Category: Medical Benefits

Applicant v The Guarantee Company of North America (17-006422)

The claimant sought entitlement to a treatment plan for physiotherapy services, and interest. Vice-Chair Flude preferred the evidence of the claimant’s physiotherapist to that of the respondent’s neurologist, and awarded the disputed treatment plan and interest.

Applicant v. TTC Insurance Company Limited (17-004391)

The claimant sought entitlement to various medical benefits for physical therapy, a psychological assessment, and psychological therapy. Adjudicator Ferguson denied the claims for physical therapy because the claimant had not demonstrated that her pain complaints were related to the accident. He awarded the $200 form fee related to the psychological assessment, and awarded the remainder of the psychological therapy. He wrote that both the claimant’s assessor and the IE assessor found that the claimant suffered psychological injuries, and the IE assessor had not explained why the proposed treatment was not fully payable.

D.M. v Aviva Insurance (17-003463)

The claimant sought entitlement to NEBs, attendant care, two medical benefits, interest, and costs. Adjudicator Johal found the claimant’s complaints of pain to be credible, but did not find that his pain-related restrictions equated to a complete inability to carry on a normal life; as such, the claimant’s entitlement to NEBs was denied. However, Adjudicator Johal preferred the evidence of the claimant’s assessors with respect to his attendant care needs, and held that he was entitled to attendant care benefits. After a review of the medical evidence, Adjudicator Johal concluded that one of the disputed benefits for chiropractic treatment was reasonable and necessary, while another for occupational therapy services was not. Adjudicator Johal declined to award costs.

Applicant v. Wawanesa Mutual Insurance (17-002589)

The claimant sought entitlement to various medical benefits outside of the MIG. Adjudicator Sohal found that the claimant was outside of the MIG due to a pre-existing back injury that would prevent her from achieving maximal recovery if she were subjected to the MIG limits. The claimant had had three back surgeries prior to the accident. The claimant was found entitled to all of the medical benefits in dispute.

Applicant v. Aviva Insurance Canada (17-005667)

The insurer denied a number of treatment plans and costs of three assessments based on its finding that the claimant’s injuries fell within the MIG. Adjudicator Boyce found that the claimant suffered from chronic pain which entitled him to treatment beyond the MIG. All of the medical benefits for physiotherapy were found reasonable and necessary. The claimant’s evidence showed that his chronic pain caused functional impairment based on its severity and persistence, which affected his daily and work life over two years post-accident. Adjudicator Boyce went on to hold that the claimant was entitled to the cost of an impairment assessment but not the costs of examinations for in-home assessments or psychological assessments as they were not reasonable or necessary.

Applicant v. Wawanesa Mutual Insurance Company (17-005427)

The claimant sought entitlement to an income replacement benefit from the time the benefit was terminated approximately one year and one month following the accident onward, and entitlement to medical benefits for chiropractic services, psychological services, and custom orthotics. Adjudicator Sewrattan held that the claimant was not entitled to any of the benefits in dispute. While the claimant advanced evidence to suggest he may have required further counseling and displayed emotional difficulty during an EUO, the evidence did not prove that the claimant was unable to perform the essential tasks of his pre-accident employment. The claimant failed to prove that the chiropractic treatment plans were reasonable and necessary as the goals of the plans were not linked to the claimant’s injuries. The psychological treatment plan was not analyzed because the insurer subsequently approved more sessions of the same treatment in dispute. Lastly, Adjudicator Sewrattan held the claimant was not entitled to payment for custom orthotics because he incurred the expense before submitting a treatment plan.

Applicant v Aviva Insurance Canada (17-007873)

The claimant sought medical benefits for chiropractic treatment. Adjudicator Kershaw held that the claimant was not entitled to the treatment because she did not prove that the treatment plan was reasonable and necessary. The claimant’s treating physician only recommended a splint and possible surgery for her left hand and stated that additional massage therapy could be helpful for her neck, upper body and low back. The orthopaedic surgeon who conducted the IE stated that no further treatment would facilitate the claimant’s recovery.

Applicant v Peel Mutual Insurance Company (17-003087)

The claimant sought various medical and rehabilitation benefits, costs of moving, and interest on the overdue payment of benefits. Adjudicator Parish held that the claimant did not demonstrate that the medical/rehabilitation benefits in dispute for physical therapy and online classes were reasonable and necessary. The treatment plans for online courses were premature at the time they were submitted. Adjudicator Parish further held that the claimant did not demonstrate that the treatment plans for optometric vision therapy, eye examinations, and eyeglasses were linked to the subject motor vehicle accident. Additionally, the moving expenses were not payable in accordance with the SABS. Moving expenses are not listed under s.16(3) of the SABS and the decision to move was made prior to the accident.

Applicant v. Aviva Insurance Company (17-004497)

The claimant sought entitlement to an orthopaedic assessment. Adjudicator Kershaw concluded that it was payable because at the time it was proposed, the claimant was experiencing ongoing pain which might have related to an orthopaedic injury.

Applicant v. Northbridge Insurance Company (17-002232)

The claimant sought entitlement to IRBs and to the cost of his US hospital bill. Adjudicator Shapiro denied both claim. In terms of the IRBs, Adjudicator Shapiro held that the claimant did not suffer a substantial inability to return to work as a truck driver based on IE opinion and surveillance evidence of the claimant engaged in post-accident long-haul driving. The claim for hospital expenses was not payable because the insurer had paid up to the $50,000 medical benefits limits.