Category: Medical Benefits

The claimant sought medical benefits outside of the MIG and interest on the overdue payment of benefits. Adjudicator Ferguson held that the claimant’s injuries fell within the MIG and dismissed the claimant’s application. Adjudicator Ferguson relied on the claimant’s self-reporting to conclude that the claimant did not have a credible psychological injury arising from the accident. Adjudicator Ferguson noted that the claimant’s own words in examination were “powerful evidence” in determining whether the claimant’s claimed psychological issues were credible. Adjudicator Ferguson also concluded that the claimant had failed to prove that she suffered from chronic pain syndrome because her self-reports were contradictory and non-credible.

The claimant disputed his MIG status; entitlement to a medical benefit for physiotherapy treatment; and interest on overdue payment of benefits. Adjudicator Norris rejected that the claimant suffered a psychological injury as a result of the accident, finding that the evidence of psychological injury relied upon by the claimant was inconsistent with the entire rest of the claimant’s medical record. Further, the claimant failed to adduce evidence sufficient to establish that a pre-existing finger fracture prohibited him from recovering within the MIG limit. Adjudicator Norris held that the claimant suffered a minor injury within the meaning of the Schedule and is subject to the MIG funding limit. Entitlement to the medical benefit in dispute was rejected as a result.

The claimant sought removal from the MIG and entitlement to psychological and physical assessments and treatment. The claimant had a pre-accident medical history relevant for depression and anxiety stemming from infertility issues. Adjudicator Hines concluded that based on the medical records and the evidence of the s. 44 and s. 25 assessors, the claimant’s pre-existing depression and anxiety did not prevent her from reaching maximum medical recovery under the MIG. Adjudicator Hines noted that the claimant had not demonstrated that the accident worsened and/or exacerbated her depression and anxiety. Adjudicator Hines preferred the evidence of the IE assessor to that of Dr. Shaul, s. 25 assessor, as Dr. Shaul’s medical reports contained inconsistencies and because she found Dr. Shaul’s reports unreliable, as Dr. Shaul never actually met the claimant. Adjudicator Hines concluded that the claimant’s injuries fell within the MIG, the disputed psychological assessment and treatment was not payable, and the disputed physical treatment was payable only up to the amounts remaining in the MIG limits.

The claimant sought a declaration that her injuries were not predominantly minor injuries to be treated within the MIG, as well as entitlement to medical benefits for treatment. Adjudicator Watt held that the claimant was not entitled to any of the relief sought. The applicant failed to adduce any medical evidence to indicate that her injuries fell outside of the MIG. The claimant also failed to adduce evidence to address the stated goals of the treatment plans at issue and how the plans would achieve those goals. As such, there was no evidence to show that the treatment plans were reasonable and necessary.

The claimant sought removal from the MIG and entitlement to psychological treatment. Adjudicator Grant concluded that the insurer failed to respond to the treatment plan within 10 days. Even though the treatment plan was denied on HCAI, no letter with the medical and other reasons for the denial was sent to the claimant until two months later. The insurer was therefore prohibited from relying upon the MIG. However, Adjudicator Grant held that the claimant failed to prove that the proposed psychological treatment was reasonable and necessary.