $297.76 per month. A subsequent insurer’s Form 1 recommended $0.00 for ACBs. The assessor opined that the provision of unnecessary support for self care tasks would promote unnecessary dependency on external supports which is not required in the course of rehabilitation. Adjudicator Gosio found that there was no objective evidence of ongoing physical impairments in the left upper extremities, and the insurer’s Form 1s were reasonable. The claimant was entitled to chiropractic and physiotherapy treatment, and ACBs in the amount of $297.76 per month for 10 months. Adjudicator Gosio found that the claimant failed to establish that 90-minute sessions of psychotherapy, as opposed to the approved 60-minute sessions, were reasonable and necessary. Pursuant to section 55 of the SABS, the claimant was barred from disputing entitlement to the orthopaedic mattress as she had failed to attend an IE assessment.

Omar v. Co-operators General Insurance Company (20-000085)

Post author By tgp-admin
Post date September 16, 2020
No Comments on Omar v. Co-operators General Insurance Company (20-000085)

The insurer brought a motion to dismiss the LAT application for failure to attend IEs and failure to disclose relevant documents in a timely matter. Adjudicator Flude found that the claimant’s failure to attend properly scheduled IEs was grounds for dismissal of the LAT application. A reasonable explanation for non-compliance with the IE had not been provided. Adjudicator Flude found that there was no authority under section 33 to dismiss the application for failure to disclose documents. It was noted that section 33 has its own remedies, including suspension of benefits during periods of non-compliance, absent a reasonable excuse.

J.C. v. Aviva General Insurance Company (19-004734)

Post author By tgp-admin
Post date September 14, 2020
No Comments on J.C. v. Aviva General Insurance Company (19-004734)

The claimant sought entitlement to various medical benefits, including medical cannabis, physical treatment, and a chronic pain program. The insurer argued that the claimant could not dispute two of the treatment plans due to IE non-attendance. The claimant responded that it wasn’t reasonable to request a psychiatric assessment for the medical cannabis. Adjudicator Johal found the insurer’s IE notice complied with section 44, and rejected the claimant’s argument that the IE request was not reasonable. The claimant was therefore barred from disputing the two treatment plans due to section 55. With regard to the remaining treatment plans, Adjudicator Johal held that the claimant failed to prove that the proposed treatments were reasonable and necessary, and dismissed the claims.

S.M. v Certas Home and Auto Insurance Company (18-010866)

Post author By tgp-admin
Post date September 2, 2020
No Comments on S.M. v Certas Home and Auto Insurance Company (18-010866)

The insurer brought a preliminary motion to bar the claimant from proceeding with his dispute as he did not attend multiple IEs. Adjudicator Moten held that the respondent’s requests for IEs to assess the claimant’s entitlement to benefits were reasonable and that the claimant could not proceed with his LAT dispute.

A.Q. v. Wawanesa Mutual Insurance Company (19-006903)

Post author By tgp-admin
Post date August 14, 2020
No Comments on A.Q. v. Wawanesa Mutual Insurance Company (19-006903)

The claimant sought entitlement to ACBs and various medical benefits. The insurer argued that the limitation period barred the ACBs claim and that the claimant failed to attend IEs related to the medical benefits claimed and was unable to dispute entitlement until attending the IEs. Adjudicator Boyce held that the insurer’s denial of ACBs in which it requested IEs triggered the limitation clock, even though the claimant did not attend the scheduled IEs. Adjudicator Boyce did not extend the limitation period under section 7 of the LAT Act because the claimant failed to show a bona fide intention to appeal the denial of ACBs within the two-years; the 45 day delay was excessive in the context of the claimant being represented and where the claimant provided no indication that he would be challenging the denial; and the insurer would suffer prejudice because the claimant prevented the insurer from obtaining contemporaneous assessments of ACBs entitlement. Regarding the medical benefits, Adjudicator Boyce held that the insurer’s IE requests were sufficiently particularized, that the requests were timely and in response to specific claims, and that the claimant’s failure to attend the IEs prevented him from applying to the LAT.

M.Y. v. Wawanesa Mutual Insurance Company (19-003973)

Post author By tgp-admin
Post date August 5, 2020
No Comments on M.Y. v. Wawanesa Mutual Insurance Company (19-003973)

The claimant sought reconsideration of the Tribunal’s decision that she was barred from litigating her claim due to failure to attend two IEs. The insurer argued that the claimant’s request for reconsideration was filed beyond the 21 as required in the Rules. Vice Chair Farlam noted that the request was only a single business days outside of the 21 day time limit as required by Rule 18.1. Vice Chair Farlam relied upon Rule 3.1(a) in order to facilitate a fair, open and accessible process and allowed the matter to proceed. Vice Chair Farlam examined the facts in evidence and found that the Tribunal had not made an error with the original decision. She noted the consistency of facts in the decision, that the claimant did not provide a reasonable explanation for not attending the examinations, and that the claimant did not provide sufficient evidence to prove the claims made at the hearing. The request for reconsideration was denied.

K.A. v. Aviva General Insurance Company (19-002676)

Post author By tgp-admin
Post date July 30, 2020
No Comments on K.A. v. Aviva General Insurance Company (19-002676)

The claimant sought entitlement to IRBs. The insurer argued that the claimant had failed to attend IE, and failed to comply with section 33 requests. Adjudicator Johal held that the claimant was barred from proceeding due to the IE non-attendance, reasoning that the IEs were reasonably required for determining entitlement to post-104 week IRBs even though IRBs had been terminated prior to the 104 week mark, and that the notices provided the requisite information. Adjudicator Johal rejected the insurer’s section 33 defence because section 33 did not prevent the Tribunal from adjudicating the claim. The consequences of section 33 non-compliance ultimately go to entitlement to a disputed benefit.

J.A. v. Intact Insurance Company (19-005110)

Post author By tgp-admin
Post date July 16, 2020
No Comments on J.A. v. Intact Insurance Company (19-005110)

The claimant disputed two treatment plans and sought removal from the MIG. The insurer requested IEs, which the claimant did not attend. Adjudicator Farlam held that the claimant was barred from proceeding with the dispute. She rejected the argument that the insurer could not request an IE to address the MIG. He unreasonably failed to attend the IE. She also noted that the IE requests advised that it was for both the MIG and a disputed treatment plan. She also held that an insurer was not required to conduct a paper review to address the MIG.

Y.R. v. Coachman Insurance Company (19-006234)

Post author By tgp-admin
Post date July 3, 2020
No Comments on Y.R. v. Coachman Insurance Company (19-006234)

The claimant disputed a determination of catastrophic impairment and entitlement to attendant care benefits. The insurer argued that the claimant failed to attend an IE and was barred from proceeding with the hearing. Adjudicator Chakravarti permitted the claimant to proceed. The request for the IE to address attendant care benefits was not made in accordance with section 42 because the request was not made after receiving a new Form 1 or made following a request for an updated Form 1 from the claimant. However, the adjudicator indicated that the insurer could request a new IE in the future (and in advance of the hearing), if the request complied with section 42. In that regard, the adjudicator set out a timeline for the parties to make any necessary requests in advance of the hearing.

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