Category: Medical Benefits

The claimant sought entitlement to three treatment plans, costs of various examinations, and interest on overdue payments. The insurer denied the first two treatment plans as the claimant had not exhausted MIG limits, but had later removed the claimant from the MIG. The insurer denied the third plan for not being reasonable and necessary, as well as a proposed orthopaedic assessment. Adjudicator Norris determined that the claimant was entitled to partial payment of the third treatment plan, and the costs of an orthopaedic assessment, as they were reasonable and necessary based on the records from the family physician.  He also granted the claimant interest on any overdue payments from the insurer. However, Adjudicator Norris upheld the denial of the first two treatment plans pursuant to section 38(5) of the SABS.

The claimant sought medical benefits for driver reintegration sessions and psychotherapy sessions, as well as travel expenses. Adjudicator Maedel held that the claimant failed to establish that the benefits sought were reasonable and necessary. Allstate had partially approved the OCF-18 in dispute for eight one-hour weekly driver reintegration sessions and six one-hour psychotherapy sessions, as recommended by an IE psychiatrist. The claimant sought benefits for two-hour weekly psychotherapy sessions and an increased hourly rate for a driving instructor. The adjudicator held that the claimant did not provide any evidence to demonstrate why two-hour psychotherapy sessions and an increased hourly rate for the driving instructor were reasonable and necessary. The adjudicator also held that the claimant did not provide evidence to establish that the transportation costs were reasonable and necessary, did not establish a link between his license suspension and the injuries sustained in the accident, and did not provide particulars of the travel expenses as per the Transportation Guideline.

The claimant sought entitlement to a neurological assessment and driving evaluation assessment. The adjudicator dismissed the claim for a neurological assessment on the basis that the claimant did not submit any evidence as to why the proposed assessment was reasonable and necessary. The adjudicator also noted that the claimant did not submit any evidence to refute the findings of the IE neurologist, who concluded that the proposed assessment was not reasonable and necessary. With respect to the driving evaluation, the adjudicator concluded that the proposed assessment was partially payable. The adjudicator concluded that the proposed mental health counselling as part of the driving evaluation was duplicative, and therefore not payable. The adjudicator also concluded that the treatment provider’s mileage was not payable as it is not an expense payable under the Guidelines.

The claimant sustained serious injuries and required 24 hour care. She moved homes to receive care from her father. The claimant and insurer disputed how much money the claimant was entitled to for the cost of rent (as a rehabilitation benefit). The claimant argued that she was entitled to the full cost. The insurer argued that she was entitled to the current cost less the estimated cost of the housing she would have resided in but for the accident. Adjudicator Ferguson held that the claimant was entitled to the lesser amount for rent. He calculated the amount as the rent for the current house less the average monthly rent for a two bedroom apartment plus 50 percent of monthly utilities. He reasoned that the claimant’s pre-accident living situation should be recognized, and that to pay for the full rent would amount to a windfall.