Category: Medical Benefits

V.K. v. Allstate Insurance Company (16-004273)

The claimant sought entitlement to attendant care benefits and medical benefits for vision-related expenses and transportation expenses. Adjudicator Truong held that the claimant was not entitled to any of the benefits or expenses at issue. The claimant’s mother provided her with attendant care; however on the limited and unreliable evidence before the adjudicator, the claimant did not meet her onus of proving that the mother sustained economic loss. Therefore, the claim for attendant care benefits did not meet the definition of “incurred” under to the SABS. The claims for prescription eyewear and an eye exam were not reasonable and necessary, and the transportation expenses submitted were not authorized transportation expenses within the meaning of the FSCO Superintendent’s Guideline No. 04/16. The claimant was not entitled to laser eye treatment expenses because no treatment plan was submitted.

Applicant v. Aviva General (17-004847)

The claimant sought entitlement to various medical benefits, the costs of a chronic pain assessment, treatment outside of the MIG, and interest. Upon weighing the medical evidence, Adjudicator Boyce determined that the claimant’s chronic pain warranted treatment outside of the MIG. Moreover, Adjudicator Boyce found the requested chronic pain assessment was reasonable and necessary. Adjudicator Boyce further held that one of the requested benefits was partially reasonable and necessary, but denied another treatment plan for being duplicative. As the claimant was found to be entitled to some of the benefits sought, he was also entitled to interest.

Applicant v. Aviva Insurance (17-006160)

The claimant sought entitlement to various medical benefits, a special award, and interest. The claimant raised a procedural issue, and asked the Tribunal to disregard attachments appended to the insurer’s written submissions, as they had not been transmitted properly via facsimile to the claimant; the attachments had been provided via mail several days later. Adjudicator Mazerolle denied the claimant’s request, as the potential prejudice to the insurer in refusing to consider the documents outweighed the effect of any delay in the claimant receiving the documents. Upon reviewing the medical documentation available, Adjudicator Mazerolle concluded that the claimant was entitled to the benefits in dispute, as they were reasonable and necessary, and to interest. However, Adjudicator Mazerolle held that the claimant was not entitled to a special award.

Applicant v. Allstate Canada (16-004348)

The claimant sought entitlement to two treatment plans for chiropractic services. Adjudicator White held that the claimant was not entitled to the recommendations proposed in the treatment plans in dispute. The claimant did not meet her onus in establishing the reasonableness or necessity of the plans. There was no evidence that the claimant had benefitted substantially from the many months of treatment she received. As a result, further facility based, largely passive treatment was not reasonable or necessary.

Applicant v. Aviva Insurance Canada (17-002957)

The claimant sought entitlement to treatment outside of the MIG, attendant care benefits, medical benefits, the costs of three examinations, and a special award. After a review of the medical evidence, Adjudicator Anwar preferred the reports of the claimant’s specialists and held that the claimant’s injuries warranted treatment outside of the MIG. Adjudicator Anwar further concluded that the claimant was entitled to the medical benefits sought, as they were reasonable and necessary, but that attendant care benefits were not warranted nor were any expenses incurred.  Moreover, Adjudicator Anwar held that the insurer did not unreasonably withhold payments from the claimant to necessitate a special award.

R.P. v. Wawanesa Insurance Company (16-002947)

The claimant requested reconsideration of the LAT’s decision in favour of the insurer’s denial of entitlement to certain medical benefits, expenses for prescription medication, and interest. He argued that the LAT violated procedural fairness by failing to either refer to or consider certain medical records in its decision. Executive Chair Lamoureux denied the request for reconsideration. She found that while the LAT’s decision did not explicitly refer to all of the documents, it did state that it considered all of the submitted documents and summarized those that were relevant to its findings. In any event, the records did not support a different result.

Applicant v. The Guarantee Company of North America (17-003906)

The claimant sought entitlement to two treatment plans. Adjudicator Reilly denied entitlement to both. Regarding the first, she held that the insurer’s initial denial was deficient because it failed to provide any medical or other reasons, but that the insurer rectified the notice with a subsequent denial. Because the claimant had not incurred the assessment during the period prior to the proper denial, it was not payable. In terms of the second benefit, Adjudicator Reilly held that it was not reasonable and necessary. She accepted that pain relief was a valid treatment goal, but that the claimant had not demonstrated any improvement from hydrotherapy.

W.C.C. v. Allstate Canada (17-001363)

The claimant sought entitlement to non-earner benefits, which had been denied by the respondent on May 22, 2013, and entitlement to two treatment plans. Adjudicator Daoud dismissed all the claims, finding that the claimant was limitation barred from disputing the denial of non-earner benefits and that the claimant had not proven that the disputed treatment plans were reasonable and necessary. The claimant argued that the two-year limitation period should be extended or should not apply for a number reasons, which were all rejected by Adjudicator Daoud. Adjudicator Daoud held that (a) an insurer’s denial of a benefit, even if it is legally incorrect, will trigger the two-year limitation clock; (b) the 26-week waiting period for NEBs is not in reference to entitlement but to when NEBs are payable; and (c) a benefit that is prematurely denied by an insurer may still be considered proper and trigger the two-year limitation period.

Z.A. v. Certas Direct Insurance (17-003297)

The claimant, who was catastrophically impaired in an earlier accident, sought entitlement to NEBs and treatment plans for medical marijuana and osteopathic treatment in relation to a subsequent accident. Adjudicator Go found that the claimant was entitled to the cost of the two disputed treatment plans plus interest, but he was not entitled to NEBs. Adjudicator Go noted that the evidence relied on by the claimant in the claim for NEBs, an OCF-3 by an OT who assessed the claimant once, a two-line report by the family doctor, and the claimant’s oral testimony given at the hearing, was less persuasive than the evidence presented by the insurer, which included IE physiatry and in-home assessment reports which addressed the claimant’s pre- and post-accident activities.

V.A. v. Wawanesa Mutual Insurance Company (17-002948)

The claimant disputed his MIG status; entitlement to payment for treatment; entitlement to payment for examinations and completion of OCF-3s; and entitlement to IRBs. Adjudicator Sewrattan denied all of the claims. The claimant, allegedly suffering from chronic pain, failed to prove that he suffered from an injury not predominantly minor in nature. The expert reports relied upon by the claimant were scant in their descriptions of methodologies used to reach the diagnoses made. The claimant was self-employed at the material time and failed to provide an intelligible basis upon which IRB could be calculated. Although he may be entitled to an IRB, he failed to prove what the weekly rate of the benefit should be. As a result, Adjudicator Sewrattan held his IRB entitlement to be $0 per week.