Category: Medical Benefits

J.H. v. CUMIS General Insurance Company (18-012367)

Post author By tgp-admin
Post date January 14, 2020
No Comments on J.H. v. CUMIS General Insurance Company (18-012367)

The claimant sought a determination that she suffered a catastrophic impairment, entitlement to IRBs, and entitlement to various medical benefits. Adjudicator Gosio held that the claimant did not meet the criteria to suffer a catastrophic impairment. He agreed that the claimant suffered a psychological impairment, but that the maximum impairment was a Class 3 moderate impairment in each of the spheres of function. The claimant continued to care for her young child, was independent with personal care, and was able to exercise independently. She visited with family and friends on occasion. The claimant appeared well-groomed and there was no evidence of self-neglect. Adjudicator Gosio did award IRBs on an ongoing basis, holding that the claimant’s anxiety prevented her from returning to work. The claims for physical therapy were rejected, as the claimant was capable of independently exercising; the HST on an approved treatment plan was awarded.

S.R. v. Certas Home and Auto Insurance Company (18-006442)

Post author By tgp-admin
Post date January 14, 2020
No Comments on S.R. v. Certas Home and Auto Insurance Company (18-006442)

The claimant was deemed catastrophically impaired. He sought entitlement to ongoing HK expenses, and entitlement to the rent differential for a larger rental home. Adjudicator Paluch rejected both claims. While he held that the claimant suffered a substantial inability to perform housekeeping tasks, he also found that the claimant had not incurred expenses related to housekeeping and concluded that the insurer had not unreasonably withheld HK expenses. In terms of the claim for rent differential, the adjudicator noted that the claimant failed to put sufficient evidence before the Tribunal regarding his current rent, the current rental market rates, the amount the claimant received for rent from his brother, or why a larger unit was needed (as opposed to removing some of the clutter in the current unit).

A.S. v. Aviva Insurance Canada (18-010483)

Post author By tgp-admin
Post date January 13, 2020
No Comments on A.S. v. Aviva Insurance Canada (18-010483)

The claimant sought entitlement to medical benefits proposed in two treatment plants. The insurer raised a preliminary issue on the claimant’s late production of evidence. Adjudicator Johal admitted the late disclosure, finding the respondent did not suffer any resulting prejudice. Nevertheless, the claimant was found not entitled to any medical benefits as the treatment plans were not reasonable and necessary. The claimant did not point to any objective evidence warranting the benefits.

J.S. v. Aviva Insurance Canada (18-008643)

Post author By tgp-admin
Post date January 13, 2020
No Comments on J.S. v. Aviva Insurance Canada (18-008643)

The claimant sought entitlement to an orthopedic assessment, a chiropractic treatment plan, interest on the payment of overdue benefits, and a special award. Adjudicator Norris found that the disputed orthopaedic assessment plan was not reasonable and necessary; it was a duplication of services as the claimant was previously assessed by an orthopaedic fewer than two months prior to the submission of the disputed orthopaedic assessment plan. There were no new orthopedic injuries reported during the time leading up to the submission of the assessment plan. Adjudicator Norris also found that the disputed chiropractic treatment plan was not reasonable and necessary, noting that the treatment plan addressed injuries that were not accident-related and the claimant had already returned to work and was independent with self care at the time it was proposed.

L.D. v. Aviva Insurance Canada (19-000674)

Post author By tgp-admin
Post date January 10, 2020
No Comments on L.D. v. Aviva Insurance Canada (19-000674)

The claimant sought entitlement to an orthopedic assessment and interest on the payment of overdue benefits. Adjudicator Boyce found that the disputed orthopedic assessment was reasonable and necessary at the time it was requested because the claimant continued to experience pain post-accident and treatment had plateaued. On this basis, Adjudicator Boyce found it reasonable that a professional assess (or re-assess) her condition to identify the source of her impairments and pain and potentially prevent her pain from becoming chronic (as it apparently became).

S.S.R. v. Unifund Assurance Company (18-004772)

Post author By tgp-admin
Post date January 9, 2020
No Comments on S.S.R. v. Unifund Assurance Company (18-004772)

The insurer sought reconsideration of the Tribunal’s award of NEBs and medical benefits, and that section 55 did not prevent the claimant from disputing entitlement to the medical benefits. Vice Chair Lester granted the reconsideration in relation to NEBs, but only in ordering that NEB entitlement began six months after the accident as opposed to four weeks, since the claim was under a transitional policy. The reconsideration was dismissed in relation to entitlement to benefits because no error in law was identified by the insurer and the findings of fact were permissible based on the evidence before the Tribunal. In terms of IE non-attendance, Vice Chair Lester noted that section 55 would only apply if the IEs in question were in relation to a disputed benefit. The notices of examination did not indicate which medical benefits were being addressed, so the Tribunal could not determine if section 55 applied.

J.P. v. Allstate Insurance Company (18-008027)

Post author By tgp-admin
Post date January 9, 2020
No Comments on J.P. v. Allstate Insurance Company (18-008027)

The claimant sought entitlement to IRBs and eight medical benefits. Adjudicator Boyce rejected the claims. He held that the claimant failed to adduce sufficient objective evidence of a substantial inability to engage in his pre-accident employment. All of his evidence was self-reported. Further, the claimant did not use any prescriptions to address his soft tissue injuries or pain. Adjudicator Boyce also rejected all of the claimed medical benefits. First, he noted that section 38(5) prevented the claimant from disputing entitlement to any OCF-18s while treatment remained under the MIG. With regard to two late denials, Adjudicator Boyce noted that any incurred treatment would be payable, but that the claimant failed to provide evidence that any treatment was incurred during the period of non-compliance.

A.G. v. Coseco Insurance (18-007969)

Post author By tgp-admin
Post date January 9, 2020
No Comments on A.G. v. Coseco Insurance (18-007969)

The claimant sought removal from the MIG, entitlement to a chronic pain assessment and chronic pain program, and interest on the payment of overdue benefits. Adjudicator Sharda found that the claimant should be removed from the MIG since the chronic pain she suffered in her neck and left shoulder were not predominantly minor injuries. Adjudicator Sharda further found compelling evidence of the claimant’s pre-existing medical condition; her chronic injuries prevented her from achieving maximal medical recovery from the injuries that were exacerbated by the accident. Additionally, Adjudicator Sharda found that the claimant’s chronic pain injuries had continued over four years post-accident and therefore by definition were chronic. The claimant was thus entitled to the chronic pain treatment plan and the chronic pain assessment, as both were reasonable and necessary, and interest.

D.O. v. Aviva Insurance Canada (18-007687)

Post author By tgp-admin
Post date January 9, 2020
No Comments on D.O. v. Aviva Insurance Canada (18-007687)

The claimant sought entitlement to various chiropractic treatment plans, a functional cognitive assessment, and interest on the payment of overdue benefits. Adjudicator Norris found the following: since the claimant incurred the disputed chiropractic treatment plans prior to their submission and without prior approval of the insurer or meeting any of the other exceptions under section 38(2), he was not entitled to payment for them; the claimant was not entitled to the disputed functional cognitive assessment as it was not reasonable and necessary because no further investigation into the claimant’s cognitive state was required (specifically, the claimant’s evidence failed to show signs of cognitive impairment significant enough to impair his independence with personal care and ability to complete activities of work and normal living, as suggested in the disputed treatment and assessment plan); and the claimant was thus not entitled to interest.

Z.K. v. Unifund Assurance Company (18-007924)

Post author By tgp-admin
Post date January 8, 2020
No Comments on Z.K. v. Unifund Assurance Company (18-007924)

The claimant sought entitlement to four physiotherapy treatment plans and the cost of an impairment assessment, a multi-disciplinary catastrophic assessment, and a neurological assessment. Adjudicator Manigat rejected the opinion of the insurer’s psychiatry assessor that there was no objective evidence of ongoing impairments and that the claimant did not have any functional limitations or physical restrictions, finding instead that the physiotherapy treatment plans were reasonable and necessary to manage the claimant’s chronic pain. The claimant was not entitled to the cost of the impairment assessment because a comprehensive impairment assessment had already been completed; nor was he entitled to the catastrophic assessment or neurological assessment, as his injuries were predominantly physical in nature.

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