Category: Medical Benefits

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.

T.S.W. v. The Dominion of Canada General Insurance Company (18-010342)

The claimant sought a determination that his impairments were outside of the MIG and entitlement to NEBs, the cost of prescription medication, and one treatment plan. Adjudicator Driesel found that the claimant was within the MIG and was not entitled to the disputed benefits.

S.K. v. Aviva Insurance Company of Canada (18-011027)

The claimant sought entitlement to four treatment plans – two for psychological services (which were partially approved), and two for physiotherapy services. Adjudicator Boyce awarded one treatment plan for physiotherapy, but denied the remainder of the claims. Regarding the partial psychological treatment plan amounts, the adjudicator held that the claimant failed to prove that the denied amounts were reasonable and necessary, and wrote that just because a maximum was available under the SABS did not mean that the maximum was always payable. In terms of the physiotherapy treatment plans, the adjudicator held that the earlier treatment plan may have provided benefit, while the latter would not.

V.L. v. Pafco Insurance Company (18-003802)

The claimant sought entitlement to chiropractic treatment and the denied portion of catastrophic impairment assessments. Adjudicator Boyce denied the claims for further chiropractic treatment because the claimant failed to prove the treatment was reasonable and necessary. He awarded the FAE component of the catastrophic impairment assessments, as well as the cost of the OCF-19 completion, but denied the remainder. He wrote that the denied psychiatric assessment and neuropsychological assessment were just attempts to garner two payments for an already approved assessment. The proposed biopsychosocial assessment was not reasonable and necessary.

D.M. v. Aviva Insurance Canada (18-008708)

The claimant sought entitlement to a treatment plan for physiotherapy. Adjudicator Grant held that the treatment plan was not reasonable and necessary. The claimant’s evidence did not show that physiotherapy was anticipated to provide any benefit. Further, the claimant stated to IE assessors that physiotherapy was not providing long-term benefit.

H.S.H. v. Aviva Insurance Company (18-002204)

The claimant sought entitlement to two medical benefits, and a series of catastrophic impairment assessments. Adjudicator Reilly rejected all of the claims. She held that the proposed benefits were not reasonable and necessary. The medical records from the family physician shows no ongoing accident-related impairments.

S.A. v. Aviva Insurance Company (18-006278)

The claimant sought reconsideration of the Tribunal’s denial of part of a chronic pain program, a bone growth stimulator, and an MRI. Adjudicator Lake dismissed the reconsideration. She held that the claimant failed to prove that the Tribunal made an error of law or fact. In essence, the claimant was seeking a re-weighing of the evidence, which was not the purpose of a reconsideration.

P.M. v. Aviva Insurance Canada (17-005419)

The claimant sought entitlement to IRBs and medical benefits. She also sought entitlement to an accounting report. Adjudicator Watt denied the claim for IRBs, as the claimant had been paid IRBs up to the date she returned to work on a modified basis. He found the treatment plans not reasonable and necessary. Finally, he held that the cost of the accounting report was not payable because it was the claimant’s behaviour which resulted in difficulties calculating the IRB. She withheld information regarding disability benefits and her return to work. Furthermore, she was not a self-employed person.

Fordjour v. Royal and Sun Alliance Insurance Company of Canada (2019 ONSC 6268)

The claimant judicial review of the dismissal of her claim on two grounds: that she her family physician should be entitled to give opinion evidence, and that the adjudicator did not properly address causation. The Divisional Court agreed with the claimant and remitted the matter for a new hearing. It held that the Tribunal erred in not permitting the family physician to give opinion evidence at the hearing. The Divisional Court also wrote that the Tribunal had not set out the causation test it had applied, and that it was no appropriate for the test to be “implied.”

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