Category: Income Replacement Benefits

Cruz v. Belair Insurance Company (20-014208)

The claimant was involved in a serious motor vehicle accident in September 2017, in which she sustained multiple fractures. She applied to the LAT seeking CAT determination under Criteria 7 and entitlement to post-104 IRBs, medical benefits, and a special award. Vice-Chair Lester decided to exclude two insurer reports that were served after the deadline for productions. The claimant was permitted to call the claims adjuster despite late service of particulars for the claim for a special award. The claimant’s assessors determined the claimant had a WPI rating of 66%. The insurer’s assessors determined the claimant had a WPI rating of 40%. Vice-Chair Lester determined that the WPI ratings of the claimant’s assessors were incorrect for a variety of reasons, including advancing a rating for a future risk. Vice-Chair Lester found that the claimant had a combined WPI rating of 47% and was not catastrophically impaired. The claimant’s pre-accident employment jobs had all been part-time short-term positions in retail, childcare, and a travel agency. Vice-Chair Lester found that the claimant was unable to sit long enough for any sedentary part-time position and was entitled to post-104 IRBs. The claimant was entitled to OT services and physiotherapy. She was not entitled to a SPECT assessment or a special award.

Papadakis v. Wawanesa Mutual Insurance Co. (2022 ONSC 6928)

The claimant appealed the Tribunal’s decision that he did not suffer a catastrophic impairment, and that he was not entitled to IRBs or further physiotherapy. The Divisional Court dismissed the appeal. The only point of law raised in the appeal was whether the Tribunal was correct to exclude a WPI rating for a contingency of future events. The Court agreed that the Tribunal was correct in excluding future contingencies. The authorities support the conclusion that the WPI rating is based on a person’s presentation at the hearing without contingency for future changes. The Court also agreed with the Tribunal’s exclusion of WPI ratings for pre-existing conditions, as the AMA Guides require deducting from the WPI rating the estimated impairment ratings for pre-existing injuries or conditions in order to obtain the net WPI from accident-related impairments. The Court dismissed the remaining grounds of appeal as not raising points of law. The arguments regarding ignoring evidence and rulings on witnesses did not raise appropriate grounds for appeal, and the claimant was not permitted to raise additional issues not contained in the Notice of Appeal.

Schuknecht v Economical Insurance Company (19-013098)

The parties agreed that the claimant was eligible for IRBs, but disagreed on the quantum of the benefit. The applicant received STD and subsequently LTD, as well as CPP disability benefits. Vice Chair Maedel confirmed that these benefits were all taxable and offset the standard weekly IRB payment, as per sections 4(1)(a) and (b) of the SABS. Vice Chair Maedel further found that the insurer was entitled to a repayment of IRBs in the amount of $4,872.90 plus interest, as it was entitled to offset the amount of LTD paid, by the CPP Disability Benefits received in order to calculate the IRB quantum. Otherwise, the claimant could receive overlapping periods of LTD and CPP Disability Benefits, resulting in potential double recovery. With respect to the calculation of IRBs post-65, Vice Chair Maedel held that the quantum is calculated on the base weekly amount prior to deduction for collateral benefits. At age 65, collateral benefits are terminated, and the IRB quantum reverts back to the base weekly amount. This quantum is then adjusted using the ramp down formula set out in section 8(1) of the SABS.

Gamble v Allstate Insurance Company of Canada (20-010512)

The claimant was found to be entitled to post-104 week IRBs for psychological reasons. The insurer terminated the claimant’s entitlement to IRBs pursuant to section 57(2) of the SABS, on the basis that she had failed to seek psychological treatment. Section 57(2) requires a person to obtain treatment that is reasonable, available, and necessary to allow them to engage in employment or self-employment. The claimant argued that she was engaging in psychological treatment with her family physician. Adjudicator Kepman agreed with the insurer that the claimant had not complied with section 57(2). The claimant’s family physician was not qualified to provide psychiatric care, and had suggested that the claimant attend supportive psychotherapy and referred the claimant to a psychiatrist. The claimant had provided no explanation as to why she had not attended any type of psychological services, despite it being suggested to her several times. As such, the claimant was not entitled to IRBs for the period in dispute.

McBeth v Allstate Canada (20-007407)

The parties agreed that the claimant met the disability test and was entitled to IRBs, but disagreed over whether he had available to him, and could have received LTD from his collateral benefits insurer through his employment. The claimant took the position that he applied for LTD, which were refused, and therefore the insurer was not entitled to deduct any potential LTD benefits from his IRB. The insurer took the position that the claimant’s claim for LTD was denied on a technical ground (not applying for the benefit on time) and he should therefore be deemed not to have applied for the benefit at all. Vice Chair Johal agreed with the insurer, emphasizing the obligation on the claimant to apply for and exhaust collateral benefits before resorting to the accident benefit insurer. If the claimant misses the limitation period within which to apply for the collateral benefit, that is akin to failing to apply for the benefit at all, and the insurer is entitled to deduct the LTD as if the claimant was receiving the benefit. As such, Vice Chair Johal held that the insurer was entitled to a deduction of LTD benefits from the IRBs being received.

O’connor v. Aviva General Insurance Company (19-006131)

The claimant brought an application seeking entitlement to IRBs from December 16, 2017 to May 2018. The date of loss was December 9, 2017. She testified that she had returned to part-time work in January 2018 and transitioned to full-time work in April or May 2018. However, the insurer identified two IE reports in which the claimant had stated that she had returned to full-time employment in January 2018. In response to her conflicting claims, the insurer had requested the claimant’s paystubs and an OCF-2 in June 2018, and further requested in a letter dated October 23, 2018, that the claimant confirm the date that she had returned to work. As the claimant had not produced any income records that could confirm her post-accident income, the insurer argued that the LAT should rule that the claimant was not entitled to any IRBs for the period being claimed. Adjudicator Neilson found that she could not deny IRBs to the claimant under s. 33(6) for a failure to provide income information, because per s. 36(5), an insurer was required to pay IRBs withheld once the information sought was received, as long as a reasonable explanation was provided for the delay. However, Adjudicator Neilson stated that she was unable to make a determination on the claimant’s entitlement to IRBs until the claimant provided the income documents requested and provided reasons for the delay.

G.P. v. Wawanesa Mutual Insurance Company (18-010583)

The claimant applied to the LAT for a catastrophic impairment designation, post-104 week IRBs, the cost of CAT assessments, and various medical benefits. Vice Chair Lester found that the claimant suffered a catastrophic impairment due to Class 4 Marked Impairments in both adaptation, and concentration, persistence, and pace. The claimant suffered from chronic pain as a result of a minor accident, which deteriorated into somatic symptom disorder with predominant pain and major depressive disorder. The claimant suffered from panic attacks once to twice per week. She was unable to deal with stressful circumstances, had not returned to work as a PSW, and became emotional and overwhelmed by minor things. The claimant was also found to meet the post-104 week IRB test. The only jobs the claimant was suited for were PSW work and an office manager role. The insurer did not have any IEs addressing post-104 week IRBs because it had terminated IRBs within the first 104 weeks. Notably, the insurer’s CAT assessments noted Class 3 Moderate Impairments in social functioning, which was relevant for the claimant’s ability to communicate effectively and ability to get along with others, and found a Class 3 Moderate Impairment in concentration, persistence, and pace, which was relevant to the claimant’s ability to sustain focused attention in a work setting. All of these conclusions supported the determination that the claimant suffered a complete inability to engage in work for which she was suited. The $26,971.50 for CAT assessments, $13,566.81 for a chronic pain program, $2,200 for a chronic pain assessment, and $1,808 for an FAE were awarded due to the insurer’s failure to comply with section 38(8). The denials did not provide adequate medical reasons for the denial, and referred the claimant to read other documents. Vice Chair Lester was critical of the insurer’s reason that something was “excessive” without providing any detail. Finally, Vice Chair Lester granted a special award of 30 percent on the awarded IRBs and treatment plans based on the insurer’s decision to “blindly follow” the IE assessor opinions without considering other evidence. The claimant suffered financial hardships as a result of the denials, including the need to apply for OW, borrow money from her family, and cut back on her diet.

Tanner v. Certas Direct (21-000564)

The claimant applied to the LAT for a catastrophic impairment designation, post-104 week IRBs, and payment of various medical benefits including partially approved CAT assessments. Adjudicator Reilly denied all claims and dismissed the application. With respect to the catastrophic impairment, Adjudicator Reilly found a maximum combined WPI of 32 percent. She found the claimant’s assessors attributed excessive impairment percentages. She found no evidence of right shoulder impairment and found lumbar spine impairment rated too high. She found the claimant’s left wrist and shoulder impairments ought to have been combined before arriving at the total WPI, rather than rating each separately. She found the rating of 18 percent WPI for grip strength to be questionable as OT and FAE assessments found normal grip strength. In terms of neurological ratings, Adjudicator Reilly found no evidence to support a rating for sexual dysfunction or hearing, and the rating for disturbances of consciousness and awareness ought to have been deferred to a psychiatrist. She found a total of 32 percent WPI for orthopaedic and neurological impairment, which did not meet Criterion 6. In terms of mental or behavioural impairment, Adjudicator Reilly did not accept the claimant’s expert’s rating of 20 percent WPI, as the facts described by the assessor were not supported by the evidence (i.e. ability to travel, ability to drive, ability to work part-time). Adjudicator Reilly preferred a maximum WPI of 10 percent for mental and behavioural impairment based on the IE assessor’s opinion. The combined physical and mental impairment did not exceed 55 percent, and the catastrophic impairment designation was dismissed. Adjudicator Reilly concluded that the claimant did not meet the post-104 week IRB test. The claimant had returned to work in a part-time fashion on multiple occasions after the accident. Surveillance showed him with greater physical abilities than reported to his assessors. The claimant’s job was terminated in 2021 because he did not want to return to the office full-time, and the management dismissed him. The claim for further CAT assessments was dismissed, as the claimant did not advance evidence to indicate why the denied amounts were reasonable and necessary. The claim for assistive devices was dismissed because they were not submitted on OCF-18s, and the claimant had exhausted his medical benefits limits.

Katsaros v TD Insurance Meloche Monnex (20-010657)

A preliminary issue hearing was held to determine whether the claimant’s application for IRBs was statute-barred per the limitation period. The claimant was involved in a motor vehicle accident on October 21, 2016 and was able to return to work within a week. Almost a year later, the claimant stopped working and began receiving short-term disability benefits from his employer. Two years later, the claimant submitted another OCF-3 indicating that he now suffered a substantial inability to carry out the essential tasks of his pre-accident employment. The insurer argued that the claimant failed to properly apply for IRBs as he did not submit an OCF-3 establishing a substantial inability within 104 weeks of the accident as required by the SABS. Vice-Chair McGee disagreed with the insurer, noting that the claimant had submitted an OCF-3 within the prescribed time. The requirement is for a completed OCF-3 to be filed. It is not necessary for the form to positively indicate that the claimant has a substantial inability, submission of the form itself will allow the window to be left open to a future income replacement benefit claim.

Rao v. Wawanesa Mutual Insurance Co. (20-001654)

The claimant applied to the LAT seeking CAT determination under Criteria 8 and entitlement to post-104 IRBs and various medical/rehabilitation benefits. Causation was an issue at the hearing. The subject motor vehicle accident occurred on April 4, 2016. At the time of the subject accident, the claimant was still recovering from an incident in August 2015, which left her with a concussion and unable to work for 8 months. The subject accident occurred while the claimant was on her way to work for the first time since August 2015. The “but for” test was applied to the issue of causation. Vice-Chair Shapiro found that while the subject rear-end collision was light, it did affect the claimant, stating “while there is a dispute of what the actual physical impact the accident had on her brain and cognitive function, I accept that it was an emotionally traumatic event.” Vice-Chair Shapiro preferred the insurer’s CAT opinions, finding that the claimant’s CAT report lacked meaningful validity testing and was generally inconsistent with the records of treating practitioners and evidence of functional abilities. Vice-Chair Shapiro found that the claimant likely sustained a mild second concussion in the subject accident, which resolved on its own. The testimony of the claimant’s treating neurologist was given less weight as she was unaware of the subject accident until she was summonsed to be a witness at a hearing, and therefore her testimony about the accident causing the claimant’s current complaints was inconsistent with her medical notes. The claimant was found not to be CAT and was not entitled to post-104 IRBs. She was entitled to driver’s therapy, plus interest if incurred, but not to the other medical benefits in dispute.