M.S. v. Aviva General Insurance Company (18-007082)

The claimant sought entitlement to four treatment plans for medical rehabilitation and cost of examinations, including chiropractic treatment, concussive therapy, and optometric services. Vice-Chair McQuaid found that the proposed treatments were not payable. In her decision, she noted that, although, she gave more weight to the evidence provided by the claimant’s family physician and treating practitioners over the IE assessors, the records and evidence provided by the claimant did not contain any recommendations by the family physician for any of the disputed treatment plans for physical therapy. The remaining treatments for optometric services were denied as the claimant had pre-existing cataracts, which were not caused by the subject accident, and the medical records indicated that, although concussive symptoms were present, that they had fully resolved by the time the concussive therapy was proposed.

R.B. v. RSA Insurance (19-002329)

The claimant sought entitlement to four treatment plans for medical rehabilitation and cost of examinations, including a catastrophic impairment assessment and medications. The insurer denied the benefits in dispute on the basis that the claimant’s medical limits had been exhausted. Adjudicator Kaur concluded that that cost of examination for a catastrophic assessment are not subject to the medical benefits limitation. The claimant was entitled to the catastrophic impairment assessments, but the remainder of the medical benefits were denied as there was no evidence on a balance of probabilities that the expenses were reasonable or necessary.

H.M. v. Intact Insurance Company (18-003979)

The claimant sought entitlement to a treatment plan for physiotherapy, and cost of examinations for a neurological assessment and a chronic pain assessment. Adjudicator Johal reviewed the medical records on file, which indicated numerous treating practitioners’ opinion that further physiotherapy would be beneficial, and concluded that the disputed treatment for ongoing physiotherapy was reasonable and necessary as the claimant did not have to prove his injuries were “substantive”, only that the need for the treatment was reasonable and necessary. Adjudicator Johal dismissed the claims for the denied examination for a neurology assessment as the treating neurologists on file did not recommend it in their records, and in fact, only recommended further physiotherapy. The chronic pain assessment was denied because while the treating practitioner diagnosed the claimant with chronic pain, there was no indication that a further assessment was required.

S.A. v. Aviva Insurance Canada (19-000995)

The claimant disputed entitlement to two treatment plans for treatments focused on neurological and concussive injuries. Adjudicator Norris noted that the claimant appeared to have predominantly psychological injuries as a result of the accident. He cited the insurer examination reports of Dr. Smyth (neurologist) and Dr. Belfon (physician) as holding greater weight than the claimant’s evidence. Adjudicator Norris also noted that primary reason for the claimant’s visits to her family doctor was in fact to report psychological symptoms, and not symptoms related to neurological or concussive symptoms. He also gave little weight to the section 25 report of Dr. Horseman (chiropractor) as it was not accompanied by any records or test results to substantiate Dr. Horseman’s conclusions. Adjudicator Norris found the treatment plans not reasonable and necessary and denied any interest.

A.H. v. Aviva Insurance Canada (18-004237)

The claimant disputed her entitlement to a treatment plan for chiropractic services. Vice-Chair Farlam concluded that the disputed treatment plan was not necessary. Although the claimant consistently complained of back pain from 2015 to 2019, a review of the medical evidence did not show a direct relation to proposed treatments and subject accident as the claimant had pre-existing back pain, had been involved in two prior accidents, and the subject accident was only directly mentioned a few times; and at one point, was not mentioned for a period of two years.

S.L. v. Aviva Insurance Company of Canada (19-002783)

The claimant sought entitlement to income replacement benefits and to medical benefits proposed in eight treatment plans, and the cost of $26,400 for catastrophic impairment assessments. The claimant argued that he suffered from pre-existing lower back pain which was exacerbated as a result of the accident and would prevent him from reaching maximum recovery under the MIG. Adjudicator Lester found that the claimant’s pre-existing strains did not remove him from the MIG and the claimant did not have a chronic pain disorder, therefore, the MIG limits applied. Adjudicator Lester concluded that the claimant exhausted all funding under the MIG and he was not entitled to any of the treatment plans in dispute. Adjudicator Lester found that the claimant suffered a substantial inability to perform the essential tasks of his employment and was entitled to IRB for a period of four months. Adjudicator Lester noted that the claimant was also entitled to interest for the IRB.

Aviva General Insurance v. Khan (2020 ONSC 1290)

The insurer sought judicial review of the Tribunal’s decision to award various medical benefits. The Court reviewed the Tribunal’s decision on a correctness standard and dismissed the appeal. It agreed with the insurer that a benefit could not be deemed incurred without a specific finding that the insurer unreasonably withheld or delayed payment of a benefit. However, the Court also wrote that the Tribunal’s decision made it clear that the benefit had been incurred because the services were provided and the claimant owed money to the treatment provider.

S.F. v. Aviva Insurance Company of Canada (18-012486)

The claimant sought entitlement to the costs of three assessments for examinations and one treatment plan for assistive devices. Adjudicator Norris found that the claimant was not entitled to any of the benefits. Adjudicator Norris concluded that the Neurological, FAE, and In-Home Ergonomics assessments were not reasonable and necessary as a result of the accident. The claimant did not submit the disputed treatment plan, and as a result Adjudicator Norris had to rely on the IE report. Adjudicator Norris concluded that the treatment plan was not reasonable and necessary as the devices were predominately for neck, back, and shoulder injuries and the claimant reported no such impairments.

S.P. v. Jevco (19-001613)

The claimant sought entitlement to income replacement benefits, to the costs of four assessments for examinations, to four treatment plans for physiotherapy services, and to payment for a disability certificate invoice. Adjudicator Watt found that the claimant was not entitled to the medical benefits, attendant care assessment, psychological assessment, functional abilities evaluation, and chronic pain assessment. In determining entitlement to IRB, Adjudicator Watt relied on the opinions of the IE assessors who indicated that the claimant could perform her pre-accident duties. Adjudicator Watt concluded that there was no evidence before the Tribunal to show that the claimant’s pain was severe enough to cause functional impairment or disability, so the IRB claim was dismissed. Finally, Adjudicator Watt found that the disability certificate invoice was not reasonable and necessary.

M.D. v. Certas Home and Auto Insurance Company (18-011652)

The claimant sought a determination that his impairments were outside of the MIG and entitlement to medical benefits proposed in two treatment and assessment plans for physiotherapy services and a chronic pain assessment. Adjudicator Grant found that the claimant’s chronic pain took him outside of the MIG, based on the chronic pain assessment report of Dr. Karmy, a chronic pain specialist. Based on the length and history of the claimant’s pain complaints and the goal of achieving pain relief, Adjudicator Grant found the chronic pain assessment and physiotherapy treatment plan to be reasonable and necessary.