Category: Income Replacement Benefits

W.A. v. Aviva General Insurance (19-000287)

The claimant sought reconsideration of the Tribunal’s decision denying his entitlement to income replacement benefits. Vice Chair Farlam dismissed the claimant’s reconsideration request, noting that reconsideration is only warranted in cases where an adjudicator has made a significant legal or evidentiary mistake preventing a just outcome, where false evidence has been admitted, or where genuinely new and undiscoverable evidence comes to light after a hearing. Vice Chair Farm reviewed the decision, and was satisfied that the totality of the medical evidence was considered and reasonable conclusions were reached based on the evidence as a whole, including credibility problems inherent in the evidence. Vice Chair Farlam also noted that all “new evidence” relied upon by the claimant on reconsideration existed and could have been obtained prior to the hearing.

Unifund Assurance Co. v. M.D.C. (19-010729)

The insured applied to the LAT for various benefits. The insurer added repayment of an overpayment of IRBs to the issues in dispute. The insured failed to attend multiple case conferences, and his application was dismissed without a hearing as the LAT determined he had abandoned his claim. The matter proceeded to a written hearing on the issue of whether the insurer was entitled to a repayment of IRBs. Adjudicator Boyce found that the insured failed to notify the insurer when he returned to full-time work, and he continued to collect IRB payments while working full time. In addition, the insured submitted an Election of Income Replacement benefits after he had returned to work. Adjudicator Boyce found that the insurer was entitled to repayment of IRBs made as a result of wilful misrepresentation.

P.P. v. Wawanesa Mutual Insurance Company (18-000957)

The claimant sought a catastrophic impairment based on a 55 percent impairment, IRBs, housekeeping expenses, and medical benefits. The insurer argued that the claimant’s impairment arose from an earlier workplace accident, and that he was not entitled to any of the claimed benefits or a catastrophic impairment designation. Adjudicator Flude agreed with the insurer and dismissed the claims. He held that the claimant failed to prove that the accident was the cause of his impairments. The primary issue related to tears in the shoulder. Adjudicator Flude held that that tears were a result of the workplace injury, and not the accident. Further, he found that the claimant’s experts wrongly attributed 18 percent WPI for potential future surgery, holding that the SABS did not permit speculative future impairment in the WPI calculation. He also concluded that the three percent WPI for medication was not proper to include because it related to medications for conditions unrelated to the accident. Without those percentages, the claimant’s total WPI was below 55 percent. Adjudicator Flude also concluded that the claimant was not entitled to IRBs because he was not working at the time of the accident. The housekeeping expenses were denied as well. Only after the accident did he re-start his carpentry business. Finally, the claimed medical benefits were denied because they related to treatment for the shoulder, and the claimant also failed to prove that the treatment was providing relief.

K.K. v. Aviva Insurance Canada (19-001300)

The self-represented claimant sought IRBs, medical benefits, interest, and a special award. Adjudicator Lake dismissed the claims. With respect to the claim for IRBs, Adjudicator Lake found that the insurer’s surveillance was persuasive as it showed the claimant working at a construction site completing various physical tasks, including carrying two cinderblocks. Adjudicator Lake also noted that the claimant’s evidence was inconsistent with respect to when he returned to work and the claimant did not submit any evidence of his post-accident work status, income, or pay stubs. Adjudicator Lake noted that when she attempted to ask the claimant about his post-accident earnings, he provided vague answers. With respect to medical benefits, Adjudicator Lake relied on the records of the claimant’s general practitioner and the IE report to conclude that the proposed treatment plans were not reasonable or necessary. In particular, Adjudicator Lake noted that at no time did the claimant general practitioner recommend chiropractic treatment.

Baskaran v. Co-operators General Insurance Company (19-012169)

The claimant applied to the LAT disputing entitlement to IRBs and two medical benefits. The insurer had requested IEs to address the post-104 week IRB test, which the claimant refused to attend. The insurer argued that the claimant could not proceed with the dispute until attending IEs. The claimant argued that she had attended IEs addressing the pre-104 IRB test, and that the insurer was not permitted to assess for a benefit it was not paying. Adjudicator Grant agreed with the insurer and barred the claimant from proceeding with the dispute. He held that the insurer was not required to re-instate IRBs in order to assess post-104 week IRB entitlement. The claimant had submitted multiple reports addressing the post-104 week IRB test, while the insurer had none. Because of the change in statutory test, it was reasonable for the insurer to assess the claimant for entitlement, particularly given that she had obtained reports supporting the benefit. The prejudice to the insurer if it did not have its own assessments to address the IRB test was greater than the prejudice to the claimant of being required to attend. There was also a clear change in the claimant’s circumstances as her son had bene fatally stabbed after the insurer’s initial IRB IEs, and the claimant psychological functioning had worsened considerably.

H.M.L. v. Northbridge Personal Insurance Company (19-000375)

The claimant requested reconsideration of the Tribunal’s decision that she did not meet the post-104 week IRB test. The claimant argued that she received catastrophic impairment assessments that were not available at the time of the decision and which would change the Tribunal’s decision. Vice Chair Mather dismissed the reconsideration request. The claimant had received her section 25 catastrophic impairment assessments after the due date for written submissions, but before the Tribunal rendered a decision. Because the assessments were in the claimant’s possession before the Tribunal’s decision, she ought to have brought a motion to have the Tribunal consider the assessments. Vice Mather also held that the assessments were unlikely to have changed the Tribunal’s decision. The information and opinions in the assessments were contradicted by the surveillance of the claimant. The assessments also did not provide an opinion on the claimant’s ability to work in a suitable employment or self-employment, as they were only directed towards the catastrophic impairment test.

H.M.L. v. Northbridge Personal Insurance Company (19-000375)

The claimant requested reconsideration of the Tribunal’s decision that she did not meet the post-104 week IRB test. The claimant argued that she received catastrophic impairment assessments that were not available at the time of the decision and which would change the Tribunal’s decision. Vice Chair Mather dismissed the reconsideration request. The claimant had received her section 25 catastrophic impairment assessments after the due date for written submissions, but before the Tribunal rendered a decision. Because the assessments were in the claimant’s possession before the Tribunal’s decision, she ought to have brought a motion to have the Tribunal consider the assessments. Vice Mather also held that the assessments were unlikely to have changed the Tribunal’s decision. The information and opinions in the assessments were contradicted by the surveillance of the claimant. The assessments also did not provide an opinion on the claimant’s ability to work in a suitable employment or self-employment, as they were only directed towards the catastrophic impairment test.

L.P.C. v. Aviva Insurance Canada (19-001009)

The claimant applied to the LAT requesting ongoing IRBs, removal from the MIG, various medical benefits, and a special award. Before the hearing, the insurer removed the claimant from the MIG, approved the four disputed treatment plans, and approved IRBs up to the 104 week mark. The claimant continued with the claim for post-104 week IRBs and a special award. Adjudicator Shapiro held that the claimant suffered a complete inability to engage in any employment, and awarded post-104 week IRBs. The claimant had been approved for CPP Disability Benefits and LTD benefits in relation to the same injuries. The claimant had limited formal education, worked in a physical job before the accident, and had only rudimentary English skills. The IEs the insurer relied on were form only four months after the accident, and failed to consider the psychological impairments that continued to worsen over time. The surveillance of the claimant did not demonstrate abilities in excess of what the claimant or her treatment providers were reporting. Adjudicator Shapiro also granted a special award of 30 percent on the medical benefits that had been denied based on the MIG. The insurer’s psychological IE had noted a psychological diagnosis, but also stated that it could be treated within the MIG. The insurer ought to have removed the claimant from the MIG once it was aware of the diagnosis. The IE assessor’s opinion about treatment being available within the MIG limits was a legal conclusion rather than a medical opinion, which the insurer should have known not to accept. No special award was given on IRBs as the medical evidence supporting post-104 week IRBs was only provided to the insurer close to the hearing date.

T.M. v. Aviva General Insurance (18-010477)

The claimant sought reconsideration of the Tribunal’s decision dismissing his claim for IRBs. The insurer sought reconsideration of the Tribunal’s decision that it was not entitled to repayment. Both requests for reconsideration were denied. Regarding the claimant’s reconsideration request, Adjudicator Grant held that the Tribunal did not make an error of law in finding that the claimant was not employed at the time of the accident and that she had not earned employment income prior to the accident. Regarding the insurer’s reconsideration request, Adjudicator Grant held that the Tribunal did not make an error in conclude that the insurer’s request for repayment sent via email did not comply with section 64 of the SABS; the insurer required the consent of the claimant to send the notice for repayment by email, even though the claimant and insurer had communicated by email on previous instances.

T.M. v. Aviva General Insurance (18-010477)

The claimant sought reconsideration of the Tribunal’s decision dismissing his claim for IRBs. The insurer sought reconsideration of the Tribunal’s decision that it was not entitled to repayment. Both requests for reconsideration were denied. Regarding the claimant’s reconsideration request, Adjudicator Grant held that the Tribunal did not make an error of law in finding that the claimant was not employed at the time of the accident and that she had not earned employment income prior to the accident. Regarding the insurer’s reconsideration request, Adjudicator Grant held that the Tribunal did not make an error in conclude that the insurer’s request for repayment sent via email did not comply with section 64 of the SABS; the insurer required the consent of the claimant to send the notice for repayment by email, even though the claimant and insurer had communicated by email on previous instances.