Category: Medical Benefits

The claimant sought entitlement to medical benefits, a social work assessment, an OCF-3 expense, and interest. Adjudicator Boyce concluded that the claimant was entitled to the three medical benefits, but not the assessment or expense. The insurer agreed to fund these treatment plans subject to a ruling with respect to the amounts proposed in excess of the maximum hourly rate in Superintendent’s Guideline No. 03/14. The insurer sought a breakdown of the services to be rendered, at what frequency or at what rate. Adjudicator Boyce found that treatment plans should clearly articulate the service provided and identify the provider and the appropriate rate. Adjudicator Boyce looked to the signing provider for each treatment plan and assumed that the provider’s area of expertise was the dominant modality for each. The applicable rate for each signing provider was then used to calculate the fees for each OCF-18. With respect to the assessment, Adjudicator Boyce found no reason to interfere with the insurer’s denial and that the type of assessment did not appear to be consistent with the claimant’s diagnosis and that there was no compelling medical evidence to indicate that a social worker assessment was required as a result of injuries sustained in the subject accident. Finally, the claimant sought $200 for an OCF-3 Disability Certificate. Adjudicator Boyce agreed with the insurer that the claimant submitting six OCF-3s from the same clinic in a three-year span was excessive where the claimant had not pointed to any change in circumstance. Further, neither the claimant, nor the clinic provided particulars to support why it was necessary to provide an updated OCF-3. Accordingly, Adjudicator Boyce found that the claimant was not entitled to the expense because it was not reasonable or necessary.

The claimant applied to the LAT disputing her entitlement to a chiropractic treatment plan. The issue in this dispute was the application of sections 38(5) and (6), and the MIG. The insurer denied the treatment plan in accordance with section 38(5) on the basis that the claimant was being treated within the MIG. Later, the insurer removed the claimant from the MIG and the claimant argued that once the insurer removed the claimant from the MIG, it failed to reconsider its denial of the disputed treatment plan and failed to make a determination regarding its reasonableness and necessity. The insurer argued that it was entitled to deny the plan pursuant to section 38(5) as this section allows an insurer to refuse to accept a treatment plan if the plan described goods and services during any period which the insured person is entitled to receive goods and services within the MIG. The insurer submitted an OCF-21 for this period showing that the claimant was treated within the MIG. Adjudicator Lake held that the claimant was treated within the MIG when the disputed treatment plan was submitted and therefore, section 38(5) applied and the LAT was prevented from reviewing the denial of the plan pursuant to section 38(6), regardless of the fact the insurer later removed the claimant from the MIG.

The claimant sought entitlement to two treatment plans, including a medical benefit for dental treatment and a rehabilitation benefit for a hot tub. The claimant also sought a special award. Adjudicator Grant found that the claimant was entitled to the OCF-18 for dental treatment, but was not entitled to the OCF-18 for a hot tub, as the expense was incurred prior to the submission of the treatment plan, contrary to s. 38(2) of the Schedule. With respect to a special award, neither party made submissions. Adjudicator Grant therefore found that an award was not appropriate in the circumstances. It was not unreasonable for the insurer to rely on the reports of its assessors when denying the OCF-18 for dental treatment.

The claimant sought entitlement to three treatment plans for chiropractic treatment. Adjudicator Lake found that the claimant was entitled to all three of the treatment plans, plus interest as a result of the insurer’s failure to comply with section 38(8). The claimant cited the decision of T.F. v. Peel Mutual Insurance Company, stating that an insurer’s “”medical and other reasons”” should, at the very least, include specific details about the claimant’s condition forming the basis for the insurer’s decision or, alternatively, identify information about the claimant’s condition that the insurer does not have, but requires. Adjudicator Lake found that the insurer’s denial notices did not comply with its obligations under section 38(8) because they mentioned “”injuries,”” but did not specify which injuries or conditions formed the basis of the decision, and did not include the IE report that it relied upon in correspondence. Further, the insurer highlighted the IE report’s recommendation for an independent exercise program, but failed to address the fact that the proposed treatment plans also included, in part, an exercise program. Finally, Adjudicator Lake stated that the insurer did not sufficiently identify the information that it still required from the claimant.