Category: Medical Benefits

D.S. v. Wawanesa Mutual Insurance Company (17-008334)

The claimant sought entitlement to medical benefits for various dental work. Adjudicator Norris concluded that the dental work was partly reasonable and necessary. He also concluded that the claimant did not need to submit the dental work on an OCF-18. The awarded dental work related only to the teeth that were damaged in the accident. However, the work was noted to put the teeth into a better state than they were prior to the accident because no other treatment options were available.

Applicant v. Aviva Insurance Canada (17-008304)

The claimant sought entitlement to a chronic pain program and a special award. Adjudicator Maleki-Yazdi found the chronic pain program reasonable and necessary. She preferred the evidence of the claimant’s treatment providers and noted that the insurer had not put forward evidence from appropriate experts. A special award was not granted because the claimant failed to explain why such an award was warranted.

F.A. v. Belairdirect Insurance Company (17-007534)

The claimant sought entitlement to five proposed assessments. Adjudicator Norris concluded that the proposed impairment assessment and chronic pain assessment was reasonable and necessary. The psychological, orthopaedic, and physiatry assessments were not awarded.

V.D. v. United Assurance Canada (17-005656)

The claimant sought entitlement to medical benefits proposed in treatment plans for chronic pain treatment and assistive devices (a self-propelled lawnmower and snow blower). The claimant had a pre-existing health history that included two back surgeries, and causation was an issue when determining whether the proposed benefits were reasonable and necessary as a result of the accident. Adjudicator Griffith found that the accident exacerbated the claimant’s pre-existing conditions, but concluded the claimant was not to entitled to the proposed benefits. Adjudicator Griffith found that the proposed chronic pain program was not reasonable and necessary on the basis that previous chronic pain treatment made the benefit in dispute redundant or unnecessary, the claimant did not have a psychological component to her pain issues, and the claimant had reached maximal medical recovery. The self-propelled lawnmower and snow blower were found not to be reasonable and necessary as a result of the accident given the evidence that the claimant could not perform lawn or snow removal tasks at the time of the accident due to pre-existing conditions.

R.M. v. Unica Insurance Inc. (17-007500)

The claimant exhausted his medical benefits coverage and sought payment of catastrophic impairment assessment outside of the medical benefits limits. He sought a total of $9,718. The insurer argued that it was not required to pay for assessments outside of the medical limits, and in the alternative, that one of the proposed assessments was not necessary. Adjudicator Mazerolle concluded that catastrophic impairment assessments are payable outside of the medical benefits limits. However, he also concluded that the assessments had to be reasonable. A proposed file review appeared duplicative of three other proposed assessments. The insurer was ordered to pay $7,718 for the assessments.

S.M. v. Certas Home and Auto Insurance Company

The claimant sought entitlement to medical benefits and removal from the MIG. The insurer argued that one of the treatment plans was barred by the limitation period, and should be dismissed. Adjudicator Norris agreed that one of the treatment plans could not be disputed because it was dispute more than two years after the denial. Turning to the medical evidence, the adjudicator concluded that the claimant suffered soft tissue injuries and that insufficient evidence of a psychological injury was placed before the Tribunal.

D.T. v. Aviva General Insurance (17-004698)

The claimant sought entitlement to two treatment plans for physical therapy. Adjudicator Norris awarded the treatment plan for chiropractic services but denied the treatment plan for physiotherapy services. He held that the chiropractic services made the claimant more functional. The claimant failed to provide evidence that physiotherapy was needed.

Applicant v. The Dominion of Canada General Insurance Company (17-006860)

The claimant sought entitlement to NEBs and various medical benefits. Adjudicator Kepman denied all claims. She held that the claimant’s post-accident presentation was largely the same as the pre-accident presentation, and that he was receiving disability support payments prior to the accident due to significant impairments and disabilities. The claimant’s wife assisted with most activities of daily living before the accident. The claimed treatment plans were not awarded because the claimant had not proven they were related to accident injuries.

K.B. v. Echelon General Insurance Company (18-000655)

The claimant sought a determination that his impairments were outside of the MIG and entitlement to benefits proposed in two treatment plans. Adjudicator Sewrattan found that the claimant’s injuries fell outside of the MIG due to a diagnosis of accident-related concussion and post-concussion symptoms. The claimant was found entitled to the in-dispute driving rehabilitation and occupational therapy assessments.

A. AH. v. Royal Sun Alliance Insurance (17-006850)

The claimant sought entitlement to the cost of various prescription medications. Adjudicator Letourneau found that some of the prescriptions in dispute were reasonable and necessary as a result of the accident.