Category: Medical Benefits

The claimant applied to the LAT disputing the quantum of IRBs he was entitled to. He also claimed the denied portions of two psychological treatment plans. The claimant was self-employed prior to the accident as a renovation contractor. He elected to use the 52 weeks of earnings prior to the accident rather than the last completed taxation year. Adjudicator Farlam accepted the accounting report of the insurer as it was based on the documentation provided by the claimant. The claimant’s own accountant used various assumptions and oral evidence from the claimant that was not supported by financial documentation. For example, the claimant did not provide purchase orders, invoices, sales summary, or time records. Adjudicator Farlam also denied the disputed portions of the psychological treatment plans. She accepted that the insurer’s decision to allow $99.75 per hour for psychotherapy was appropriate (rather than the $224.42 per hour claimed). She also held that the claimant failed to prove why “documentation support activity” was reasonable and necessary. The special award claim was also dismissed. The insurer’s delay in payment of IRBs was due to the claimant’s failure to provide financial documentation.

The claimant sought entitlement to post-104 week IRBs, physiotherapy, and a special award. Adjudicator Mather granted the claim for ongoing IRBs, but dismissed the claim for further physical therapy. She also granted a special award of 50 percent on IRBs. The claimant was a self-employed taxi driver for over a decade prior to the accident. He suffered a concussion in the subject accident which led to psychological impairments. He was also in a second accident and made a claim for accident benefits with the same insurer. The insurer denied IRBs based on IEs completed with regard to the subject accident (which concluded he did not have a psychological disorder) despite having IEs from the second accident in which the claimant was diagnosed with major depressive disorder, general anxiety, panic attacks, and vehicular phobia. The psychological IE in the subject accident ignored various relevant factors and cherry-picked evidence that was supportive of denying IRBs (such as the claimant attempting a return to work for a few hours per day). Given the claimant’s lack of other relevant job experience and poor English skills, there were no other potential types of employment that were suitable for him. Adjudicator Mather found the insurer’s denial of IRBs to be unacceptable. She held that the insurer failed in its adjusting of the claim by ignoring the psychological diagnoses in its own IEs related to the second accident. She also noted that the insurer continued to approve psychotherapy while taking the position the claimant did not have a psychological impairment preventing him from working. The claimed physiotherapy was dismissed as the claimant did not provide evidence of the need for further physical therapy. He also failed to provide evidence of treatment received to date or the progress that physical treatment provided.