Category: Medical Benefits

M.B. v. Aviva General Insurance Company (19-000030)

The claimant sought entitlement to psychological treatment, a chronic pain program, and interest on the payment of overdue benefits. Adjudicator Boyce found that the claimant was entitled to the portion of the disputed psychological treatment plan for psychological sessions; however, with respect to the remaining elements of the disputed treatment plan, he agreed with the insurer’s position that there were other methods of determining the effectiveness of treatment aside from a progress report, and transportation was not required since the clinic was close to the claimant’s home. With respect to the disputed chronic pain program, Adjudicator Boyce found that the claimant’s complaints of pain to her family physician and treating practitioners were “consistent, continuous and voluminous.” As such, Adjudicator Boyce found on the evidence that the chronic pain program was partially reasonable and necessary: the rehabilitative components were well-supported by the documentation and he agreed that one progress report would be beneficial, but he did not find that a second progress report or the social work and education elements of the plan were reasonable and necessary.

J.P. v. Aviva General Insurance Company (18-007398)

The claimant sought entitlement to various medical/rehabilitation benefits, interest on the payment of overdue benefits, and a special award. In this amended decision, Adjudicator Punyarthi preferred the claimant’s evidence over the insurer’s, finding that it persuasively demonstrated the claimant was entitled to the disputed benefits. Adjudicator Punyarthi further found that the claimant was entitled to a special award since the insurer provided reasons for denial to the claimant that were not consistent with its actual reasons for denial, and failed to consider medical treatment records on file when deciding to deny the claimant’s requests for treatment. By engaging in this conduct, Adjudicator Punyarthi found that the insurer unreasonably delayed or withheld payments to the claimant; as such, the insurer was ordered to pay an award to the claimant of 50 percent of the denied benefits (and interest) at issue. Adjudicator Punyarthi noted that the insurer’s omissions were a significant breach of its obligations to the claimant and that an award at the maximum 50 percent was thus warranted.

D.K. v. Certas Direct Insurance Company (18-010057)

The claimant sought entitlement to NEBs and medical/rehabilitation benefits. Adjudicator Boyce found that the claimant did not suffer a complete inability to carry on a normal life, agreeing with the findings in the insurer’s examination reports; while the reports noted headaches and intermittent neck and back pain, Adjudicator Boyce found it was “a stretch to equate these impairments to having a complete inability to carry on a normal life.” Adjudicator Boyce further found that the claimant was entitled to an orthopedic assessment and psychological treatment since the insurer had indeed approved these treatment plans. The claimant was not entitled to any of the other disputed examinations and treatment plans since he had not met his burden to prove they were reasonable and necessary.

O.R.O. v. Aviva Insurance Canada (18-007650)

The claimant sought reconsideration of the Tribunal’s denial of disputed medical benefits. Adjudicator Baker was not persuaded that there was an error in law committed by the Tribunal and that the claimant’s reconsideration was a request to re-litigate the dispute.

V.R. v. Aviva Insurance Company (18-002880)

The claimant sought reconsideration of the Tribunal’s decision not to award various medical benefits. Adjudicator Flude rejected the request. He wrote that the reconsideration request was essentially a request that the Tribunal reverse its findings of fact and prefer the claimant’s assessor over the insurer’s assessor. The reconsideration request was dismissed.

A.B. v. Aviva Insurance Canada (18-004653)

The claimant sought entitlement to physiotherapy and the cost of an occupational therapy assessment conducted as part of a catastrophic impairment assessment. She also argued that HST was not part of the medical benefits limits. Adjudicator Ferguson accepted that HST was payable outside of the medical benefits limits. He concluded that the occupational therapy assessments were not payable because no physician was involved in completion of the OCF-19, and an occupational therapist was not qualified to complete the OCF-19 independently. The disputed medical benefits were also denied.

M.S. v. Dominion of Canada General Insurance (19-000579)

The claimant sought removal from the MIG and entitlement to six medical benefits. Adjudicator Norris held that the MIG applied to the claimant’s injuries. There was no evidence that the claimant’s pre-existing medical issues would impact his recovery under the MIG. He also held that the alleged psychological injuries and chronic pain were not outside of the “minor injury” definition.

N.D. v. Aviva Insurance Company (18-009345)

The claimant sought entitlement to three medical benefits. Adjudicator Victor dismissed all of the claims. She held that the claimant could not prove that the partially denied psychological treatment was reasonable and necessary, and that further physical therapy was reasonable and necessary. The claimant had returned to work, had full range of motion, and was participating in activities of daily living.

J.W. v. Wawanesa Insurance (18-003407)

The claimant suffered catastrophic injuries in Quebec in 2000. She elected to receive no fault benefits under the Quebec SAAQ. Over time, Ontario had raised its hourly rates for service providers, while Quebec’s hourly rates remained lower. The claimant argued that despite receiving Quebec no fault benefits, she should be entitled to payment at the Ontario hourly rates for service providers. Adjudicator Flude rejected the claimant’s position, holding that once she had elected to receive Quebec no-fault benefits, she was to be treated as a Quebec resident under the Quebec SAAQ for the duration of her no fault claim.

M.C. v. Aviva General Insurance Company (18-006840)

The claimant sought entitlement to NEBs, psychological services, and a psychological assessment. Adjudicator Watt found that the claimant had not proven that he met the requirements to qualify for NEBs, in light of evidence that the claimant had minimal physical functional impairment and the claimant’s own evidence under oath that he was able to perform all self-care tasks and had no functional limitations from the accident. Adjudicator Watt did not find psychological services and a psychological assessment reasonable or necessary since the claimant admitted in examination under oath that he was not claiming any psychological issues as a result of the accident.