Category: Medical Benefits

Applicant v. Aviva Canada Inc. (17-005825)

The claimant sought entitlement to various medical benefits and a special award. Adjudicator Létourneau concluded that all of the proposed treatments were reasonable and necessary for the claimant’s injuries. The family physician had diagnosed chronic pain and recommended ongoing physical therapy. The claimant also demonstrated psychological impairments that required ongoing treatment. The IE reports did not directly contradict the recommendations in the treatment plans. Adjudicator Létourneau also issued a special award of 25 percent against the insurer. He concluded that once the claimant had provided the outstanding clinical notes and records of all treatment providers in his Case Conference summary, the insurer had sufficient information to determine that the denied medical benefits were reasonable and necessary. The insurer’s delay in not approving the denied benefits was unreasonable.

Applicant v. Aviva Insurance Canada (17-006138)

The claimant sought entitlement to two treatment plans for chiropractic and psychological services. Adjudicator Watt found that the claimant was not entitled to the benefits in dispute. Adjudicator Watt found that many of the medical complaints raised by the claimant were not connected to the 2013 motor vehicle accident. Adjudicator Watt found that the treatment plans were not reasonable and necessary as a result of the accident. The claimant’s MIG status was not listed as an issue in dispute, but Adjudicator Watt also found that there was no evidence before the Tribunal that would take the claimant outside of the MIG. Adjudicator Watt found that the self-represented claimant had circumvented the disclosure process by returning consents for third party information late, which unfairly prevented the respondent from obtaining a decoded OHIP summary. The respondent sought a costs award. Adjudicator Watt noted that the previous adjudicator in the dispute resolution process found that the self-represented claimant had acted disrespectfully and unprofessionally, but he held that this behaviour did not meet the high standard required for an order for costs.

M.R. v Aviva Insurance Canada (17-007428)

The claimant sought entitlement to various medical benefits and the costs of a chronic pain examination. The Tribunal was also asked to determine whether the claimant was statute-barred from disputing one of the denied benefits, as he failed to commence his application within the two year time frame. Adjudicator Kepman concluded that the application for one benefit was time-barred as the claimant failed to provide any reasons for the delay. Adjudicator Kepman further concluded that the claimant had failed to adduce evidence to indicate that the requested benefits or the chronic pain examination were reasonably or necessary.

Applicant v. Aviva Insurance Canada (17-007527)

The claimant sought a determination that her impairments were outside of the MIG and entitlement to medical benefits proposed in three treatment plans. Adjudicator Maleki-Yasdi found that the claimant’s psychological impairment took her outside of the MIG, based on evidence that pre-existing psychological issues were exacerbated by the accident. The claimant was found entitled to payment for physical treatment, a psychological assessment, and psychological treatment.

Applicant v. Unifund Assurance Company (17-006691)

The claimant sought a determination that his impairments were outside of the MIG and entitlement to medical benefits proposed in five treatment plans. Adjudicator Kepman found that the claimant’s injuries fell outside of the MIG and that he was entitled to payment for two treatment plans for chiropractic services as well as the cost of a functional abilities assessment and an in-home assessment. The claimant was found to be outside of the MIG based on pre-existing chronic lymphocytic leukemia that would prevent maximal medical recovery within the MIG limits.

Applicant v. Motor Vehicle Accident Claims Fund (17-001681)

The claimant suffered a catastrophic impairment following a motorcycle accident which caused a traumatic brain injury. He sought entitlement to NEBs, ACBs, a rehab support worker, home modifications, and a special award. The Fund denied his entitlement to the claimed benefits. It also argued that the claimant did not have a valid licence and was not entitled to NEBs, and that no attendant care services had been incurred. Regarding the exclusion, Adjudicator Hines concluded that it did not apply because the claimant did have a valid driver’s licence (G1) even though it was not the proper licence for operating a motorcycle. She awarded NEBs, concluding that the claimant’s life had changed significantly following the accident. Even though the claimant was receiving ODSP for various disabilities before the accident, the brain injury resulted in significant changes in the claimant’s independent functionality. ACBs were also awarded at the rate of $6,000 per month. Adjudicator Hines concluded that 24 hour care was reasonable based on the claimant’s brain injury and the need for constant supervision. She also held the ACBs to be deemed incurred up to the date of the hearing because the Fund had failed to consider its IEs with a critical eye to ensure that they were medically sound and unbiased. Rehab support worker services were awarded because it was reasonable to teach the claimant skills and strategies to reintegrate into the community. Home modifications were not awarded because the majority of recommended modifications were for someone with severe physical disability rather than a brain injury. Finally, Adjudicator Hines granted a special award in relation to ACBs and the rehab support worker. She concluded that the denials were unreasonable and that the Fund did not critically consider its own IE reports. The Fund also failed to follow the recommendations of its own independent adjustors.

Applicant v. Allstate Canada (17-005189)

The claimant sought entitlement to two treatment plans for physical and psychological treatment. Adjudicator Grieves denied the claims. She held that the claimant’s physical complaints were not supported by prescriptions or referrals to specialists, and no objective evidence of injury was submitted. Similarly, the adjudicator denied entitlement to the psychological treatment based on the insurer’s IE report, in which the assessor found no diagnosable DSM-5 diagnosis, and noted that there were no references of psychological complaints to the family physician by the claimant.

O.G. v. RSA Insurance (17-007972)

The claimant sought entitlement to seven medical benefits. Adjudicator Ferguson held that the claimant failed to provide evidence that the disputed treatment plans would provide pain relief or the goals and efficacy of the treatment.

Applicant v. Aviva General Insurance Company (17-007475)

The claimant sought entitlement to a psychological assessment. Adjudicator Punyarthi denied the claim. He held that the claimant failed to explain why the proposed assessment was necessary and that the fees were reasonable. He was also critical of the contents of the Pilowsky report because the diagnoses did not correspond to the evidence that was collected by self-reporting tests.

Applicant v. The Guarantee Company of North America (17-003860)

The claimant sought entitlement to IRBs and three treatment plans. Adjudicator Anwar awarded IRBs but denied the treatment plans. He concluded that the claimant’s injuries prevented him from working as a drywaller and steel framer. The medical benefits were denied because the claimant failed to provide the disputed treatment plans as evidence and the Tribunal therefore could not determine that they were reasonable and necessary.

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