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.
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.
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.
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.
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.
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.
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.
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.
The claimant sought removal from the MIG, entitlement to NEBs, nine disputed treatment plans, interest, costs, and a special award. Adjudicator Gosio concluded that the claimant’s psychological injuries warranted treatment outside of the MIG, and approved one of the treatment plans sought. However, Adjudicator Gosio held that the claimant was not entitled to NEBs, payment of the remaining treatment plans, or to the costs or award sought.
The claimant sought entitlement to IRBs and three medical benefits. Adjudicator Go dismissed all of the claims other than the claimed psychological assessment. She held that there was insufficient information to support objective limitations or restrictions to support the IRB claim, and the claimant had not provided sufficient information to quantify the IRB even if it had been awarded. In terms of the medical benefits, two of the treatment plans were submitted to the wrong insurer and had never been submitted to the proper insurer. The claimed psychological assessment was awarded because Adjudicator Go favoured the evidence of the claimant’s assessor over that of the IE assessor.
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150 York Street, Suite 1800
Toronto, Ontario M5H 3S5
416.507.1850
© 2020 Thomas Gold Pettingill LLP