Category: Medical Benefits

A.M.F. v. The Dominion of Canada General Insurance Company (17-006710)

The insurer sought reconsideration of the Tribunal’s decision that the claimant suffered a catastrophic impairment and that she was entitled to two medical benefits for physical therapy. Adjudicator Parish rejected the reconsideration. She found that all of the insurer’s arguments essentially amounted to re-argument of the case. The Tribunal was not required to make note of every finding of every expert in its decision, nor was it required to address all case law submitted by the parties. The Tribunal’s decision to accept the opinion of the claimant’s assessors over the insurer’s assessors was not an error of law. Nor was use of the California Method for converting a GAF into WPI.

P.G. v. Intact Insurance Company (18-005386)

The claimant sought entitlement to ongoing IRBs and over $20,000 in assessments related to the IRB claim. Adjudicator Parish held that the claimant was entitled to IRBs up to the 104-week mark, but that the claimant’s functionality did not meet the “complete inability” test. She also awarded the cost of an occupational therapy situational assessment, orthopaedic assessment, and vocational assessment because they were relevant to the claimant’s injuries and claim for IRBs. The proposed psychological assessment, neurological assessment, executive summary, and transportation were not awarded because the claimant had not sought or been referred for psychological or neurological treatment; the executive summary was duplicative of the awarded assessments; and there was no evidence that transportation to the assessments was required.

R.F. v. Unifund Assurance Company (18-007571)

The claimant sought removal from the MIG and entitlement to two medical benefits for further physiotherapy. Adjudicator Mazerolle concluded that the claimant suffered a psychological impairment as a result of the accident, and was not restricted by the MIG limits. He awarded the two claimed medical benefits, writing that such treatment was promoting the claimant’s recovery.

D.K. v. Aviva General Insurance (18-007372)

The claimant sought entitlement to two medical benefits for further chiropractic treatment. Adjudicator Norris awarded the first treatment plan, holding that the treatment was providing the claimant with functional improvement at that time. The second treatment plan was denied. By that time, the claimant had returned to work on a full time basis and there was a lack of evidence of the need for any further passive therapy.

B.D.W. v. Aviva General Insurance Company (18-006313)

The insurer sought reconsideration of the Tribunal’s award of one medical benefit. Adjudicator Parish rejected the reconsideration, writing that the Tribunal’s decision was based on a weighing of the evidence and the varying opinions of the experts. There was nothing in the decision suggesting that the Tribunal acted outside its jurisdiction or violated the rules of fairness.

N.D. v. Unifund Assurance Company (17-008580)

The claimant sought reconsideration of the Tribunal’s denial of a chiropractic treatment plan and a psychiatric assessment, arguing that the Tribunal made an error of fact and law. Adjudicator Hans denied the reconsideration request. Regarding the chiropractic treatment plan, the Tribunal had ample evidence to come to the conclusion that it was not reasonable and necessary. Regarding the psychiatric assessment, Adjudicator Hans concluded that section 38(2) appropriately applied to bar payment because it was completed prior to the submission of the treatment plan.

Applicant v. Unica Insurance Company (17-007052)

The claimant sought reconsideration of the Tribunal’s order that she did not suffer a catastrophic impairment and that she was not entitled to a chronic pain assessment. Vice Chair Lester rejected the reconsideration, holding that the Tribunal had weighed the evidence before it and had good reason to give more weight to the insurer’s assessors. The Tribunal provided an adequate explanation for this decision.

D.K.M. v. Aviva General Insurance Company (18-010072)

The claimant sought removal from the MIG and entitlement to physiotherapy. Adjudicator Maleki-Yazdi concluded that the claimant suffered chronic pain syndrome, which entitled him to non-MIG benefits. The proposed physiotherapy was reasonable and necessary for improving the claimant’s pain level, functionality, and strength.

D.G. v. Wawanesa Mutual Insurance Company (18-004667)

The claimant sought removal from the MIG and entitlement to two medical benefits for psychological treatment. Adjudicator Norris concluded that the claimant suffered from psychological injuries as a result of the accident, which removed him from the MIG. The proposed medical benefits were found reasonable and necessary.

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

The claimant sought reconsideration of the Tribunal’s decision that his injuries fell within the MIG and that he was not entitled to claimed medical benefits. The issue of the MIG was accidentally included in the LAT application, and the claimant had been removed from the MIG prior to the hearing based on an IE. Adjudicator Lester held that it was an error for the Tribunal to make a decision on the MIG when it was not an issue in dispute. The error resulted in the medical benefits not being adjudicated. The hearing adjudicator was ordered seized of the matter to make a determination on whether the medical benefits were reasonable and necessary.

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