Category: Medical Benefits

R.S. v. Aviva Insurance Company (17-008532)

The claimant sought removal from the MIG and entitlement to various medical benefits. Adjudicator Norris concluded that the claimant suffered a minor injury. The claimant’s family physician and the insurer’s assessor came to the same conclusion that the claimant suffered soft tissue injuries and did not suffer chronic pain. The claimant’s expert was not persuasive because it relied upon self-reporting that was inaccurate. Finally, the adjudicator dismissed the argument that high cholesterol was a condition that would prevent maximal recovery under the MIG.

Applicant v. Toronto Transit Commission (17-009121)

The claimant sought entitlement to NEBs, ACBs, medical benefits, and a special award. Adjudicator Boyce denied entitlement to NEBs and ACBs, but awarded two medical benefits for physiotherapy and chiropractic therapy. With regard to NEBs, the adjudicator noted that the claimant’s grades increased after the accident, she did not require assistance with personal care more than two months after the accident, and she continued to maintain a social life. With regard to personal care, the claimant received some assistance from her mother in the first few weeks after the accident, but did not require long-term care. Further, the claimant’s mother did not suffer an economic loss as a result of providing care. The claimant also failed to provide a Form 1 before such services had ceased. Finally, the adjudicator agreed that pain relief was a valid goal and that further treatment was reasonable and necessary. A special award of $1,000 was granted because the insurer had delayed payment of earlier benefits and was not transparent with the claimant regarding her claim.

M.G. v. The Guarantee Company of North America (17-008687)

The claimant sought entitlement to NEBs, ACBs, and various medical benefits. Adjudicators Punyarthi and Watt dismissed the claims. They held that the claimant continued to engage in most of her pre-accident activities, despite doing so with pain. They rejected the claimant’s Form 1, as well as the invoicing provided by the claimant which appeared to be completed by the claimant rather than the service provider. The claim for an attendant care assessment was found not reasonable and necessary, since the claimant was not entitled to ACBs. Further physical therapy was not awarded based on the claimant’s evidence that it did not provide pain relief. Botox injections and psychological treatment were similarly rejected.

Applicant v. The Guarantee Company of North America (17-006956)

The claimant sought reconsideration of the Tribunal’s decision that she was not entitled to payment for catastrophic impairment assessments. Vice Chair Shapiro upheld the decision. He wrote that the Tribunal accurately considered whether there was some objective evidence to suggest that the claimant may suffer a 55 percent WPI. The Tribunal found that further investigation for catastrophic impairment status was not reasonable and necessary.

J.E.C.L. v. Allstate Insurance Company of Canada (17-006909)

The claimant sought entitlement to NEBs and a chronic pain assessment. Adjudicator Boyce concluded that the claimant’s activities remained largely the same after the accident. Although he suffered from pain, he was not practically prevented from the majority of his activities. Adjudicator Boyce also noted that the claimant failed to prove that his reported injuries related to the accident. The claimant’s ODSP file and disability tax application suggested long-standing impairments. The chronic pain assessment was awarded on the basis the claimant was experiencing continuous pain.

Applicant v. Aviva Insurance Company (17-008198)

The claimant alleged that a stroke six weeks after the accident was caused by the accident. She sought entitlement to IRBs and an electric scooter. The parties agreed that the “but for” test was the appropriate test for causation. Adjudicator Parish concluded that the medical evidence did not prove that the stroke was caused by the accident. The injuries the claimant did sustain in the accident did not support entitlement to IRBs or an electric scooter.

K.W. v. Certas Direct Insurance Company (17-008502)

The claimant sought entitlement to two treatment plans for physical therapy. Adjudicator Ferguson dismissed both claims. He held that the claimant had reached maximum medical improvement and that the claimant had returned to a high degree of function. Furthermore, the claimant was not reporting pain relief as a result of passive physical therapy.

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.