Category: Income Replacement Benefits

H.C. v. Certas Direct Insurance Company (16-001285)

The claimant sought entitlement to income replacement benefits along with two treatment plans, costs, and a special award. Adjudicator Bass reviewed the medical evidence, along with surveillance submitted by the insurer. It was found that the claimant’s reports were “overly pessimistic in light of the surveillance evidence from only a few months later.” As a result, it was concluded that the claimant did not sustain a substantial inability to perform the essential tasks of his employment. The treatment plans claimed were also denied as Adjudicator Bass found the claimant’s injuries to be minor.

Applicant v. Aviva (16-001144)

The claimant sought entitlement to income replacement benefits and an orthopaedic assessment. The insurer paid IRBs for four months and terminated them after a number of IE reports. The orthopaedic assessment was denied based on a MIG position. As a preliminary issue, the insurer sought to add the claimant’s LinkedIn page to show the claimant was working and therefore required IRB repayment. Adjudicator Treksler allowed the new evidence to be admitted, but found the page insufficient evidence to warrant repayment of IRBs. Adjudicator Treksler found that the claimant was entitled to IRBs and held that he should be removed from the MIG. The fact that the claimant did not return to his employment, but instead, went to school in a different field was seen as supporting the IRB claim.

J.V. v. Wawanesa Mutual Insurance Company (16-000722)

The claimant sought an order for IRBs in the amount of $280 per week. Adjudicator An concluded that the claimant suffered a substantial inability to engage in the essential tasks of her employment up to the date of her return to work.

C.S.Z. v. Allstate Insurance Company of Canada (16-000270)

The claimant sought IRBs in the amount of $400 per week. Adjudicator Marzinotto allowed the admission of surveillance evidence. She also allowed the admission of a report without an Acknowledgement of Expert’s Duty. In terms of the benefits in dispute, the adjudicator denied the claim for IRBs, stating that the claimant had not proved his entitlement and had not provided information that would allow the Tribunal to calculate the weekly quantum.

M.J. v. Pembridge Insurance Company (16-000583)

The claimant sought IRBs and medical marijuana. The adjudicator dismissed the IRBs claim because the claimant had refused to provide post-accident income records. The claim for medical marijuana was dismissed because the claimant did not provide a proper “medical document” supporting the need for medical marijuana. The term “medical document” is defined in the federal Marihuana for Medical Purposes Regulations.

N.E. v. Waterloo Regional Municipalities Insurance Pool (16-000066)

The claimant sought IRBs at a rate above the weekly rate paid by the insurer. The claimant also sought removal from the MIG. Adjudicator Gottfried dismissed the claim for increased IRBs as the claimant had not provided any documentation to support increasing the weekly quantum. The adjudicator also noted that entitlement to ongoing IRBs does not mean one’s injuries are non-MIG. The claimant was restricted to MIG-level medical benefits

N.C. v. RBC General Insurance Company (16-000282)

Following an accident, the self-employed claimant stopped operating his business in January 2016. Adjudicator Sewrattan concluded that the IRB calculation could not take into account business losses, as the claimant did not have business losses (as calculated by the Income Tax Act) after he ceased operations of his business. In terms of medical benefits, the adjudicator concluded that the claimant’s injuries did not fall in the MIG and wrote that pain reduction is a valid goal when assessing whether a treatment plan is reasonable and necessary.

Applicant v. Old Republic Insurance Company (16-000179)

The insurer appealed a decision by an adjudicator that the claimant was entitled to IRBs up until a particular date in the future. The Executive Chair held that the adjudicator made an error of law by setting an end date for the reinstated IRBs. An insurer has an ongoing obligation to adjust a file, and by setting an end-date, the Order potentially fettered the insurer’s ability to adjust the claimant’s file.

Applicant v. Old Republic Insurance Company (16-000179)

The insurer appealed a decision by an adjudicator that the claimant was entitled to IRBs up until a particular date in the future. The Executive Chair held that the adjudicator made an error of law by setting an end date for the reinstated IRBs. An insurer has an ongoing obligation to adjust a file, and by setting an end-date, the Order potentially fettered the insurer’s ability to adjust the claimant’s file.

J.W. v. Echelon General Insurance Company (16-000082)

The claimant sought IRBs for both the first 104 weeks after the accident, and beyond the first 104 weeks after the accident. Adjudicator Flude accepted the that the claimant met the “complete inability” test as neither the claimant nor the insurer submitted evidence of employment for which the claimant might reasonably be suited by education, training, or experience.