Category: Medical Benefits

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)

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)

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)

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)

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.

Applicant v Aviva Insurance Canada (16-003638)

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.

Applicant v. Aviva Insurance Canada (17-005950)

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.

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.