Category: Medical Benefits

D.C. v. Aviva Insurance Company (17-002921)

The claimant sought entitlement to NEBs, medical benefits, and the cost of various examinations. The insurer raised s. 55 and s. 33 defences. Pursuant to s. 55, Adjudicator Ferguson held that the claimant was barred from commencing part of the application as a result of his failure to attend IE assessments. He was only barred from pursuing the issues in dispute that were relevant to the IE assessments. Adjudicator Ferguson held that the claimant was entitled to NEBs for an initial period based on the insufficiency of the insurer’s  s. 35(1) notice; however, the insurer was entitled to withhold payment of NEBs during the period in which the claimant was not in compliance with s. 33 requests.

Applicant v. Certas Direct (17-002792)

The claimant sought entitlement to IRBs, one treatment plan, and interest. Adjudicator Msosa held that the medical evidence did not indicate the claimant had suffered a substantial inability to perform his employment as a security guard and was therefore not entitled to IRBs. The claimant argued that the treatment plan was payable as the insurer had failed to provide ten days notice, as required by section 38(11). Adjudicator Msosa found that the insurer had responded within the timelines required by the SABS, and further concluded that the claimant was not entitled to the medical benefit sought as it was not reasonable and necessary.

Applicant v. Certas Direct Insurance Company (16-003108)

The claimant sought entitlement to NEBs, ACBs, and a chronic pain assessment. The insurer argued that the claimant was barred from seeking the chronic pain assessment for failure to attend an IE assessment. Adjudicator Anwar found that the claimant was barred from pursuing the cost of the chronic pain assessment due to her nonattendance at a s. 44 assessment and because the LAT application was filed prior to the insurer providing a response to the proposed treatment. The adjudicator found that the claimant failed to prove that she sustained a complete inability to carry on a normal life as a result of the accident. In coming to this conclusion, Adjudicator Anwar noted that he found the records of the claimant’s family doctor more persuasive that the IEs and s. 25 medicolegal reports, the evidence of the claimant and her son, and the report of the family doctor prepared for the hearing.  The claimant was also not to be entitled to ACBs.

Applicant v. Aviva Insurance Company (17-002638)

The claimant sought entitlement to ongoing IRBs, various medical benefits outside of the MIG, and a special award. The claimant submitted that psychological impairments and chronic pain took him outside of the MIG. Adjudicator Boyce found that the claimant’s impairments were predominantly minor injuries, holding that in the absence of evidence of a full or partial tear, the claimant’s shoulder tendonitis was within the MIG. The claimant was found not to have a psychological diagnosis. Adjudicator Boyce held that the claimant had not proven that he had missed work as a result of the accident and was therefore not entitled to IRBs. A special award was denied.

Applicant v. Aviva Insurance Company (17-003600)

The claimant sought entitlement to medical benefits outside of the MIG and a special award. Adjudicator Victor found that the claimant was outside of the MIG because of the extent of her psychological symptoms, and she was entitled to the cost of a psychological assessment, plus interest. The claimant was not found entitled to a special award.

S.L. v. Aviva Insurance Company of Canada (17-004989)

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.

Applicant v. Co-Operators Insurance Company (17-006513)

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.

J.B. v Allstate Canada (17-005951)

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.

Applicant v. Aviva Insurance Company (17-005081)

The claimant sought entitlement to three treatment plans, and interest on overdue payments.  The insurer brought a preliminary issue concerning whether the applicant was precluded from submitting evidence regarding the benefits in dispute; more specifically, the claimant had failed to submit two of the treatment plans to the Tribunal. Adjudicator Go determined that, it was in the interests of fairness to admit the treatment plans despite their late filing. Adjudicator Go further held that the claimant was not entitled to any of the medical benefits sought, or to interest.

Applicant v. Certas Home and Auto Insurance Company (17-005145)

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.