Category: Medical Benefits

E.K. v. Portage La Prairie Mutual Insurance Company (18-001333)

The claimant sought entitlement to four medical benefits. Adjudicator Ferguson dismissed the claims. He held that the proposed assessments were not reasonable and necessary, and that the proposed treatment was not proven to be related to an accident-related impairment.

J.V. v. RBC General Insurance Company (17-001981)

The claimant sought entitlement to various medical benefits. Adjudicator John awarded the all of the claimed assessments and treatment. She found that the claimant continued to suffer from chronic pain which affected her activities of daily living. She also suffered psychological injuries that required ongoing treatment. Adjudicator John was not persuaded by surveillance which showed the claimant engaging in certain normal activities. She also held that a partial release at FSCO did not prevent the claimant from disputing entitlement to the medical benefits that formed part of the LAT dispute.

J.M. v. Certas Home & Auto Insurance Company (18-001153)

The claimant sought entitlement to two medical benefits. The claimant also sought to add a new medical benefits claim as part of a written hearing. Adjudicator Punyarthi permitted the issue to be added, but held that it was not payable because a treatment plan had never been submitted in relation to the incurred treatment. The two medical benefits for physical therapy that were originally part of the dispute were not awarded because the claimant failed to demonstrate that passive treatment was warranted for her injuries.

N.M. v. Aviva General Insurance (17-007986)

The claimant sought entitlement to one medical benefits for physical therapy. Adjudicator Ferguson dismissed the claim. He held that the claimant failed to demonstrate that the claimed benefit was reasonable and necessary.

G.T. v. The Commonwell Mutual Insurance Group (17-004072)

The claimant sought entitlement to IRBs and two medical benefits. Adjudicator Gosio concluded that the claimant suffered a substantial inability to perform her job as a bartender up to the end of the 104 week period, but she did not meet the “complete inability” test. He accepted that there were other similar employment options available to the claimant, and for which opportunities existed in her community. The medical benefits for physical therapy and psychological therapy were found reasonable and necessary.

A.J. v. Aviva General Insurance (18-000214)

The claimant sought entitlement to payment of physical therapy. Adjudicator Mather concluded that the treatment was not reasonable and necessary because there was no evidence that such treatment was beneficial and that further treatment was required.

M.B. v. Aviva Insurance Canada (18-002289)

The claimant sought entitlement to a functional abilities evaluation/vocational assessment and a chronic pain assessment. Adjudicator Ferguson held that functional abilities evaluation/vocational assessment was payable up to the Professional Services Guideline limits, but denied entitlement to the chronic pain assessment. The FAE was awarded because the claimant was not able to do his pre-accident work and sought appropriate alternatives. The chronic pain assessment did not add anything to the claimant’s treatment as he was already diagnosed with chronic pain and given recommendations.

J.R. v. RSA Insurance (18-000770)

The claimant sought removal from the MIG and entitlement to four medical benefits. Adjudicator Hamud concluded that the claimant suffered chronic pain syndrome and that his injuries did not fall within the MIG. The family physician’s clinical notes and records supported the conclusion, and the IE physicians failed to fairly consider the claimant’s reports of pain. Adjudicator Hamud also found the claimed treatment plans for physical therapy and a chronic pain assessment to be reasonable and necessary.

S.A. v. Aviva Insurance Canada (18-000651)

The claimant sought entitlement to medical benefits for physiotherapy and a chronic pain assessment. Adjudicator Maleki-Yazdi denied both claims. She held that the claimant’s right hip pain (which was the basis for the medical benefits) was not caused by the accident, but rather a subsequent slip-and-fall. Further, the claimant did not present evidence that the alleged accident-related injuries were causing functional impairment. Neither of the sought medical benefits were reasonable and necessary.

S.P. v. Gore Mutual Insurance Company (17-003686)

The claimant applied for accident benefits one year after an accident. She sought entitlement to a treatment plan for physical therapy. The insurer denied the claim and argued that the claimant was barred from pursuing accident benefits due to her late application. Adjudicator Msosa held that the claimant provided a reasonable explanation for the late application. The claimant had divorced from her husband and she did not receive the claims materials sent to her by the insurer. She also stated that she believed that her symptoms would resolve, but when they didn’t, she sought physical therapy. Adjudicator Msosa also found the physical therapy to be reasonable and necessary for the claimant’s ongoing pain.