Category: Medical Benefits

The claimant sought medical benefits for chiropractic services and interest on overdue amounts. Adjudicator Punyarthi held that the treatment plan was neither reasonable nor necessary and that the claimant was not entitled to interest. In support of her claim, the claimant relied on a physician’s report that made a number of treatment recommendations. However, the services on the treatment plan were not listed within the treatment recommendations in the physician’s report. Adjudicator Punyarthi also held that the physician’s report relied on by the claimant contained inconsistent statements regarding the claimant’s prognosis. There was also no affidavit evidence submitted by the claimant on the reasonableness and necessity of the treatment plan.

The claimant sought medical benefits for a psychological assessment and psychological treatment and interest. The insurer maintained that the claimant’s injuries fell within the MIG and the disputed medical benefits were not payable. Adjudicator Sharma concluded that the claimant’s injuries fell within the MIG and dismissed the claimant’s application. Adjudicator Sharma preferred the evidence of the IE assessor to that of the s. 25 assessor. Adjudicator Sharma attached little weight to Dr. Pilowsky’s s. 25 psychological assessment, concluding that it was not credible.

The claimant sought entitlement to various medical benefits and cost of examinations related to an alleged knee injury. Adjudicator Ferguson held that the knee impairment was not caused by the accident, and the disputed treatment plans were not payable. However, he also concluded that one of the examinations was not properly denied by the insurer, and was therefore payable.

The claimant and insurer disagreed over the payment of seven disputed medical and rehabilitation benefits, including the cost of IV injections, the cost of an EEG assessment, the cost of a functional abilities evaluation and the cost of a dietician assessment. The insurer submitted that the disputed benefits were not reasonable and necessary and relied on the conclusions of the IE assessors. Adjudicator Makhamra concluded that six of the disputed medical and rehabilitation benefits were payable, preferring the evidence of the claimant’s treating providers to the evidence of the IE assessors. Adjudicator Makhamra dismissed the claimant’s claim for a functional abilities evaluation preferring the evidence of the IE assessor that the claimant was self-limiting on examination and therefore, concluded that a FAE would be of little benefit to the claimant.

The claimant sought payment for a TMJ assessments and oral orthotics. The insurer argued that the claimant’s dental impairments were not accident-related. The Adjudicator concluded that on either the “but for” test or the “material contribution” test the claimant’s dental impairments were not caused by the accident. In reaching her conclusion, the Adjudicator relied on the claimant’s clinical notes and records and the opinions of the IE assessors. These records revealed that the claimant’s pre-accident and post-accident TMJ symptoms were so similar that the Adjudicator was unable to conclude that the post-accident symptoms were caused by the accident. The Adjudicator dismissed the claimant’s application.

The claimant sought entitlement to one treatment plan for chiropractic services. The claimant was being treated outside of the MIG as a result of a psychological impairment. Adjudicator Fircot found that the claimant had not proven on a balance of probabilities that the proposed treatment was reasonable and necessary. The claimant’s claim was denied.