Category: Medical Benefits

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.

A.L. v. Aviva Insurance Canada (18-001867)

The claimant sought entitlement to ACBs, transportation expenses, and interest. Adjudicator Grant concluded that the claimant was entitled to attendant care benefits from February 22, 2016 to August 11, 2017 in diminishing amounts over that period. He found it unreasonable for the attendant care need to increase over time, and rejected the claimant’s Form 1s that increased over time. He also awarded the cost of transportation expenses in accordance with the Transportation Expense Guideline because the claimant suffered driving anxiety and was prohibited from driving while on pain medications. The awarded amounts were the amounts set out in the treatment plans, rather than the totals claimed by the claimant.

L.F. v. Aviva Insurance Canada (18-001243)

The claimant sought entitlement to two treatment plans for physical therapy. The insurer argued that it had already approved and paid for the disputed treatment. Adjudicator Grant held that the insurer was not required to pay any further amounts on the treatment plans because the insurer had paid for all invoiced amounts.

K.T. v. Aviva Insurance Canada (18-003870)

The claimant sought entitlement to NEBs, removal from the MIG, and two medical benefits. Adjudicator Grant concluded that the claimant suffered a predominantly minor injury as a result of the accident, and did not meet the “complete inability” test. The claimant suffered soft tissue injuries in the accident. His post-accident functionality was similar to his pre-accident functionality. Though he suffered from many psychological issues prior to the accident, there was no exacerbation caused by the accident.

E.M. v. Aviva Insurance Company (18-004588)

The claimant sought entitlement to a chronic pain assessment. Adjudicator Grant concluded that the assessment was not reasonable and necessary. The claimant had already participated in a chronic pain assessment, and the proposed assessment was duplicative. The claimant’s treatment providers were suggesting treatment rather than assessments to focus on her recovery. Finally, the claimant had not undergone surgery, and there was no reason for a further assessment prior to the surgery being completed.

N.S. v. Coseco Insurance Company (18-002659)

The claimant sought removal from the MIG and entitlement to two treatment plans. Adjudicator Grant concluded that although the claimant suffered serious physical issues, those issues were not caused by the accident. There was no accident-related issue supporting removal from the MIG or the disputed treatment plans.

S.G. v. Aviva Insurance Company (18-002269)

The claimant sought entitlement to four treatment plans for chiropractic services. Adjudicator Parish dismissed all of the claims. She held that further physical therapy was not reasonable and necessary. The claimant made infrequent complaints of back pain, and the complaints he did made were similar to pre-accident complaints

M.G. v. Aviva Insurance Canada (18-001568)

The claimant sought entitlement to four medical benefits, and argued that the insurer’s denials did not comply with section 38. Adjudicator Fricot concluded that the denial complied with section 38 because it explained the basis for the denial with reference to the claimant’s medical condition and the IE report. She also held that the insurer was not liable to pay for any expenses on the disputed treatment plans prior to the submission of the treatment plans. She ultimately awarded the cost of four pool sessions at a reduced rate and the cost of prescriptions.

C.H. v. Aviva Insurance Canada (18-002710)

The claimant sought removal from the MIG and entitlement to medical benefits for psychological treatment. Adjudicator Go concluded that the claimant suffered psychological injuries as a result of the accident. The treatment for psychological therapy was reasonable and necessary.

E.B. v. Aviva Insurance Canada (18-010159)

The claimant sought entitlement to acupuncture, massage, and chiropractic therapy, a social work assessment, an in-home assessment, the cost for the production of a disability certificate, and interest on the overdue payment of benefits. Adjudicator Norris did not find the disputed treatment, assessments, and cost for the production of a disability certificate to be reasonable or necessary for the following reasons: the claimant was reported to be virtually pain-free and functional at the time the chiropractic and physiotherapy treatment plan was proposed; there was no evidence of the claimant experiencing the social problems that the social work assessment aimed to address; there was no evidence showing the claimant required an in-home assessment due to being disabled from completing his personal care tasks; and the insurer did not request the production of the disability certificate. As such, no interest was payable to the claimant since no benefits were owed to him.