Category: Medical Benefits

Applicant v. Unica Insurance Inc. (17-007052)

Post author By tgp-admin
Post date July 20, 2018
No Comments on Applicant v. Unica Insurance Inc. (17-007052)

The claimant sought a declaration that she sustained a catastrophic impairment, and sought entitlement to ACBs and medical benefits. The insurer denied all of the claims and argued that the claim for ACBs was time barred. Adjudicator Ferguson held that the claimant did not suffer a catastrophic impairment. He preferred the evidence of the IE assessors over that of the claimant’s assessors because the claimant’s assessors did not conduct any psychological testing, did not discuss the four areas of function, and did not explain how his scores for physical impairments were made. Adjudicator Ferguson held that the claim for ACBs was time barred and that the claimant only had two years from the date the insurer reduced her ACBs entitlement to apply to the LAT. The claims for medical benefits were dismissed because the claimant failed to provide evidence that they were reasonable for her injuries.

Applicant v. Aviva Insurance Canada (17-007959)

Post author By tgp-admin
Post date July 18, 2018
No Comments on Applicant v. Aviva Insurance Canada (17-007959)

The claimant sought entitlement to IRBs and the cost of a chronic pain assessment. Adjudicator Watt dismissed both claims. Regarding IRBs, he held that the claimant was able to work. None of the claimant’s own physicians said that the claimant was unable to work, and the IE assessors made the same conclusions. Regarding the chronic pain assessment, the claimant made no submissions so the claim was dismissed.

Applicant v. Aviva Insurance (17-005631)

Post author By tgp-admin
Post date July 18, 2018
No Comments on Applicant v. Aviva Insurance (17-005631)

The claimant sought entitlement to a chronic pain assessment and assistive devices. Adjudicator Kepman found the claimant credible and granted the chronic pain assessment based on ongoing wrist pain years after the accident. The insurer had paid part of the claims for assistive devices, but denied the remainder based on the cost. Adjudicator Kepman concluded that the claimant failed to explain why the proposed costs were reasonable when similar alternatives were available at a lower cost.

Applicant v. Wawanesa Mutual Insurance Company (17-005887)

Post author By tgp-admin
Post date July 17, 2018
No Comments on Applicant v. Wawanesa Mutual Insurance Company (17-005887)

The claimant (who was represented by a litigation guardian due to pre-existing mental disability) sought entitlement to six treatment plans for physical therapy. Adjudicator Watt concluded that the therapy was not reasonable and necessary. The claimant had been receiving similar treatment for four years and there was no evidence that further treatment of a chiropractic nature was required. Adjudicator Watt wrote that the claimant had not proven that any ongoing physical issues were related to the accident, and instead may have been related to the claimant’s self-injurious behaviour.

Applicant v Aviva Insurance Canada (17-006470)

Post author By tgp-admin
Post date July 16, 2018
No Comments on Applicant v Aviva Insurance Canada (17-006470)

The applicant sought medical benefits for a massage therapy chair and extended warranty. Adjudicator Ferguson held that the applicant was entitled to the benefit claimed as it was reasonable and necessary. The applicant was also entitled to interest on overdue payment of benefits due. The adjudicator preferred the applicant’s treatment plan from an occupational therapist and a physiatry report over Aviva’s evidence. Aviva relied on a letter from an occupational therapist who did not recommend the chair but provided no reason for his opinion. Additionally, Aviva’s submissions did not address pre- and post-levels of well-being or functionality, except for pain, whereas the applicant’s evidence found that a chair would increase the applicant’s physical activity and improve family interaction. Aviva further argued that the cost of the chair was unreasonable, but the adjudicator found that Aviva did not make a case that cheaper models were as effective and the applicant did not claim the most expensive model available.

Applicant v. Royal Sun Alliance (RSA) (17-006236)

Post author By tgp-admin
Post date July 16, 2018
No Comments on Applicant v. Royal Sun Alliance (RSA) (17-006236)

The claimant sought entitlement to two years of IRBs, removal from the MIG, and six treatment plans. Adjudicator Punyarthi concluded that the claimant sustained a concussion and that his injuries were therefore not minor. All of the disputed treatment plans were awarded because they directly addressed the impairments the claimant was suffering. Finally, Adjudicator Punyarthi awarded IRBs on the basis that the claimant could not complete the essential tasks of his employment as a produce clerk at a grocery store.

Applicant v. Desjardins General Insurance Group (17-005974)

Post author By tgp-admin
Post date July 16, 2018
No Comments on Applicant v. Desjardins General Insurance Group (17-005974)

The claimant sought entitlement to seven treatment plans and a special award. Adjudicator Purdy granted all the claims. She concluded that the medical evidence showed a compression fracture was directly caused by the accident, and that the proposed treatment was appropriate for addressing the injury. She was critical of the IE assessor focusing on standard healing times rather than the claimant’s reports of pain. A special award of 50 percent was granted because the insurer had sufficient evidence regarding the injuries and need for treatment, including the opinions of some of the IE assessors.

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

Post author By tgp-admin
Post date July 16, 2018
No Comments on Applicant v. Guarantee Company of North America (17-006956)

The claimant sought entitlement to NEBs and funding for catastrophic impairment assessments. The insurer argued that the limitation period barred the claim for NEBs, and that the claimed catastrophic impairment assessments were not reasonable and necessary. Adjudicator Flude agreed with the insurer. He held that the claim for NEBs was barred by the limitation period and that section 7 of the Licence Appeal Tribunal Act did not warrant allowing the dispute to proceed. He also held that the catastrophic impairment assessments were not payable because there was no reasonable basis to conduct an assessment to determine if the claimant suffered such an impairment. Surveillance showed the claimant with normal functionality, and assessment of the claimant revealed no accident-related physical or psychological impairment.

S.B. v. Wawanesa Mutual Insurance Company (17-004020)

Post author By tgp-admin
Post date July 10, 2018
No Comments on S.B. v. Wawanesa Mutual Insurance Company (17-004020)

The claimant sought entitlement to the cost of an in-home assessment and chiropractic treatment proposed in one treatment plan. Adjudicator Daoud found that the claimant was not entitled to the benefits in dispute. Adjudicator Daoud held that experiencing some difficulty with housekeeping and home maintenance tasks does not warrant the need for an in-home assessment.

Applicant v. Certas Home and Auto Insurance Company (17-006967)

Post author By tgp-admin
Post date July 3, 2018
No Comments on Applicant v. Certas Home and Auto Insurance Company (17-006967)

The claimant sought a determination that her impairments were outside of the MIG as well as entitlement to medical benefits proposed in two treatment plans. Adjudicator Parish found that the claimant was removed from the MIG as a result of the insurer’s failure to comply with the “medical and all other reasons” requirement in s. 38(8) of the SABS. The incurred psychological assessment in dispute was found payable pursuant to s. 38(11) of the SABS. Adjudicator Parish found the proposed psychological treatment to be reasonable and necessary. The claim for a Special Award was denied.

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