Category: Incurred Expense

Applicant v. The Guarantee Company of Canada (16-001348)

The claimant originally sought attendant care benefits on an ongoing basis. The initial adjudicator’s decision only addressed attendant care benefits up to the date of the hearing and held that the claimant was nominally entitled to $666.23 per month, but that no attendant care services had been incurred. The claimant sought reconsideration of that decision on the basis that he should be entitled to any incurred attendant care benefits beyond the date of the hearing. Executive Chair Lamoureux agreed with the claimant and held that the adjudicator’s failure to explicitly consider entitlement beyond the date of the hearing (a period that was set out in the Case Conference Order) was an error in law. She held that the claimant was entitled to attendant care benefits of up to $666.23 per month, provided the services were incurred. Because the claimant’s accident occurred in 2004, Executive Chair Lamoureux acknowledged that the stricter requirements of the 2010 SABS did not apply, but that the service at issue still needed to have been provided in order to be incurred under the 1996 SABS (relying upon the FSCO decision in McKnight v. Guarantee).

Applicant v. Allstate Insurance Company (16-002285)

The claimant was catastrophically impaired. An assessment of attendant care needs yielded a monthly rate beyond the statutory maximum. The insurer agreed to pay up to the statutory maximum; however, invoices showed services incurred for less and therefore only the amounts on submitted invoices were paid. The claimant argued that once an economic loss was established, the entire value of the Form 1 was payable. Adjudicator Purdy concluded that the insurer is only liable to pay the attendant care amounts that have been incurred by the applicant. Additionally, treatment plans for both a neuropsychological assessment and neuropsychometric testing were, in fact, one large assessment that would produce two reports – it was therefore subject to the maximum $2,000.00 maximum cap for assessments.

K.B. v. Unica Insurance Inc. (16-002023)

The claimant and the insurer agreed that the claimant was medically entitled to attendant care benefits; the dispute pertained to the quantum. The claimant’s entitlement was limited to the amount of economic loss sustained by his service provider mother. At the time of the accident, his mother was unemployed, but looking for work. The claimant argued that the economic loss should be equal to the income his mother earned in her last pre-accident employment.  Adjudicator Sewrattan dismissed the claim for attendant care, and held that there was no evidence that the claimant’s mother would have found employment, or that she would have been able to work in a similar job.

M.P. v. Certas Home and Auto Insurance Company (16-000525)

As a result of the accident, the claimant suffered severe knee injuries. The claimant’s wife was a personal attendant at Seniors for Seniors. She provided attendant care service to the claimant, and the claimant sought entitlement to ACBs. Adjudicator Sewrattan held that the claimant was not entitled to ACBs because the service provider was not a professional, and the service provider had not sustained an economic loss as a result of providing services.

V.L. v. TD Meloche Monnex (16-000308)

The claimant applied for caregiver benefits. The claimant did not reside with his parents (the alleged dependants), but rather resided approximately 900 metres away on foot and 3 kms away by car. Adjudicator Treksler awarded caregiver benefits stating the legislation was silent on the term “reside” and therefore must be interpreted on a case-by-case basis as it is a question of fact. The adjudicator was also satisfied that the caregiver expenses had been incurred based on a notarized confirmation.

B.U. v. Aviva Canada Inc. (16-000143)

The claimant sought removal from the MIG and entitlement to ACBs and various medical benefits. The claimant was removed from the MIG based on psychological grounds and awarded various assessments and psychological treatment. ACBs were denied. Adjudicator Lester noted that even if the claimant had been found to require personal assistance, the evidence did not satisfy the proof of an incurred expense.