Category: Medical Benefits

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.

K.H. v. Unifund Insurance Company (17-007586)

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.

Applicant v. Aviva Insurance Canada (17-003957)

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.

J.M. v. Certas Home and Auto Insurance Company (18-001406)

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.