The claimant sought a determination that his impairments were outside of the MIG and entitlement to benefits proposed in three treatment plans. Adjudicator Ferguson found that the claimant’s injuries fell within the MIG and that the treatment plans in dispute were not payable as the MIG limits had been exhausted.
The claimant sought entitlement to medical benefits for physical and psychological therapy. Adjudicator Goela awarded all of the claimed benefits. She held that the claimant suffered from chronic pain and psychological injuries. She relied upon the records of the family physician which supported the need for ongoing treatment.
The claimant was involved in an accident in 1997. She applied for a catastrophic impairment determination in 2007, which found that she did not meet the definition. She did not dispute the determination. In 2016 she submitted a new OCF-19 seeking a catastrophic impairment determination and sought payment for assessments in that regard. The insurer argued that the claimant was not entitled to seek a catastrophic impairment determination and that it was not required to pay for assessments because the 10 year period had expired. Adjudicator Hines concluded that the claimant was permitted to submit a treatment plan for catastrophic assessments, and that such assessments could be payable because such assessments did not fall under the medical/rehabilitation limits. However, she also concluded that the procedure in the 2010 SABS applied rather than the 1996 SABS, meaning that the claimant’s entitlement to such assessments was limited to $2,000 per assessment and that rebuttal reports were not payable by the insurer. Finally, Adjudicator Hines concluded that the insurer was not required to pay for the claimed assessments because they were not reasonable and necessary. The evidence suggested that the claimant remained quite functional and did not demonstrate an ongoing functional limitation that had developed between 2007 and 2017.
The claimant disputed his entitlement to NEBs and various medical/rehabilitation benefits. The dispute proceeded by way of a written hearing. Adjudicator Boyce held that while the claimant suffered from pain, the claimant managed his pain and it did not prevent the claimant from engaging in self-care and in his daily activities. Adjudicator Boyce noted that the claimant could dress himself independently, walk for periods of time, and sit and stand without assistance. The claimant also reported that he could drive and use public transportation with pacing. Adjudicator Boyce held that while the evidence submitted by the claimant demonstrated that he suffered from pain and psychological impairments, it was insufficient to meet the high threshold of entitlement to NEBs. With respect to the disputed medical benefits, Adjudicator Boyce found the cost of physical rehabilitation treatment and the cost of a chronic pain assessment reasonable and necessary given the claimant’s pain complaints. As the claimant did not advance sufficient evidence that he was not independent with his self-care, Adjudicator Boyce found that the proposed attendant care assessment was not reasonable or necessary.
The claimant sought entitlement to NEBs and various medical/rehabilitation benefits. The hearing proceeded in-person and by writing. Adjudicator Boyce concluded that the claimant did not suffer a complete inability to carry on a normal life. Adjudicator Boyce noted that while the claimant’s injuries prevented her from returning to some of her pre-accident activities of daily living, she still went grocery shopping, attended Temple, and went swimming post-accident. As such, Adjudicator dismissed the claim for NEBs. With respect to the claimant’s dispute over medical benefits, Adjudicator Boyce awarded some of the disputed medical benefits. Adjudicator Boyce concluded that physical treatment was reasonable and necessary given the claimant’s reports of ongoing pain and because he had observed the claimant in discomfort during the hearing noting that the claimant needed to take breaks and used a cane and back brace at the hearing. Adjudicator Boyce dismissed the claimant’s claim for transportation, as this expense was not payable under the SABS and dismissed her claim for out of pocket expenses, noting that the insurer had paid in full all reasonable out of pocket expenses.
The claimant sought entitlement to the balance of a partially approved chronic pain assessment treatment plan and interest. Adjudicator Victor awarded the balance of the treatment plan, less transportation expenses, and interest on the overdue payment of benefits. Adjudicator Victor noted that she arrived at her decision largely in part due to the claimant’s credibility and supporting medical records that documented the claimant’s accident-related complaints. Adjudicator Victor noted that the claimant’s chronic pain affected his lifestyle and career, resulting in him taking significant time off work post-accident and him ultimately having to change employment to a job requiring lighter physical requirements. At the hearing, the insurer relied on IE reports to maintain that the balance of the disputed treatment plan was not payable. Adjudicator Victor criticized Dr. Oshidari’s IE report, calling it a “copy and paste” of an earlier report and that it was therefore, unreliable. Given the claimant’s ongoing pain complaints and the effect of his pain on his ability to function post-accident, Adjudicator Victor awarded the balance of the treatment plan for a chronic pain assessment, less transportation expenses, which were not payable under the SABS.
The claimant disputed her entitlement to eight treatment and assessment plans and post-104 week IRBs. Adjudicator Kershaw awarded all of the medical benefits in dispute, save for a portion of a treatment plan that sought funding for a weighted vest. With respect to the weighted vest, Adjudicator Kershaw agreed with the IE neurologist’s opinion that the vest had no scientific utility and therefore was not reasonable and necessary. As for the claim for post-104 week IRBs, Adjudicator Kershaw noted that it was accepted by both the IE assessors and the claimant’s doctors that the claimant had psychological difficulties. Adjudicator Kershaw also relied on the claimant’s doctors’ reports noting that the claimant had cognitive difficulties and dizziness, which he opined would preclude her from returning to employment. Adjudicator Kershaw did not accept the insurer’s vocational assessor’s evidence identifying other suitable employment opportunities for the claimant, noting that the claimant’s psychological and cognitive issues prevented her from returning to gainful employment. As such, Adjudicator Kershaw concluded that the claimant was entitled to post-104 week IRBs.
The claimant sought entitlement to a chronic pain assessment. Adjudicator Ferguson held that the claimant failed to prove entitlement. He noted that the claimant was not diagnosed with chronic pain by any independent medical assessors, nor had the risk of chronic pain been raised with any independent assessors. The claimant also failed to explain why a chronic pain assessment was reasonable and necessary when the claimant still had physiotherapy and psychological services available to him which he had not pursued.
The claimant sought entitlement to three assessments. Adjudicator Reilly dismissed all three claims. She held that the claimant failed to provide evidence supporting the need for the assessments. The claimant had not sought treatment for years since the accident, and had experienced subsequent injuries in unrelated incidents. She also noted that the evidence suggested that the claimant had returned to his pre-accident activities and employment.
The claimant sought entitlement to IRBs from the date of denial until her return to work and various medical benefits, including a chronic pain assessment, and a two-part physiatrist assessment. Adjudicator Lake held that the claimant did not meet the IRBs test and both the chronic pain assessment and two-part physiatry assessment were not reasonable and necessary. The only evidence on the claimant’s essential tasks of pre-accident employment were from self-reports to medical professionals. There were no entries in medical records regarding her ability to work for the period in dispute. The insurer relied on three IE reports (psychology, neurology, orthopedic surgeon) which all concluded that the claimant did not suffer an inability to perform the essential tasks of her pre-accident employment. The adjudicator found the IE reports to be largely convincing accounts of the claimant’s post-accident condition. With regard to the disputed chronic pain assessment, the adjudicator preferred the two IE reports from the insurer which both found that the assessment was not reasonable and necessary. The adjudicator noted that the referring chiropractor did not make a finding as to whether the claimant’s alleged chronic pain occurred as a result of the accident, failed to comment on pre-accident migraines, and omitted details of pain levels and complaints, whereas one of the IE assessors was authorized to practice on chronic pain management. Additionally, there was no medical documentation on file beyond the assessment report from the referring chiropractor. With regard to the two-part physiatry assessment, there was conflicting evidence regarding the claimant’s impairments as she was able to return to work in a physical role, yet unable to complete ADLs involving her work tasks. The adjudicator also noted that the claimant did not pursue other recommended investigations, such as an MRI, to determine her physical status, which was one of the goals of the treatment plans.
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