Category: Medical Benefits

C.S. v. Aviva Insurance Canada (18-007039)

The claimant sought entitlement to a rehabilitation treatment plan and interest on the payment of overdue benefits. Adjudicator Grant found that the claimant did not demonstrate that the rehabilitation benefits in dispute for personal training and a gym membership were reasonable and necessary. The treatment plan was contradicted by the claimant’s self-reporting that she had already received education about stretching and strengthening, as well as Dr. Kleinman’s report on the extent of the claimant’s injuries and recommended treatment. The treatment plan was found not payable.

S.P.F. v. Aviva General Insurance (18-010856)

The claimant sought entitlement to medical benefits proposed in two psychological treatment plans. Adjudicator Grant found that the treatment plans were not reasonable and necessary, based on the claimant’s self-reporting and the reports of section 44 assessors. The claimant had acknowledged that he had not experienced any significant disruption, and he denied a desire to participate in psychotherapy counselling. Adjudicator Grant also noted that if the claimant required further psychological treatment, he still had approximately $3,879.00 of approved and not incurred funding available for treatment.

Applicant v. Unifund Assurance Company (18-008089)

The insurer filed a request for reconsideration arising from a decision in which the Tribunal found that CAT Assessments were not a medical benefit and therefore their funding did not fall within the $50,000 limit under section 18 of the SABS. Adjudicator Victor dismissed the insurer’s request for reconsideration and granted the claimant’s request for costs in the amount of $100, noting that the insurer had only raised the same arguments it made at the hearing and was essentially trying to re-litigate the decision based on the same arguments.

C.D. v. Certas Home and Auto Insurance Company (18-006437)

The claimant sought reconsideration of the Tribunal’s denial of mileage expenses related to her case manager. Vice-Chair Lester upheld the previous decision and dismissed the reconsideration. She noted that the claimant re-argued her case from the previous decision, and did not explain how the decision erred in fact or law. She also did not argue as to how the mileage expenses were reasonable or necessary.

P.K. vs. Aviva Insurance Canada (18-011533)

The claimant disputed entitlement to a partially approved OCF-18 for psychological services in the amount of $3,591.87. The insurer paid $2,444.15 of the OCF-18 based upon the Professional Services Guideline for psychological services. Adjudicator Norris noted that the insurer was correct in its payment of the services within the PSG. He commented that the $224.42 per one hour session requested was not appropriate or in accordance with the PSG, while the $149.61 paid by the insurer was. The claimant also argued that the insurer was non-compliant with section 38 for delivering a late response which was “overly generic.” Adjudicator Norris agreed, noting that the denial letter was late and did not provide specific medical or other reasons for the denial. He awarded entitlement to the goods and services incurred during the period of non-compliance, staring on the 11th business day up to the day when the insurer provided a compliant notice.

E.M. v. The Guarantee Company of North America (18-000674)

The claimant filed a request for reconsideration following a decision in which the Tribunal concluded that he was not entitled to NEBs or various medical benefits. The claimant argued that the Tribunal erred in law by not engaging the Heath analysis and not considering evidence tendered at the hearing. Adjudicator Punyarthi dismissed the reconsideration request, noting that the Tribunal correctly cited the test for NEBs and appropriately weighed the evidence tendered at the hearing. It was beyond the scope of a reconsideration to engage in a re-weighing of the evidence.

E.M. v. The Guarantee Company of North America (18-000674)

The claimant filed a request for reconsideration following a decision in which the Tribunal concluded that he was not entitled to NEBs or various medical benefits. The claimant argued that the Tribunal erred in law by not engaging the Heath analysis and not considering evidence tendered at the hearing. Adjudicator Punyarthi dismissed the reconsideration request, noting that the Tribunal correctly cited the test for NEBs and appropriately weighed the evidence tendered at the hearing. It was beyond the scope of a reconsideration to engage in a re-weighing of the evidence.

A.A. v. Technology Insurance Company Inc. (18-007493)

The claimant sought removal from the MIG and entitlement to chiropractic services and rebuttal assessments. Adjudicator Paluch concluded that the claimant suffered from chronic pain syndrome, which was not simply a clinically associated sequela to his minor injuries. There was also evidence of disc bulges, protrusion and canal stenosis which are not minor injuries. The claimant was awarded the chiropractic treatment since it provided him with pain relief. The rebuttal assessments were not payable because there was no evidence as to the purpose of the assessment or why a rebuttal report was necessary.

K.K. v. Coseco Insurance (18-002839)

The claimant disputed his MIG determination and entitlement to various medical benefits. The respondent raised a preliminary issue, arguing that the claimant was statute-barred from proceeding with his claim in respect of two of the disputed treatment plans for failure to dispute entitlement within the two year limitation period. Adjudicator Norris agreed, noting that the insurer’s denial letters were clear and unequivocal denials of the benefits and included notice of the two year limitation period, information on the claimant’s right to dispute, and medical and other reasons for the denial. Adjudicator Norris further concluded that the claimant had not met his onus of establishing that his injuries fell outside of the MIG, and was thus bound by the $3,500 funding limit.

Y.L.C. v. Gore Mutual Insurance Company (18-010499)

The claimant disputed his entitlement to chiropractic treatment and income replacement benefits. The insurer denied the proposed chiropractic treatment based on a physiatry IE report which found that further facility-based treatment would not be helpful. Vice Chair Lester nevertheless determined that the disputed treatment plan was reasonable and necessary, given the records from the treating facility which showed ongoing improvements in the claimant’s range of motion and the fact that the claimant’s family physician had recently referred him to a chronic pain clinic for the same types of issues he complained of to the physiatry assessor. Vice Chair Lester concluded that she did not have jurisdiction to deal with the merits of the IRB claim, as the insurer had not denied entitlement to IRBs but rather suspended entitlement for failure to comply with a section 33 request for production of financial documentation.

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