Category: Medical Benefits

M.M. v. Aviva General Insurance (19-002201)

The claimant sought entitlement to IRBs and three medical benefits. Adjudicator Chakravarti held that the claimant was not entitled to any of the claimed benefits. She found that the claimant was not credible, and that insufficient evidence was put forward to show that the claimant was working or had worked 26 of the past 52 weeks prior to the accident. The purported employer said that documents with his company name on the letterhead were misrepresentations. The claimant also failed to put forward convincing evidence regarding the three claimed medical benefits.

M.Z. v. Certas Home and Auto Insurance (19-005344)

The minor claimant suffered serious injuries in an accident. He received attendant care for over one year, but ACBs were terminated thereafter. He sought entitlement to further ACBs and one medical benefit for physiotherapy. Adjudicator Boyce denied the claim for further ACBs, but partially approved the claim for physiotherapy. The medical evidence suggested that the minor claimant had largely healed from his physical injuries within the year. The claimant’s treating surgeons and doctors had noted that the claimant’s injuries had resolved and the claimant was participating in normal activities. Adjudicator Boyce also noted that the claimant’s Form 1 oddly recommended support with activities that his parents were performing before the accident (meal preparation, bathroom cleaning). Further, there was no evidence of attendant care services being incurred.

J.Z. v. Certas Home and Auto Insurance (19-005337)

The minor claimant suffered a broken arm in an accident. He received attendant care for over one year, but ACBs were terminated thereafter. He sought entitlement to further ACBs and one medical benefit for physiotherapy. Adjudicator Boyce denied both claims. The medical evidence suggested that the minor claimant had largely healed from his physical injuries within the year. The claimant’s treating surgeons and doctors had noted that the claimant’s injuries had resolved and the claimant was participating in normal activities. Adjudicator Boyce also noted that there was no evidence of attendant care services being incurred.

S.B.S. v. Wawanesa Mutual Insurance Company (17-006935)

The claimant sought entitlement to ongoing IRBs and two medical benefits. The insurer argued that the claimant was not credible, and that her impairments were caused by other health issues and second motor vehicle accident. Adjudicator Neilson found the claimant to be a poor historian who consistently exaggerated her complaints. She concluded that the claimant did not suffer a substantial inability to engage in her pre-accident employment as a result of the accident, and that her reported impairments were caused by things and events other than the subject accident (she also did not meet the complete inability test). The claim for psychological treatment was dismissed; further chiropractic treatment was awarded based on it providing pain relief at the time it was proposed. Adjudicator Neilson also dealt with a number of preliminary motions, in which she ordered: the insurer’s witnesses would not be excluded for failure to produce the full IE file; the claimant’s treating OT and psychologist could not testify as experts, but rather as treating practitioners; that the claimant could call the adjuster as a witness; and that the claimant could refer to and rely upon psychological testing data that was served late.

B.M. v. Aviva Insurance (18-009182)

The Tribunal had awarded two of three treatment plans for chiropractic services, and denied the third as being duplicative. The claimant sought reconsideration on the denied treatment plan; the insurer sought reconsideration of the two approved treatment plans. Adjudicator Johal dismissed the claimant’s reconsideration request and attempt to introduce new evidence. Adjudicator Johal granted the insurer’s reconsideration request and found all three treatment plans to be not reasonable and necessary. He accepted that the Tribunal had awarded the treatment plans based on providing pain relief, but without any evidence of improved function and without objective evidence of a change in pain.

D.S. v. Aviva Insurance Company of Canada (18-006592)

The insurer sought reconsideration of the Tribunal’s award of medical benefits based on section 38 deficient denials, on the basis that the Tribunal failed to consider whether the benefits were incurred. Adjudicator Grant dismissed the reconsideration request. While he agreed with the insurer that the benefits were not deemed incurred under section 3(8), he also explained that a benefit was only payable if it meets the requirements of the SABS (i.e. payment is owed once incurred, and interest owed once overdue).

R.K. v. Allstate Insurance (19-000502)

The claimant sought entitlement to monthly ACBs and one treatment plan for physiotherapy. Vice Chair Flude concluded that the claimant’s impairments all preceded the accident, and that she did not require attendant care nor further physiotherapy. The claimant’s self-reporting to her experts was contradicted by the medical records and the surveillance.

A.M. v. Wawanesa Mutual (18-008775)

The claimant sought a catastrophic impairment determination, as well as entitlement to NEBs, ACBs, various medical benefits, and the denied portion of catastrophic impairment assessments. The insurer argued that the claimant’s psychological injuries and epilepsy were not accident-related, but resulted from pre-existing conditions. Adjudicator Lake agreed with the insurer and dismissed all claims. She found that the claimant had suffered from various pre-accident impairments (epilepsy, migraines, major depressive episodes related to the death of the claimant’s daughter). Further, surveillance of the claimant showed that she was not credible in her self-reporting. Adjudicator Lake was also critical of the claimant’s experts assigning the maximum WPI when converting psychological impairment. With respect to psychological impairment caused by the accident, Adjudicator Lake found Class 1 and 2 impairments. The claims for NEBs and ACBs were similarly dismissed. The denied portions of the CAT assessments were not reasonable and necessary, and the claimed medical benefits were dismissed.

S.K. v. Technology Insurance Company Inc. (19-003749)

The claimant sought entitlement to social work services, HST on treatment plans, and the cost of CAT assessments. Adjudicator Chakravarti held that the limitation period applied to the social work services because the denial of the proposed rate was clear and unequivocal. Section 7 of the LAT Act did not apply because the claimant did not provide any details as to why the dispute was brought outside the limitation period. The limitation period did not apply to the HST claim because the insurer provided contradictory reasons in the denial letter. The limitation period did not apply to the CAT assessments either because the denial letter only indicated that the insurer had not made a decision regarding the proposed costs.

R.K.K. v. Cooperators General Insurance Co. (19-002834)

The claimant sought entitlement to IRBs and a series of assessments to address the “complete inability” test, and removal from the MIG. Adjudicator Watt did not accept the opinions of the claimant’s medical experts as they relied upon the claimant’s self-reporting, which was not credible. The claimant had reported to Ontario Works that she had no restrictions on working. She was also seen on surveillance engaging in normal activities. Adjudicator Watt concluded that the claimant did not suffer from somatic symptoms disorder, and that her injuries fell within the MIG. Further IRBs were denied, as were the claimed assessments.