Category: Medical Benefits

B.Y. v. Economical Insurance Company (19-005084)

The claimant sought entitlement to IRBs and various medical benefits. Adjudicator Watt dismissed all of the claims. He held that the claimant was able to return to work based on medical evidence and based on surveillance evidence. The claimed medical benefits were similar to treatment that the claimant said did not reduce his symptoms or increase functionality, and were therefore not reasonable and necessary. Further, the claimant did not pursue any of the treatments his family physician had recommended.

B.N. v. The Co-Operators Insurance Company (19-006455)

The claimant sought removal from the MIG and entitlement to three treatment plans for psychology services and chiropractic treatment. This case also raised the issue of whether an insurer can properly deny medical benefits for a psychological assessment and psychological treatment without requiring the claimant to attend an in-person IE for a psychological assessment. With respect to the MIG, the claimant did not provide the required evidence from his health care providers to support that he had pre-existing conditions that would prevent him from achieving maximum recovery. In addition, the treatment plans and psychological report lacked credibility and the claimant’s psychological complaints were not medically supported. The adjudicator ruled that the claimant did not sustain more than predominately minor injuries. For this reason, the treatment plans were not reasonable or necessary. In determining whether the insurer provided proper medical reasons for denying the disputed treatment plans, Adjudicator Mather was satisfied that the insurer had made it clear to the claimant what medical evidence it was looking for to substantiate the claim. Adjudicator Mather held that the insurer provided a valid medical reason for denying the benefits for the psychological assessment and psychological treatment.

Z.P. v. Certas Direct Insurance Company (19-003226)

The claimant suffered a catastrophic impairment and sought entitlement to three treatment plans for home modifications and assistive devices. With respect to a $9,025.30 home modification assessment, the insurer had already paid $2,000 and argued that it was the maximum payable under the SABS. Vice Chair McQuaid agreed that the maximum payable was limited to $2,000 and dismissed the remaining $7,025. With regard to assistive devices, Vice Chair McQuaid concluded that the treatment plan was reasonable and necessary for the claimant’s impairments. For the third treatment plan regarding architectural working drawings, Vice Chair McQuaid found that there was a question as to whether the claimant still wanted to pursue home modifications after the proposal of Adapt-Able was withdrawn. The architectural drawings were therefore not payable.

A.T. v. Aviva Insurance Canada (18-010303)

The claimant sought entitlement a treatment plan for $14,804.51 for medical services, which he claimed was not properly denied in accordance with section 38 of the SABS. The claimant further argued that the insurer’s denial was deficient as it referenced a different health provider than the one listed on the disputed plan, and it did not reference the amount being denied. The second denial referenced the opinions of the IE assessors, but did not include the reports on which the denial was based. The insurer argued that its medical and other reasons were clearly stated in the denial. The insurer did not make an argument with regard to the failure to deliver the IE reports within 10 business days, but noted that the IE reports were provided one month later. Adjudicator Manigat ruled that the treatment plan in dispute was not properly denied as per section 38 of the SABS, but that the insurer rectified the error when it subsequently provided the IE reports. The claimant was therefore only entitled to payment of amounts incurred during the period of non-compliance, as well as interest on any amounts incurred during that period.

L.D. v. Certas Home and Auto Insurance Company (19-001472)

The claimant disputed entitlement to four treatment plans for physical treatments and a chronic pain assessment, an invoice for completion of an OCF-3, a MIG determination, interest and a special award. The claimant alleged that he suffered from chronic pain as a result of the accident. In support of his claims, the claimant submitted medical records from his family doctor showing a long history of complaints of back pain post-accident. The notes further indicated that treatments would give relief. The claimant also submitted a chronic pain report from a specialist. The insurer submitted its own independent reports, but never sent the claimant to independent assessments under section 44 of the SABS. The insurer raised concerns with the merits of the claimant’s report and the quality of the report itself. Adjudicator Norris agreed with the concerns, but held that the insurer did not provide a competing medical opinion to rule out chronic pain. The adjudicator ruled that the claimant was out of the MIG, that all disputed treatment plans were reasonable and necessary, that the claimant was not entitled to payment of the OCF-3 as he had returned to work post-accident and failed to prove it was reasonable and necessary, that interest was payable on all benefits, and granted a 40 percent special award for the insurer’s failure to recognize the claimant’s medical evidence, especially in light of the fact that the insurer had no competing medical opinion on which to continue to deny benefits and maintain a MIG position in light of the volume of evidence presented by the claimant.

O.S. v. Certas Home and Auto Insurance Company (18-006633)

The claimant disputed entitlement to three treatment plans for chiropractic services, an orthopaedic assessment, and a neuropsychological assessment, as well as multi-disciplinary CAT assessments. Adjudicator Pinto ruled that all disputed plans were not reasonable or necessary based upon the evidence provided. In her decision, she noted that the disputed treatment plans did not provide medical reasons for the necessity of the services provided in relation to the subject accident. A review of the claimant’s medical records did not show that the claimant’s treating practitioner’s, specifically the family doctor, believed it was reasonably possible that the claimant was catastrophically impaired. All claims were dismissed.

C.W. v. Aviva Insurance Company (19-002426)

The claimant sought removal from the MIG and entitlement to various medical benefits. Adjudicator Farlam found that the claimant sustained minor injuries in the accident. While the disability certificate noted COPD, mild stroke, right sciatica, low back pain, they appeared to be self-reported by the claimant, and there was no pre-accident medical records documenting the alleged pre-existing medical conditions. Adjudicator Farlam also considered the claimant’s arguments that section 38 of the SABS entitled him to payment of incurred medical benefits. The adjudicator accepted that one of the disputed treatment plans was responded to 10 days late. However, the claimant had not incurred any of the proposed treatment during that time frame, so the insurer was not liable to pay anything.

G.S. v. Western Assurance Company (19-003626)

The claimant applied to the LAT seeking entitlement to occupational therapy services proposed in one treatment plan. Causation was an issue at the hearing. The insurer submitted that the claimant’s concussion symptoms were caused by documented pre- and/or post-accident incidents, and not caused by the subject accident. The claimant submitted that the pre-accident incident, the accident, and the post-accident incident combined to cause the concussion symptoms. Adjudicator Ferguson found that the claimant did not sustain a concussion until after the accident, and the proposed occupational therapy services were not reasonable and necessary because the claimant’s concussion symptoms were not causally linked to the accident.

K.P. v. CUMIS General Insurance (18-001556)

The claimant applied to the LAT seeking entitlement to pre- and post-104 IRBs, psychological treatment, and physical treatment. Adjudicator Letourneau found that, due chiefly to the pain management needs of the claimant and the diagnoses presented by treating practitioners, the claimant was entitled to the medical benefits in dispute. The claimant was not entitled to IRBs .

A.W.A. v. Certas Home and Auto Insurance (18-007207)

The claimant sought entitlement to IRBs, a series of catastrophic impairment assessments, and further physiotherapy. Adjudicator Gosio awarded IRBs up to the 104 week mark, but denied the remainder of the claims. The claimant worked as a machine operator, and his chronic neck pain inhibited his work. The claimant did not submit any evidence that he met the “complete inability” test. The proposed physiotherapy was not reasonable because it made the claimant’s pain worse. Finally, there was no reasonable basis on which to award the catastrophic impairment assessments. The evidence of psychological impairment was minimal, and he did not meet the criteria for any psychological disorder.