Category: Medical Benefits

I.D.C. v. Aviva Insurance Canada (17-004536)

The claimant sought entitlement to NEBs, removal from the MIG, and various medical benefits. She alleged that the accident aggravated injuries from an earlier accident. Adjudicator Sharda held that the claimant suffered from pre-existing psychological impairments and chronic pain, which were worsened by the accident, and entitled to her treatment outside of the MIG; further physiotherapy was also awarded. Finally, Adjudicator Sharda awarded NEBs on the basis that the claimant’s pre-accident activities of daily living were restricted. The claimant’s affidavit evidence went unchallenged by the insurer.

D.M. v. Aviva General Insurance Company (18-003850)

The claimant sought entitlement to three medical benefits. The insurer approved the treatment plans shortly after written submissions were due. Adjudicator Norris held that interest was also payable on the treatment plans from the date of the LAT application onwards.

B.H. v. Certas Home and Auto Insurance Company (17-006967)

The insurer sought reconsideration of the Tribunal’s decision that the denial letter for a psychological assessment was deficient and that the insurer was barred from applying the MIG; the assessment was also found reasonable and necessary. Vice Chair Lester dismissed the reconsideration. She held that the Tribunal had not violated the rules of procedural fairness or natural justice. She also held that the Tribunal had not made a significant error of law or fact such that a different result would have been reached.

P.V. v. Aviva Insurance Company (18-009130)

The claimant sought entitlement to nine assessments in relation to a catastrophic impairment determination. The insurer approved four (an orthopaedic assessment, an occupational therapy assessment, a psychiatry assessment, and a WPI rating); it denied five other assessments. Adjudicator Boyce accepted that each assessment had to be reasonable and necessary for the completion of the OCF-19 in order to be payable. He found only one further assessment – a functional review evaluation – to be reasonable and necessary. The remaining four assessments were largely duplicative and not essential for the completion of a catastrophic impairment determination.

Applicant v. Certas Direct Insurance Company (17-008853)

The claimant sought removal from the MIG, and entitlement to ACBs and various medical benefits. The insurer argued that the claimant was barred from proceeding to a hearing due to his failure to attend an IE addressing attendant care benefits. Vice Chair Helt concluded that the claimant was not barred from proceeding with his claim for ACBs because the IE notices contained the wrong address for the IE location. In terms of the claimed benefits, Vice Chair Helt found that the claimant suffered from psychological injuries falling outside of the MIG. She awarded the claimed psychological assessment and therapy, but held that the proposed physical therapy was not reasonable and necessary. Finally, in terms of the ACBs, Vice Chair Helt concluded that the claimant did not require personal care and that he had not incurred any attendant care expenses.

J.A. v. Aviva Insurance Company (18-005595)

The claimant sought removal from the MIG and entitlement to three treatment plans and two assessments. Adjudicator Grant concluded that the claimant suffered from psychological injuries which was not a minor injury. He awarded the proposed psychological assessment, but rejected the proposed treatment plans for physical therapy and the proposed attendant care assessment.

G.M.K. v. Aviva Insurance Company of Canada(18-009487)

The claimant sought a determination that his impairments were outside of the MIG and entitlement to a psychological assessment. Adjudicator Manigat concluded that the claimant’s injuries fell within the MIG. The claimant relied on a section 25 psychological report, in which he was diagnosed with PTSD and Major Depressive Disorder. The respondent relied on a psychological IE, in which the assessor opined that the claimant did not suffer from a psychological impairment as a result of the accident. The adjudicator preferred the respondent’s IE report, noting that the claimant had attended his family doctor’s office on several occasions after the accident, but had at no point brought up any psychological issues.

G.J. v. Aviva General Insurance Company (18-006663)

This preliminary issue hearing was brought to determine whether the claimant was statute barred from proceeding with his appeal of a number of medical benefits and expenses because he did not submit treatment plans before incurring the expenses, and because he did not attend an IE that the respondent had determined was necessary for it to consider the benefits. Adjudicator Makhamra concluded that the claimant could proceed with his appeal of an expense for foot orthotics, as it fell under one of the exceptions under section 38 of the SABS which states that expenses for goods under $250 are not required to be submitted through a treatment plan. However, the adjudicator found that the claimant was barred from proceeding with the remaining issues because he was required to submit a treatment plan before incurring them, and did not do so. The adjudicator also found that the claimant’s failure to attend the reasonably necessary and properly scheduled IE prevented his dispute from proceeding to a hearing.

B.M. v. Allstate Insurance (18-008410)

The claimant sought a determination that his impairments were outside of the MIG and entitlement to a chronic pain assessment. Adjudicator Maleki-Yazdi concluded that the claimant’s injuries fell outside of the MIG due to chronic pain, and that the claimant was entitled to the cost of the chronic pain assessment. The claimant continued to reported severe and persistent pain in her right shoulder and neck over five years after the accident, which had not improved with treatment. The adjudicator concluded that the claimant’s pain affected her life in a significant way, as it limited her ability to work, perform her regular activities of daily living, and caused disturbed sleep.

Hedley v. Aviva Insurance Company of Canada (2019 ONSC 5318)

Aviva sought reconsideration of the Tribunal’s reconsideration that its section 38 denial did not provide sufficient “medical and any other reasons for the examination,” and that the claimant was not required to attend the IE. The Court upheld the reconsideration decision as falling within the range of reasonableness. The Court wrote: “where reasons are required, they must be meaningful in order to permit the insured to decide whether or not to challenge the insurer’s determination. Mere ‘boilerplate’ statements do not provide a principled rationale to which an insured can respond. In essence, such statements constitute no reasons at all.”