Category: Medical Benefits

M.N. v. Aviva Insurance Canada (18-006097)

The claimant sought reconsideration of the Tribunal’s refusal to re-open her application for entitlement to certain psychological services. The claimant and the insurer had agreed to resolve entitlement to proposed psychological services that were proposed. The services proposed were to be provided by a psychologist at the Guideline rates. The claimant then incurred the treatment with a psychotherapist, but at the psychologist rates. Vice Chair Shapiro concluded that the Tribunal was correct in refusing to re-open the original application. The nature of the dispute was not whether the claimant was entitled to the proposed services, but rather, whether the claimant incurred services that had been approved by the insurer and the proper rate of payment for the services the claimant incurred.

F.F. v. Aviva Insurance Canada (18-002994)

The claimant sought entitlement to medical marijuana and the cost of an assessment. Adjudicator Grant awarded both claims. He accepted that medical marijuana was a superior reliever of pain, anxiety and depression for the claimant, and that it was being recommended by the claimant’s family physician.

D.M. v. Aviva Insurance Canada (17-006781)

The insurer sought reconsideration of the Tribunal’s award of an orthopaedic assessment. Vice Chair Mather granted the reconsideration and denied the claimed assessment. She held that the Tribunal made a significant error of law in concluding that section 38(8) required a “clear and unequivocal” denial of the goods and services it was not agreeing to pay for. She held that the denial satisfied the requirements of section 38(8), and that the claimant failed to attend an IE. Vice Chair Mathers reviewed the submissions of the parties and held that the claimant failed to prove that the orthopaedic assessment was reasonable and necessary. She noted that the claimant had refused a similar referral from his family physician, and his medical imaging did not show any abnormalities. Further, the clinical notes and records did not support the existence of any orthopaedic injury.

H.S. v. Aviva Insurance Canada (17-007384)

The claimant sought removal from the MIG and entitlement to four treatment plans for physical therapy. As a preliminary matter, the insurer sought to admit as evidence two addendum report authored after the production deadline. Adjudicator Harper refused to admit the addendum reports, reasoning that they could have been obtained much earlier, since the records reviewed were in the insurer’s possession for some time. Regarding the claimed benefits, Adjudicator Harper concluded that the claimant suffered a concussion, which fell outside of the MIG. She also concluded that the disputed physical treatment was reasonable and necessary because the claimant had long-lasting injuries and she had not achieved maximal recovery.

M.A.A. v. RBC Insurance (18-004989)

The claimant sought entitlement to two treatment plans. Adjudicator Ferguson held that the treatment plans were not reasonable and necessary. The claimant’s family physician did not support the need for further physical therapy and the IE assessor concluded that the claimant had met maximum medical recovery. The psychological assessment also was not reasonable because the claimant indicated she did not need psychological treatment, and the IE assessor found no significant psychological problems.

A.R. v. Aviva General Insurance (18-000838)

The insurer sought reconsideration of the Tribunal’s award psychological treatment and a psychological assessment, and the calculation of interest. Adjudicator Hines dismissed the reconsideration requests for the treatment plan and assessment, concluding that the Tribunal did not make an error in weighing the evidence. Adjudicator Hines granted the reconsideration in terms of interest, holding that interest accrued as of 10 days after the treatment plans were submitted, rather than the day they were submitted.

P.Y. v. Aviva General Insurance Company (17-003692)

The claimant sought reconsideration of the Tribunal’s decision that the claimant’s injuries fell within the MIG and the denial of three treatment plans. Following the Tribunal’s decision, the insurer removed the claimant from the MIG. The claimant argued that this was new evidence that could not have reasonably been obtained earlier. Adjudicator Grieves granted the reconsideration and ordered that the claims for three treatment plans be determined by the adjudicator originally hearing the matter.

J.Y. v. Aviva Insurance Canada (17-009034)

The claimant sought reconsideration of the Tribunal’s decision to dismiss all of his claims. Adjudicator Watt dismissed the reconsideration request. He held that the claimant had failed to provide written submissions to the Tribunal as ordered by the hearing adjudicator; that the surveillance considered by the Tribunal was not improper; that the Tribunal considered the proper test for IRBs; and that the Tribunal was not required to accept the evidence of an assessor whose report was inconsistent and contrary to other evidence.

F.P. v. Aviva Insurance Company of Canada (18-006800)

The claimant sought entitlement to a treatment plan for chiropractic services. Adjudicator Grant dismissed the claim. He noted there was no supporting evidence that the treatment was reasonable and necessary; the claimant had returned to work immediately after the accident and had not missed any time from work; and that the claimant’s pre-accident pain complaints were similar to post-accident pain complaints.

N.A. v. Aviva General Insurance (18-006048)

The claimant sought entitlement to a TMJ assessment. The insurer argued that the Tribunal had already determined whether the claimant suffered TMJ injuries in the accident during an earlier proceeding. Adjudicator Grant agreed with the insurer that the causation of the claimant’s TMJ symptoms had already been addressed by the Tribunal, and that res judicata barred the claimant from re-litigating the issue. He also held it would be an abuse of process for the Tribunal to make a determination contrary to the Tribunal’s earlier decision.