Category: Incurred Expense

Duval v. Aviva General Insurance (20-001990)

The claimant disputed entitlement to $1,030.84 in monthly attendant care benefits, treatments plans for cannabis and an orthopaedic mattress, interest, and a special award. Aviva initially accepted the Form 1 and paid attendant care invoices as they were submitted. Aviva then denied attendant care based on an orthopaedic assessment and Form 1. The claimant argued that she required attendant care due to pain and tingling in her arms, hands and fingers, as well as shoulder, back and neck pain caused by the accident. Aviva noted that the claimant continued to work as a law clerk post-accident, which required the use of her hands and arms; and continued to care for her children and remained active in the community, which was detailed in a surveillance report showing the claimant running various shopping errands without any difficulty. Adjudicator Chakravarti ruled in the claimant’s favour and found her entitled to attendant care, noting that the claimant consistently reported issues with functional impairments in her hands and arms to her medical practitioners. Furthermore, the insurer’s assessors admitted in their findings that functional limitations were present and that the claimant was limited by pain on examination. Adjudicator Chakravarti ruled that the claimant was entitled to attendant care at a reduced rate of $537.00 per month, which was appropriate based on what was actually incurred during the time Aviva paid the benefit. However, ongoing attendant care was not deemed to have been incurred as the claimant failed to prove that Aviva acted unreasonably or that she did not incur attendant care expenses because Aviva acted unreasonably. The claimant was not entitled to the remaining benefits as she failed to prove that they were reasonable and necessary as a result of the accident. No special award was granted.

Malitskiy v. Unica Insurance Inc. (2021 ONSC 4603)

The claimant appealed the LAT reconsideration in which the Tribunal held that he was only entitled to ACBs calculated by using the Form 1 hourly rate multiplied by the time received for each service (rather than the full Form 1 amount of $6,000), and the Tribunal’s decision that the claimant was not entitled to a special award. The Divisional Court dismissed the appeal. It held that the quantum of ACBs payable was properly determined using the hourly rates set out in the FSCO Guidelines and the Form 1, and that the insurer was not required to pay for attendant care services in excess of those hourly rates. The Court also held that the Tribunal’s reconsideration applied the proper principles of law (as described in Plowright v Wellington). A special award could not be granted simply because the insurer had made the wrong adjusting decision.

Switzer v. Waterloo Insurance (19-011403)

The claimant disputed his entitlement to attendant care benefits, housekeeping expenses, and two chair lifts. He also disputed the weekly quantum of IRBs he was entitled to receive. The claimant also sought a special award. The insurer argued that the accident was not the cause of the claimant’s impairments, and that they all pre-existed the accident from six earlier motor vehicle accidents. The insurer also argued that the claimant made material misrepresentations in relation to his claim for housekeeping expenses. Adjudicator Lake found that the accident was a necessary cause that exacerbated the claimant’s pre-existing psychological and cognitive conditions, but did not cause the claimant any new physical impairments or exacerbate his previous physical conditions. Adjudicator Lake declined to award ACBs because the claimant failed to prove that any expenses were incurred. The claimant failed to call his alleged service provider to give evidence and could not prove that the service provider was a professional acting in the course of his employment or self-employment. Adjudicator Lake also wrote that she would have declined to award ACBs due to the claimant’s failure to prove the service actually provided to him. There were no time dockets, daily logs, job diaries, or any information about the dates and times services were performed. Regarding HK expenses, Adjudicator Lake held that the claimant failed to prove that he suffered a substantial inability to complete his home maintenance and housekeeping tasks as a result of the accident. Regarding IRBs, Adjudicator Lake held that the claimant was entitled to $711.15 per week in IRBs during 2018 and $1,000 per week from January 2019 onwards. The claimant was self-employed as a lawyer at the time of the accident, and was a partner at a law firm prior to that. The last full fiscal year worked by the claimant at the law firm was 2016. The claimant did not complete a fiscal year at either his own law firm or as a partner at a law firm in 2017. Adjudicator Lake rejected the insurer’s position that consideration of self-employment income was restricted to a business being operated at the time of the accident. The claimant continued to practice law after the accident, so the insurer was entitled to deduct post-accident earnings in accordance with the SABS. No evidence was provided of the claimant’s income from 2019 onwards. Adjudicator Lake declined to grant a special award, as the only benefit found payable was IRBs, and the interpretation of the SABS that led to the dispute was not excessive, imprudent, or stubborn. Finally, Adjudicator Lake rejected the insurer’s position that the claimant made material misrepresentations in relation to the claim for HK expenses. She agreed that the housekeeper’s testimony called into question evidence given by the claimant regarding creation of invoices, the discrepancy was not a “material fact” with respect to the application for HK expenses; the discrepancy related to the author of the invoices rather than the content.

Butler v. Allstate Insurance (19-013444)

The claimant applied to the LAT disputing entitlement to attendant care benefits and medical benefits. The dispute proceeded by written hearing. Adjudicator Lake held that the claimant was not entitled to ACBs for the three periods claimed. For the first period, Adjudicator Lake dismissed the claim as the claimant sought benefits prior to submission of a Form 1, which was not permitted per s. 42. For the second period, Adjudicator Lake dismissed the claim because, while Allstate approved ACBs at the rate of $3,000 per month, the claimant did not provide any evidence that his son and attendant care provider sustained an economic loss nor that the claimant incurred the expenses as the claimant did not submit attendant care invoices. Adjudicator Lake did not find there was any evidence that Allstate withheld ACBs and therefore, she declined to deem the expenses incurred. As for the third period, Allstate reduced the claimant’s ACBs to $448.49 per month. Adjudicator Lake held that even if she accepted the claimant’s higher ACB rate, the claimant again failed to produce evidence that ACBs were incurred and that his son suffered an economic loss. Adjudicator Lake also dismissed the claimant for “planning, service” under the treatment plans, as this was not payable per the FSCO Professional Services Guideline.

Salim v. Aviva General Insurance (19-006944)

The claimant was involved in a serious accident. He was skateboarding and was hit by a vehicle and suffered nasal, left elbow, pelvic, and sacral fractures, and psychological injuries. The claimant applied to the LAT disputing entitlement to NEBs, ACBs, and the full cost of partially approved medical benefits. Adjudicator Farlam dismissed the claimant’s dispute in its entirety. With respect to NEBs, Adjudicator Farlam noted that the claimant travelled post-accident, resumed full-time education, and resumed his participation in sports including judo and wrestling. Adjudicator Farlam held that while the claimant required help with some self-care tasks and had ongoing physical and psychological limitations, he did not meet the NEBs disability test. With respect to ACBs, Adjudicator Farlam noted that the claimant reported that his family cared from him. However, the claimant did not submit proof of incurred expenses nor economic loss. Adjudicator Farlam noted that the claimant did not submit OCF-6s, receipts, invoices, or any other proof of incurred benefits. Adjudicator Farlam dismissed the claimant’s submissions that ACBs be “deemed incurred” as he did not believe that ACBs were reasonable and necessary in light of the 8 month delay in submitting a Form 1. With respect to the disputed medical benefits, Adjudicator Farlam opined that the claimant had not proven that the balance of the treatment plans were reasonable or necessary.

S.K. v. Aviva Insurance Canada (19-001127)

The claimant sought entitlement to ACBs, the balance of a partially approved social work assessment (seeking a higher hourly rate), and the cost of catastrophic impairment assessments. The insurer had denied ACBs on the basis that the claimant had not received the claims services and that insufficient information was provided regarding the services allegedly provided. The insurer denied the catastrophic impairment assessments because the claimant proposed them only one year after the accident. Adjudicator Grieves concluded that the claimant was entitled to ACBs of $3,000 per month, subject to the claimant proving that the services had been incurred. She accepted that the claimant required personal care services due to post-accident ankle surgery and knee surgery. She rejected the insurer’s position that surveillance suggested that the claimant was not receiving the services claimed, as the claimant and her family members were able to explain why the claimant and personal care workers were not seen at her house on certain days. Adjudicator Grieves also rejected the insurer’s argument that the payable ACB was calculated based on the specific service provided multiplied by the hourly rate for that service set out in the Professional Services Guideline. She held that the purpose of the hourly rates was to calculate the maximum ACB payable, and that the amount payable by the insurer was based on the rate charged by the service provider (provided that it was reasonable and not excessive) for whichever services were provided, subject to the statutory maximum and/or the Form 1 total. The denied portion of the social work assessment was also awarded. Adjudicator Grieves held that $135 per hour was a reasonable rate for a social worker, rather than the $100 approved by the insurer. Finally, the catastrophic impairment assessments were denied as being not reasonable. Although the claimant was approaching her combined medical and ACBs limit, she could not apply for a catastrophic impairment until the two year mark unless her condition was unlikely to improve. The medical evidence suggested that the claimant continued to show medical improvement. Additionally, the assessors proposing the catastrophic assessments did not explain why each of the proposed assessments was reasonable or necessary.

Salvi v. CUMIS General Insurance Company (19-005573)

The claimant sought entitlement to ACBs and various medical benefits for occupational therapy services, assistive devices, and chiropractic services. Adjudicator Paluch rejected the claim for ACBs and most of the medical benefits, but allowed the claims for assistive devices and one of the occupational therapy services. Regarding the ACBs claim, the claimant failed to prove that any services were incurred. The claimant’s affidavit submitted in support of the claim was vague and unhelpful as it did not provide specific details of services, times, duration, level of care, and no exhibits were provided from care providers detailing this information either. Adjudicator Paluch also questioned how the claimant could require 10 hours of supervisory care when the medical evidence was clear that the claimant could respond to an emergency independently. The adjudicator declined to deem the expenses incurred under section 3(8) as the claimant failed to advance any arguments, analysis, or evidence how the insurer unreasonably withheld or delayed payment, other than stating in a general way that the benefits were wrongfully denied. Adjudicator Paluch awarded the claim for a new mattress because there was evidence that the claimant had poor sleep as a result of her injuries and the new mattress did provide improved sleep. A portion of claimed occupational therapy sessions were also awarded because the insurer’s denial did not comply with section 38(8) (no medical reason was provided as to why the proposed treatment was “quite excessive”). Adjudicator Paluch was critical of the claimant’s failure to provide documentation as ordered in the Case Conference Order. Claimant’s counsel insisted on payment for records before production of same, despite the Order not requiring the insurer to pay for the records. Once the records were in the claimant’s possession, she should have provided them. Her failure to do so prevented the Tribunal from having the ability to review the complete clinical notes and records.

S.M. v. Mutual Insurance Company (18-008474)

The claimant sought reconsideration of the LAT’s denial of retroactive ACBs and the decision regarding the amount of ACBs that were found payable. The accident occurred prior to September 1, 2010. Interpretation of the transitional provisions in the 2010 SABS and 1996 SABS was an issue in dispute, including interpretation of provisions relating to interest and the applicability of the requirement for benefits to be incurred before they are payable. The request for reconsideration was denied. Adjudicator Johal found that there was no error in law in the determination that there is no strict bar against filing an application for retroactive attendant care benefits, but the burden is on the claimant to “explain the urgency, impossibility or impracticability of compliance with s. 42(5) of the Schedule.” Adjudicator Johal found that there was no error in law in determining that the “incurred” definition applied to this claim, even though the accident occurred before September 1, 2010. Adjudicator Johal held that “rights are based on what is set out in the Insurance Act and regulations at the time of a claim rather than the date of the accident.” Adjudicator Johal found that there was no error in law in the finding that the applicable interest rate was 1%, in accordance with the 2010 SABS.

G.R. v. Aviva General Insurance Company (18-004375)

Both the claimant and the insurer sought reconsideration of the Tribunal’s decision awarding seven medical benefits, denying attendant care expenses, and granting a special award on a functional impairment assessment, which had been deemed incurred. The claimant argued that ACBs should have been awarded and should have been deemed incurred under section 3(8). Adjudicator Mazerolle rejected the claimant’s reconsideration request holding that the claimant had not incurred any ACBs, and that the Tribunal made no error in not deeming the expenses incurred. He also rejected the argument that McMichael v. Belair applied, reasoning that it was decided under an earlier version of the SABS that did not require attendant care services to be incurred. Adjudicator Mazerolle granted the insurer’s reconsideration request in relation to the functional impairment assessment. He accepted that the insurer was not given an opportunity to respond to the argument that it should be deemed incurred under section 3(8). He requested that both parties make submissions on whether the insurer’s unreasonable withholding or delay in payment of the functional impairment led the claimant not to incur the expense.

R.A. v. Aviva Insurance Company (19-002890)

The claimant applied to the LAT for entitlement to ACBs, a variety of OCF-18s for treatment and assessments, the cost of a psychological pre-screen, the cost of two OCF-3s, and a special award. Based on monthly invoices for ACBs (all in the same amount), which did not particularize the exact dates or times services were provided or provide information about the service provider, Adjudicator Lake was unable to find on a balance of probabilities that the applicant had received attendant care services. Adjudicator Lake found that a failure to advise the claimant of eligibility for ACBs upon removal of the MIG did not constitute an unreasonable withholding or delaying of benefits. ACBs were not deemed to be incurred pursuant to section 3(8). Pursuant to s. 38(11), Adjudicator Lake found benefits proposed in multiple OCF-18s were payable because the insurer did not include specific details about the claimant’s medical condition in its denial letters. Adjudicator Lake found that the claimant was not entitled to ACBs, the cost of the psychological pre-screen, the cost of the two OCF-3s, chronic pain treatment, psychological treatment, a driver re-integration program, or OCF-18s that were duplicates of other approved OCF-18s. The claimant was entitled to shockwave therapy, a psychological assessment, a chronic pain assessment, and an exercise program.