Category: Medical Benefits

The claimant sought a determination that her impairments were outside of the MIG and entitlement to medical benefits proposed in two treatment plans. Adjudicator Boyce found that the claimant’s psychological and/or neurological impairment took her outside of the MIG, based on the medical opinions of her assessors. The claimant was subsequently found entitled to payment for a psychological assessment. However, Adjudicator Boyce found a chiropractic treatment plan not payable as it was not reasonable and necessary. The claimant failed to demonstrate that her pain was caused by the accident or that she required further facility-based intervention to achieve relief.

The claimant sought a determination that his impairments were outside of the MIG and entitlement to medical benefits and costs of examinations proposed in five treatment plans. Adjudicator Sharma found that the claimant’s injuries were predominantly minor and fell within the MIG. Contrary to the claimant’s submissions arguing otherwise, Adjudicator Sharma found no compelling evidence of a pre-existing medical condition that would prevent maximal recovery and remove the claimant from the MIG. The disputed treatment plans were found not payable.

The claimant sought a determination that her impairments were outside of the MIG and entitlement to medical benefits proposed in seven chiropractic, attendant care, and psychological treatment plans and assessments. The claimant also argued the MIG limit did not apply to the psychological-based treatment plans, citing the insurer’s failure to state in its denial letters that the MIG applies. Adjudicator Grant found that the chiropractic treatment plans and attendant care assessments fell within the MIG due to a lack of objective medical evidence suggesting otherwise. He further found that the insurer’s denial letters in response to the psychological-based treatment plans failed to comply with section 38(9) of the Schedule, as it did not provide the required notice to the claimant of the insurer’s position that the MIG applied to his impairments. The insurer was subsequently prohibited from arguing that the injuries related to those treatment plans were predominantly minor injuries to which the MIG applied and was required to pay those medical benefits.

The claimant sought removal from the MIG and entitlement to a chronic pain assessment, a neurological assessment, an orthopedic assessment, assistive devices, and interest on the payment of overdue benefits. Adjudicator Grant found that the claimant’s injuries were predominantly “minor injuries” and that injuries she suffered later, as a result of a July 21, 2016 accident, were more significant. As such, Adjudicator Grant did not have to address the disputed assessments, which were denied due to the insurer’s position that the MIG applied to the claimant’s injuries. With respect to OCF-18 for assistive devices, the insurer approved it subject to the claimant submitting the treatment plan to her collateral benefits provider; the insurer agreed to pay the remaining balance. Since the claimant did not provide any evidence that the OCF-18 was submitted to her collateral benefits provider, Adjudicator Grant found that the insurer was not required to pay any amount of the treatment plan until the claimant provided proof of submission to her collateral benefits provider.