Category: Income Replacement Benefits

V.H.T. v. Certas Home and Auto Insurance Company (16-000874)

The claimant sought entitlement to IRBs and further medical benefits. A preliminary motion was first heard to address the admissibility of late documents. Adjudicator Sapin held that the late documents were admissible, that the insurer had sufficient time to review the new documents, and that the insurer should have requested an adjournment if it believed prejudice would result. In terms of the benefits in dispute, Adjudicator Sapin held that the claimant was entitled to post-104 week IRBs due to ongoing psychological issues, chronic pain, and inability to use his right hand. The medical benefit sought were not awarded because the claimant did not provide evidence that they were reasonable and necessary, or were not on a treatment plan.

S.B. v. Aviva General Insurance (16-004395)

The claimant sought entitlement to medical and income replacement benefits. The insurer asserted a MIG position. Adjudicator Derek concluded the claimant had not proven he had injuries to warrant removal from the MIG, nor had a pre-existing condition impeding recovery within the MIG. Regarding IRBs, the claimant only relied on his disability certificate. The insurer’s IE reports were seen as a more valid depiction of the claimant’s functionality and the claim was dismissed.

Applicant v. TD General Insurance Company (16-000608)

The claimant was involved in two motor vehicle accidents, and sought IRBs in relation to both accidents. Adjudicator Leslie held that the claimant had not provided evidence regarding the impairments preventing him from performing his work functions beyond the date the insurer had paid IRBs. Further, the claimant himself reported that he was not prevented from returning to work.

Applicant v. TD Home and Auto Insurance Company (16-000929)

The claimant sought reconsideration of the original adjudicator’s denial of further IRBs. Executive Chair Lamoureux denied the request for reconsideration and held that the adjudicator’s reasons were based on the medical evidence before the Tribunal, and the adjudicator was entitled to weigh the evidence as he saw fit.

Applicant v. TD Home and Auto Insurance Company (16-000929)

The claimant sought reconsideration of the original adjudicator’s denial of further IRBs. Executive Chair Lamoureux denied the request for reconsideration and held that the adjudicator’s reasons were based on the medical evidence before the Tribunal, and the adjudicator was entitled to weigh the evidence as he saw fit.

Applicant v. Aviva Insurance Company (16-001144)

The original adjudicator had awarded IRBs up to the 104 week mark, which was a future date; the weekly quantum of IRBs awarded was not analysed in the decision. The insurer appealed the adjudicator’s order related to the period and quantum of IRBs. Executive Chair Lamoureux accepted the insurer’s arguments and held that the order should be varied to remove the specified future date, and ordered a rehearing on the issue of IRB quantum.

M.K. v. Dumfries Mutual Insurance Company (16-000501)

The claimant sought IRBs and removal from the MIG. Adjudicator Theoharis rejected the claimant’s case. She held that the claimant did not suffer impairments that would entitle her to IRBs or removal from the MIG. In particular, Adjudicator Theoharis relied upon surveillance showing the claimant engaging in multiple activities she said she could not do. Adjudicator Theoharis placed no weight on the s. 25 psychological report, as it took the claimant’s self-reporting at her own word. There was also no mention of psychological difficulties in the claimant’s family doctor’s notes.

O.O. v. Aviva Insurance Company of Canada (16-00946)

The claimant, an articling student, sought entitlement to income replacement benefits and one psychological assessment plan. The claimant led a letter as evidence which was by the firm wishing him success in his future endeavours; it did not state that he was terminated. Adjudicator Truong found that the claimant was not terminated due to injury and denied entitlement.

M.M. v. Northbridge Personal Insurance Corporation (16-000682)

The claimant sought entitlement to ongoing IRBs. Adjudicator Sewrattan applied a three-part test: (1) Was the claimant employed at the time of the accident, (2) Causation; did the claimant sustain an impairment preventing him/her from returning to work, and (3) Does the claimant suffer a substantial inability to perform the essential tasks of his/her employment, (a) what are the essential tasks of employment, and (b) is the claimant substantially unable to perform said tasks. The claimant’s entitlement claim was dismissed.

M.M. v. Northbridge Personal Insurance Corporation (16-000682)

The claimant sought entitlement to ongoing IRBs. Adjudicator Sewrattan applied a three-part test: (1) Was the claimant employed at the time of the accident, (2) Causation; did the claimant sustain an impairment preventing him/her from returning to work, and (3) Does the claimant suffer a substantial inability to perform the essential tasks of his/her employment, (a) what are the essential tasks of employment, and (b) is the claimant substantially unable to perform said tasks. The claimant’s entitlement claim was dismissed.