Category: LAT Rules

The claimant sought entitlement to two medical benefits for chiropractic treatment and interest. In addition to the two treatment plans that the parties agreed would be addressed in the written hearing, the claimant’s initial submissions addressed a number of new issues that were not contained in his application to the Tribunal, that were not raised or addressed at the case conference and were not confirmed in the Case Conference Order as being properly in dispute. The claimant also filed a Notice of Motion with the Tribunal seeking to add 15 additional issues or amendments to the written hearing, the bulk of which were those addressed in his initial submissions but were not captured by the Case Conference Order or addressed by the insurer in its response. Adjudicator Boyce noted that granting the claimant’s request to add additional issues at this stage in the proceeding would be procedurally and substantively unfair to the insurer and would not result in a fair and open process. Accordingly, the claimant’s motion was dismissed without prejudice, as these issues and sub-issues would require a fresh application in order to proceed properly and fairly and in order to afford the insurer the requisite amount of procedural fairness. With respect to the medical benefits, the claimant submitted that because he was not aware of the insurer’s denial of the treatments he incurred in this current dispute he continued to submit expenses via OCF-6 and not via the requested OCF-18 treatment plans. Adjudicator Boyce held that section 38(2) was triggered because the claimant incurred all of the chiropractic treatment prior to submission of the treatment plans in dispute. The adjudicator agreed that none of the section 38(2) exceptions applied to the claimant’s case and held that there was no issues with any of the insurer’s denial notices, with its adjusting of the claimant’s claims or its reliance on IEs.

The claimant sought entitlement to two medical benefits for physiotherapy and occupational therapy services. The claimant had a significant pre-accident medical history that included a workplace accident, two separate motor vehicle accidents in 2013, chronic lumbar radiculopathy, and chronic lower back pain. He was also involved in a subsequent motor vehicle accident in 2016 after the subject accident. The insurer argued that the disputed treatment plans fail the test for causation. The claimant submitted the disputed treatment plans shortly after the 2016 accident. The insurer argued that the claimant ought to have commenced an accident benefits claim in relation to that loss. The claimant argued that the accident need not be the sole cause of the injuries in order to meet the “but for” test as established in Sabadash v. State Farm. Vice Chair McGee found that the subject accident met this threshold and deemed the two treatment plans to be reasonable and necessary. An issue was also raised as to whether the insurer satisfied the IE notice requirements in section 44(5) of the Schedule. The insurer sent IE notices to the claimant, but omitted crucial information as to the reasons for the sought examination. The notices simply stated “Rescheduled assessment” and “RESCHEDULED” as the reasons. Vice Chair McGee found that the insurer’s notice was patently deficient. Neither of the IE notices provided comprehensible “medical or other reasons” for the requested examinations. She reasoned that an insured person should not be expected to piece together “medical or other reasons” for an examination from disparate notices and correspondence or to advise an insurer of deficiencies in those notices so they may be corrected. Vice Chair McGee concluded that the appropriate remedy was the exclusion of the IE reports.