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.
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.
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.
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.
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.
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.
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.
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 sought medical benefits for psychological issues, interest on the overdue payment of benefits, and a special award. The insurer argued that the claimant’s injuries fell within the MIG. Adjudicator Reilly held that the claimant was entitled to medical benefits for a psychological examination and psychological treatment as both were reasonable and necessary. The claimant was entitled to interest for any overdue payment of benefits, but was not entitled to a special award. The claimant’s assessors diagnosed Major Depressive Disorder and Post-Traumatic Stress Disorder with Phobic Avoidance to driving; an IE psychologist found no evidence which would warrant any psychological diagnosis and found that the claimant exhibited symptom magnification. Adjudicator Reilly preferred the claimant’s expert assessment to that of the IE psychologist, because the IE psychologist used the DSM-IV criterion instead of DSM-V, and discounted complaints of anxiety and feelings of being overwhelmed. Additionally, the IE psychologist did not review the claimant’s expert report, despite it being available. Adjudicator Reilly held that the IE psychologist’s failure to review the claimant’s expert report was not enough to warrant a special award, as the insurer still took appropriate steps to evaluate the condition of the claimant.
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.