Category: Medical Benefits

S.S. v. RBC Insurance Company (18-000222)

The claimant sought entitlement to NEBs, a social work assessment, the cost of completing three disability certificates, and interest. Adjudicator Boyce found that the claimant did not meet the stringent test to qualify for NEBs. The claimant stated that her pain improved with treatment and was not debilitating; she also reported independently carrying out her daily routines and self-care. As such, while Adjudicator Boyce acknowledged that test did not require the claimant to be bed-ridden, he held that the test demanded more evidence of impaired functionality and inability. Adjudicator Boyce did not find a social work assessment reasonable or necessary since there was no evidence that the assessment could address the claimant’s specific complaints. Adjudicator Boyce also did not find the cost of completing the three disability certificates to be reasonable or necessary since the insurer did not request them and they failed to provide new or additional information about the claimant’s impairments.

A.A. v. Certas Direct Insurance Company (18-00856)

The claimant sought entitlement to physiotherapy, a driver evaluation assessment, a neurological assessment, and interest. Adjudicator Watt found the following: the claimant was not entitled to a driver evaluation assessment since she had already been assessed and returned to driving; there was insufficient evidence to suggest that a neurological assessment would have a rehabilitative purpose leading to a reduction of pain, so such an assessment was not reasonable or necessary; and no interest was payable to the claimants since no benefits were owed to her.

K.H. v. Gore Mutual Insurance Company (18-009689)

The claimant sought entitlement to a treatment plan that included physiotherapy, massage therapy, and swim passes, interest on the payment of overdue benefits, and a special award. Adjudicator Norris found that the claimant was entitled to the disputed treatment because it was reasonable and necessary to address the claimant’s ongoing pain and functional limitations. The claimant was diagnosed with chronic pain syndrome and there was evidence that her ongoing pain symptoms responded well to treatment. However, Adjudicator Norris did not find that the insurer’s conduct warranted the claimant’s entitlement to a special award: the claimant argued that the respondent acted unreasonably in failing to redact the assessor’s prognosis from the insurer’s examination report when prognosis was an issue the parties agreed to omit from the insurer’s examination requisition prior to scheduling the assessment; however, Adjudicator Norris found no obligation, legislative or otherwise, for the insurer to redact/revise the report. The claimant was awarded interest on the payment of the disputed treatment plan.

S.K-A. vs. Aviva General Insurance (18-011590)

The claimant sought entitlement to massage therapy, a cost award, and interest on the payment of overdue benefits. Adjudicator Norris found that there was no clear indication that massage therapy was a reasonable and necessary component of the claimant’s treatment. As such, no interest was owed to the claimant.

M.F. v. Belair Insurance (18-003847)

The claimant sought entitlement to post-104 week IRBs and various medical benefits. In terms of post-104 IRBs, Adjudicator Grieves concluded that the claimant did not suffer a complete inability to engage in any employment for which he was reasonably suited. In doing so, the adjudicator noted that the claimant had only applied for IRBs a few days prior to the 104 week mark, and found that the claimant’s previous job as a delivery driver was still a viable occupation as he had worked in that capacity post-accident. Adjudicator Grieves also concluded that none of the disputed treatment plans were payable. The claimant was independent in self-care and had returned to work and school since the accident. As such, an in-home occupational therapy assessment and occupational therapy services were not reasonable and necessary. Adjudicator Grieves also noted that the proposed psychological assessment was not reasonable and necessary, given that the clinical notes and records submitted made no reference to any psychological complaints in the two years since the accident.

A.D. v. Certas Home and Auto Insurance (18-006204)

The claimant disputed his MIG determination and sought entitlement to a number of treatment plans for physical and psychological treatment. The claimant submitted no clinical notes and records, and there was no evidence to support that he was ever seen by a medical doctor for his accident-related impairments. Given the lack of evidence to demonstrate that the claimant was unable to recover within the MIG, Adjudicator Grant concluded that the claimant had failed to meet his onus of establishing entitlement to treatment outside of the MIG limits.

R.R. v. State Farm Insurance Company (19-000226)

The claimant sought entitlement to IRBs and two treatment plans for chiropractic services. The insurer argued that the claimant was barred from proceeding with the three disputed claims because she failed to dispute the denials within the two year limitation period. Adjudicator Norris agreed with the insurer, finding that the insurer’s refusals to pay the benefits claimed were clear and unequivocal. Adjudicator Norris also declined to exercise his discretion to extend the limitation period pursuant to section 7 of the LAT Act, noting that the length of the delay was significant (nearly one year beyond the expiration of the limitation period) and that the claimant made no submissions to indicate that she had an intention to dispute the denial prior to the expiration of the limitation period.

C.M. v. Wawanesa Mutual Insurance Company (18-008199)

The claimant sought entitlement to attendant care benefits and a number of treatment plans for occupational therapy and physiotherapy services. Adjudicator Boyce concluded that the claimant was not entitled to attendant care as she had not demonstrated that the services were “incurred” pursuant to section 3(7)(e) of the SABS. The claimant did not provide evidence that the care was provided by a professional service provider, nor that her mother sustained an economic loss. Adjudicator Boyce also concluded that the disputed treatment plans were not reasonable and necessary, noting that aside from the OCF-18s listing her impairments and the retroactive expert reports, the claimant had provided no corroborating records from medical professionals to support the treatment sought nor the injuries claimed. Given the claimant’s failure to produce medical evidence concurrent with the accident, Adjudicator Boyce found no reason to interfere with the insurer’s determinations.

N.S. v. Scottish & York (17-007962)

The insurer sought reconsideration of the Tribunal’s decision that it had to fund a catastrophic impairment assessment over and above the $50,000 medical/rehabilitation limit for those with non-catastrophic injuries. Vice-Chair Flude confirmed the Tribunal’s decision, finding that the Tribunal did not make any significant error of law. Section 18(5) of the SABS provides that assessments are included in the applicable monetary limits when conducted “in connection with any benefit or payment”. Relying on his own decision in J.M. v. Aviva, Vice Chair Flude held that catastrophic impairment is a designation, not a benefit. As such, he held that catastrophic impairment assessments are not caught by section 18(5) and must be funded over and above the $50,000 medical/rehabilitation limit.

A.L. v. Aviva Insurance Canada (18-008991)

The claimant sought entitlement to two treatment plans, one for occupational therapy services and one for physiotherapy services. Adjudicator Manigat concluded that the denied treatment plans were not reasonable and necessary. With respect to the occupational therapy treatment plan, Adjudicator Manigat accepted that the claimant had to make certain adjustments to cope with some pain and use pacing strategies to resume her pre-accident activities. However, the adjudicator noted that any impact on the claimant’s ability to function had been remedied through the use of coping strategies, and that the claimant’s ongoing pain was not sufficient to render the treatment plan payable. With respect to the physiotherapy treatment plan, Adjudicator Manigat noted that the claimant had not submitted any physiotherapy requests for over 1.5 years prior to submission of the denied treatment plan, and there was no evidence to substantiate that further facility based treatment would result in additional benefit to the claimant.