Category: Medical Benefits

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.

R.S. v. Aviva Canada Inc. (18-003440)

The claimant sought entitlement to a chronic pain treatment program. Adjudicator Moten concluded that the claimant was entitled to the denied treatment plan, preferring the claimant’s expert report over the insurer’s IE reports. Notably, none of the IE assessors were pain medicine specialists and none of the IE reports specifically addressed the issue of chronic pain. Adjudicator Moten also noted that the treatment plan was targeted, concise, and for a proportionate amount of time.

J.T. v. Aviva General Insurance (18-003238)

The claimant sought entitlement to 8 treatment plans, the cost of completion of two OCF-3s, and a special award. Adjudicator Lake found that the claimant was entitled to the majority of the treatment plans in dispute. She was not entitled to the cost of the two OCF-3s that were not requested by the insurer. She was entitled to the psychological portion only of a treatment plan for a multidisciplinary chronic pain program. Temporary pain reduction was found to be a legitimate goal for proposed acupuncture treatment. Adjudicator Lake denied entitlement to proposed treatment that was the same as treatment which had previously been approved by the insurer but not incurred by the claimant. A functional abilities assessment was found reasonable and necessary based on evidence the claimant was having difficulty with some personal care tasks. A special award of 25 percent of the disputed amount of three treatment plans was awarded to the claimant based on a finding that the insurer failed to consider all of the information available to it when making claims decisions.

D.K. v. The Guarantee Company of North America (18-007722)

The claimant sought entitlement to attendant care benefits in the amount of $3,022.33 per month, physical treatment proposed in three treatment plans, and the cost of various expenses related to food, prescriptions, assistive devices, and other goods. Vice Chair Lester found that the claimant was entitled to the physical treatment plans and the cost of non-prescription Tylenol. The clamant was not entitled to attendant care benefits based on a finding that the benefits were not reasonable and necessary, and there was no evidence the non-professional service providers sustained an economic loss. The decision refers to a s. 25 Form 1 but it does not indicate that a s. 44 Form 1 was completed. Vice Chair Lester found that the recommendation for $3,022.33 in attendant care services did not coincide with the test results that demonstrated the claimant had the functional ability to complete tasks. Expenses related to fibromyalgia were not payable as this was a pre-existing condition, and the claimant had not submitted medical evidence to show the condition was worsened by the accident.

A.G. v. Aviva General Insurance (18-012669)

The claimant sought entitlement to one treatment plan for physiotherapy services. Adjudicator Grant found that the proposed physiotherapy was not reasonable and necessary. He found that the claimant had previously undergone physiotherapy, there was a lack of evidence of benefit from the previous treatment, and that none of the medical evidence established the benefit of further physiotherapy.

E.D. v. Aviva General Insurance (18-004361)

The claimant sought entitlement to one treatment plan for chiropractic services. Adjudicator Grant found that the proposed treatment was not reasonable and necessary. He noted that a treating physician’s mention of a chronic pain condition, be it ‘syndrome’ or specific use of the term ‘chronic pain,’ is not enough to establish the necessity of a treatment plan. Adjudicator Grant found that references to chronic pain in the medical records appeared to be in reference to a non-accident-related condition, and the claimant failed to establish that due to ‘chronic pain’, the treatment was reasonable and necessary.

S.B. v. Aviva General Insurance Company (17-001414)

The claimant sought reconsideration of seven medical benefits following a determination that the MIG was improperly included as an issue in dispute (the claimant had been removed by the insurer, but the adjudicator held that the MIG applied). Adjudicator Watt considered each of the disputed medical benefits. He held that none of the disputed medical benefits was reasonable and necessary.

R.R. v. Aviva Insurance Company of Canada (17-006460)

The insurer sought reconsideration in relation to a chronic pain treatment program, which had been awarded by the Tribunal. Adjudicator Gosio allowed the reconsideration on a portion of the treatment plan for 27 sessions of psychotherapy. He held that 15 of the 27 sessions were not reasonable and necessary.

C.S. v. Wawanesa Mutual Insurance Company (18-004665)

The claimant sought a determination that his impairments were outside of the MIG and entitlement to treatment plans for psychological services and chiropractic treatment. Adjudicator Grant found that the claimant suffered from chronic pain, which removed him from the MIG. He was not entitled to the two treatment plans in dispute, which were found to be not reasonable and necessary as a result of the accident. The treatment plans in dispute were not supported by any medical evidence or recommendation from the treating physician. Subjective reports of some relief from previous physiotherapy did not establish that the in-dispute chiropractic treatment plan was reasonable and necessary. A psychological pre-screening report was not sufficient evidence to indicate the existence of a psychological impairment that was not sequelae of minor injuries.

B.S. v. The Co-operators General Insurance Company (18-003423)

The claimant sought entitlement to four treatment plans for physical therapy and seven proposed assessments. Adjudicator Norris rejected all of the claims. He held that the evidence the claimant relied upon (an OT paper file review) was biased and not limited to the appropriate scope of an occupational therapist.