Category: Medical Benefits

N.R. v. Aviva Insurance Canada (17-00912)

The claimant sought removal from the MIG and entitlement to further physical therapy and a psychological assessment. Adjudicator Mather concluded that the claimant suffered from chronic pain syndrome, which adversely affected his wellbeing; the MIG did not apply to his injuries. Further physical therapy was awarded based on the goal of reducing pain and increasing the claimant’s activities of normal living. The psychological assessment was not payable because the claimant failed to prove that he suffered a psychological impairment.

V.M. v. Aviva General Insurance Company (17-007475)

The claimant sought reconsideration of the Tribunal’s decision denying a claimed assessment. Vice Chair Barry denied the reconsideration, holding that the claimant failed to provide particulars as to the error in fact or law. Further, the reconsideration request was made outside of the time frame for making the request.

E.D. v. Aviva General Insurance Company (18-002597)

The claimant sought entitlement to the remainder of a partially approved treatment plan for physical therapy and gym equipment, and a special award. Adjudicator Lake awarded the remainder of the treatment plan, but declined to grant a special award. She held that the proposed treatment was reasonable for pain reduction, increase in strength and range of motion. She also agreed that in-home gym equipment was more reasonable for the claimant, who was a mother of four, rather than attending a local gym.

V.D. v. Aviva Insurance Canada (18-007435)

This is a preliminary issue decision addressing the following issues: 1) whether the claimant was statute barred from applying to the LAT for non-earner benefits for failure to attend a s. 44 OT assessment, and 2) whether the claimant was barred from proceeding with her claim for payment of a psychological assessment. Adjudicator Ferguson held that the claimant was not barred from applying to the LAT pursuant to s. 55 because the insured’s notice of assessment did not provide adequate medical and other reasons for requesting the OT assessment. Adjudicator Ferguson held that the LAT had no jurisdiction over the cost of examination claimed by the claimant as there was no dispute over the claimant’s entitlement or the amount payable. The only issue was that the insurer required a detailed breakdown of costs from the treatment provider prior to paying the incurred benefit. Adjudicator Ferguson held that the claimant could not proceed with her claim for the cost of the psychological assessment.

V.K. v. Unica Insurance Inc. (18-007227)

This is a preliminary issue decision on whether the cost of assessments to determine catastrophic impairment falls within the $50,000.00 limit on medical and rehabilitation benefits. Adjudicator Ferguson concurred with previous decisions that CAT assessments are not a benefit, and found that the insurer is obliged to pay the full cost of CAT assessments subject to professional services guidelines, and with the caveat that it remains the claimant’s responsibility to show that any assessment is reasonable and necessary. Adjudicator Ferguson found that the cost of CAT assessments is not subject to the $50,000.00 limit.

D.0. v. Primmum Insurance Company (18-001673)

The claimant sought a determination that his impairments were outside of the MIG and entitlement to two treatment plans for physiotherapy. The claimant submitted that the he developed chronic pain as a result of the accident. In support of his position, he relied on three OCF-3s, a s. 25 chronic pain report, and family doctor records. The insurer relied on a s. 44 physiatry report and argued that the claimant was not diagnosed with chronic pain syndrome and had not been referred to a chronic pain specialist. Adjudicator Hans found that the claimant’s physical impairments were outside of the MIG as a result of chronic pain and that the disputed benefits were reasonable and necessary. Adjudicator Hans held that a diagnosis of chronic pain syndrome was not required to remove a claimant from the MIG.

B.E. v. Aviva General Insurance Company (18-005760)

The claimant sought a determination that his impairments were outside of the MIG and entitlement to a various medical benefits. Vice Chair Kershaw found that the claimant established that she had a psychological injury and chronic pain injuries, and was therefore not subject to the $3500 MIG limit. Based on these findings, the adjudicator concluded that the disputed treatment plans for physical rehabilitation, a psychological assessment, and a chronic pain assessment were reasonable and necessary.

V.R. v . Aviva Insurance Company (18-0028800)

The claimant sought entitlement to passive chiropractic treatment and a chronic pain assessment. Vice Chair Flude found that the proposed treatment and assessment were not reasonable and necessary. Vice Chair Flude found that the medical records supported the IE assessor’s opinion that an active exercise program, rather than passive treatment, was required.

The Applicant by his Guardian, K. R. v. Unifund Assurance Company (18-001975)

The claimant was catastrophically impaired in a motor vehicle accident in August 2017, and remained in a coma until the date of his death on September 11, 2018. The claimant claimed for legal fees incurred in obtaining a guardianship order, arguing that the legal fees were a rehabilitative benefit. The respondent argued that the legal fees were not goods and services, and further denied liability based on the claimant’s failure to submit and treatment plan in advance of incurring the expense. Adjudicator Fricot concluded that the claimant was not entitled to payment for the legal fees incurred in obtaining a guardianship order. She noted that irrespective of whether the expense was a rehabilitation expense, the claimant did not submit a treatment plan in advance of incurring the legal costs associated with obtaining the guardianship order. As such, the respondent was not liable to pay those costs.

A.A. v. Aviva Insurance Company (17-008472 and 17-004680)

The claimant sought reconsideration of the Tribunal’s denial of the cost of a chronic pain assessment. Vice Chair Trojek concluded that the Tribunal did not make an error in fact such that it would likely have reached a different result had the error not been made. The reconsideration request was dismissed.