The claimant sought entitlement to two treatment plans proposing a psychological assessment and a physiatry assessment. Adjudicator Boyce concluded that neither cost of examination was payable, noting that the claimant had already received approval for a slate of nine catastrophic impairment examinations. As such, the examinations were duplicative, and not reasonable and necessary.
The claimant sought entitlement to a medical benefit, interest, and a special award. Adjudicator Chakravarti found that the proposed medical benefit was reasonable and necessary. Adjudicator Chakravarti noted that in a separate and earlier LAT hearing, Adjudicator Gueller removed the claimant from the MIG. Adjudicator Chakravarti held that she was persuaded by the claimant’s treating practitioners that the claimant required further medical treatment.
The claimant applied to the Tribunal seeking entitlement to IRBs and medical benefits. The insurer raised a preliminary issue requesting that the Tribunal bar the claimant’s dispute over IRBs due to his failure to attend a s. 44 FAE with a kinesiologist. Adjudicator Létourneau concluded that the claimant was entitled to IRBs for the pre-104 week period but not entitled to IRBs for the post-104 week period. With respect to the preliminary issue, Adjudicator Létourneau concluded that the proposed s. 44 FAE was not reasonably necessary. Adjudicator Létourneau found that the s. 44 neurological and physiatry assessments afforded the insurer ample opportunity to assess the claimant’s physical impairments and that a kinesiologist would not be able to comment more specifically on medical impairments than what was already obtained. Adjudicator Létourneau also noted that the claimant worked as a taxi driver pre-accident and that the FAE would not likely have provided more detail with respect to the claimant’s pre-accident job duties. With respect to the IRB dispute, Adjudicator Létourneau concluded that the claimant had provided sufficient evidence that but for the accident, he would have continued to drive a taxi. Adjudicator Létourneau pointed to the claimant’s back pain with prolonged sitting and mental impairments as causing his inability to complete the tasks of his pre-accident employment. As for the post-104 week period, Adjudicator Létourneau noted that the claimant had returned to driving, evidenced by the claimant’s own reporting and surveillance. Adjudicator Létourneau concluded that the claimant could return to work as a driver in other capacities, such as a chauffeur or delivery driver, and that he therefore did not meet the post-104 week disability test. Finally, Adjudicator Létourneau awarded all of the medical benefits plus interest.
The insurer sought reconsideration of the Tribunal’s decision, arguing that it had made a significant error of law or fact by referring to evidence not before it, placed the onus on the insurer, and failing to adhere to case law. On reconsideration, Adjudicator Norris held that he did not err in law in his decision. Adjudicator Norris held that he had reviewed the evidence and preferred the evidence of the claimant’s treating psychologist with respect to the reasonable cost of the proposed psychological assessment. Adjudicator Norris also held that the case law submitted by the insurer was unsupportive and therefore, did not apply.
The claimant sought reconsideration of the Tribunal’s decision based on there being new evidence that the claimant could not have reasonably obtained earlier and based on the insurer’s concession at the close of the proceedings that the MIG did not apply. Adjudicator Grieves granted the claimant’s reconsideration request. Adjudicator Grieves accepted that the new evidence, being a s. 25 psychological report, was not reasonably available to the claimant at the time of the hearing and would have affected the Tribunal’s result with respect to its MIG finding. Adjudicator Grieves also criticized the parties for not advising the Tribunal that the insurer had agreed at the close of proceedings to remove the claimant from the MIG, as this would have affected the Tribunal’s result. Adjudicator Grieves ordered that the matter be sent back to the Tribunal to determine the reasonableness and necessity of the disputed treatments plans as the claimant was now out of the MIG.
The claimant applied to the Tribunal disputing his entitlement to four treatment plans and interest. Of the four disputed treatment plans, the claimant disputed his entitlement to an orthopaedic assessment and MRI. Adjudicator Kaur concluded that the claimant did not prove that the orthopaedic assessment and MRI were reasonable and necessary as he failed to show how or why he could not obtain the assessment and MRI through OHIP. The claimant also disputed his entitlement to physiotherapy, which Adjudicator Kaur found was not reasonable and necessary, as the claimant did not provide evidence of a treating practitioner recommending this type of modality for his accident-related injuries. Finally, the claimant disputed his entitlement to a chronic pain assessment. Adjudicator Kaur noted that the claimant failed to provide any clinical notes and records that illustrated a history of ongoing pain complaints and that therefore, the proposed chronic pain assessment was not reasonable or necessary.
The claimant sought reconsideration of the Tribunal’s denial of the cost of catastrophic impairment assessments. Adjudicator Lester held that section 25(1)(5) only obligates an insurer to pay the reasonable fees charged in connection with filling out the application for the catastrophic determination rather than the assessments themselves. She also agreed that the reasonable and necessary standard applies to the determination of whether catastrophic impairment assessments would be payable by the insurer.
The claimant sought reconsideration of the Tribunal’s decision to reject her claims for a chronic pain program and a self-propelled lawn mower and snow blower. Adjudicator Paluch dismissed the reconsideration request. He concluded that the Tribunal had not misapprehended the evidence or erred in its legal analysis. The Tribunal was permitted to weigh the evidence as it saw fit, and to make a determination based on the weighing of evidence.
The claimant sought reconsideration of the Tribunal’s denial of the cost of catastrophic impairment assessments. Adjudicator Lester held that section 25(1)(5) only obligates an insurer to pay the reasonable fees charged in connection with filling out the application for the catastrophic determination rather than the assessments themselves. She also agreed that the reasonable and necessary standard applies to the determination of whether catastrophic impairment assessments would be payable by the insurer.
The claimant sought entitlement to five treatment plans. In addition to arguing that they treatment was reasonable and necessary, the claimant also argued that the insurer’s denials of three medical benefits did not comply with section 38(8) of the SABS. Adjudicator Grant found that the proposed treatment was not reasonable and necessary due to the lack of medical evidence. The claimant could not show that treatment was assisting him in any way or improving his functionality. Adjudicator Grant awarded the expenses related to two treatment plans which were not denied within the 10 day period required by section 38(8).
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150 York Street, Suite 1800
Toronto, Ontario M5H 3S5
416.507.1850
© 2020 Thomas Gold Pettingill LLP