The claimant, who was working as a PSW at the time of the accident, sought entitlement to pre-104 IRBs and a treatment plan proposing a psychological assessment. Adjudicator Reilly found that the claimant was entitled to the cost of the proposed assessment plus interest, but she was not entitled to IRBs. Adjudicator Reilly concluded that the claimant failed to prove that she suffered a substantial inability to perform her pre-accident employment.
The claimant sought entitlement to treatment outside of the MIG, five treatment plans, and a special award. Adjudicator Sewrattan found that the claimant suffered from Chronic Post Traumatic Pain Syndrome and was entitled to treatment outside of the MIG. Adjudicator Sewrattan preferred the claimant’s expert report over the insurer’s, as the insurer’s report failed to address the claimant’s pre-existing carpal tunnel syndrome and the issue of chronic pain. Adjudicator Sewrattan found that all of the treatment plans in dispute were reasonable and necessary. Adjudicator Sewrattan held that the claimant was not entitled to a special award as the insurer had not acted unreasonably.
The claimant sought entitlement to the cost of three assessments. Adjudicator Fricot concluded that the chronic pain assessment was reasonable and necessary based on the medical evidence showing a reasonable possibility that the claimant suffers from chronic pain. The orthopaedic and neurological assessment were denied due to the lack of relevant symptoms supporting impairments in those areas.
The claimant sought entitlement to one treatment plan. Adjudicator Goela found that the treatment plan for physiotherapy was reasonable and necessary. Adjudicator Goela noted that the IE assessor’s acknowledgment that the claimant still required daily stretching and range of motion exercises supported the need for the proposed physiotherapy.
The claimant sought entitlement to four medical benefits. Adjudicator Mazerolle found the proposed physiotherapy and chiropractic therapy to be reasonable and necessary based on the persistent nature of claimant’s injuries. An acupuncture treatment plan and a proposed orthotics assessments were denied due to the lack of evidence connecting the claimant’s injuries to the proposed benefits.
The claimant sought removal from the MIG and one treatment plan. Adjudicator Kepman concluded that the claimant’s back spasm were clinically associated sequelae to a soft tissue injury, and that the claimant was therefore restricted to MIG-level benefits.
The claimant sought entitlement to the cost of an attendant care assessment and interest. Adjudicator Kowal dismissed the claimant’s application as the claimant had not incurred the cost of the attendant care assessment. However, Adjudicator Kowal held that in order for an initial s. 25 attendant care assessment to be found payable, five criteria must be met: (1) the claimant’s injuries be outside the MIG; (2) the OCF-18 for an attendant care assessment be submitted to an insurer and compliant with s. 32; (3) the attendant care assessment be incurred; (4) the attendant care assessment and Form 1 be completed by a registered nurse or occupational therapist; and (5) the fees be reasonable as per the Professional Services Fee Guidelines.
The claimant sought entitlement to three disputed treatment plans and the payment of an OCF-3. Adjudicator Anwar found that the claimant was entitled to all three disputed treatment plans but not the cost of the OCF-3. Adjudicator Anwar concluded that the accident aggravated the claimant’s pre-existing chronic back and neck pain and the proposed treatment plans were reasonable and necessary. Adjudicator Anwar held that the 27 minute surveillance video was not sufficient to sway him that the claimant did not have functional limitations and did not suffer from chronic pain. Adjudicator Anwar opined that as the insurer did not provide the surveillance report to its assessors or rely on the report to deny the treatment plans, he did not attach any weight to the surveillance. As for the OCF-3, Adjudicator Anwar concluded that as the insurer did not request the updated OCF-3 and as the OCF-3 did not provide any new information, the insurer was not liable to pay for this expense.
The claimant sought entitlement to a number of medical benefits. The insurer denied the treatment plans based on IE reports and the LAT agreed with the denials. On reconsideration, however, Executive Chair Linda Lamoureux determined that the Tribunal arrived at the determination in a manner that was procedurally unfair to the claimant. At the Tribunal level, the claimant failed to submit the disputed treatment plans as evidence. Executive Chair Lamoureux determined that the Tribunal deciding in the absence of these documents, without asking the claimant’s counsel for the materials was a breach of procedural fairness and remitted the matter back to the Tribunal for a new determination.
The claimant sought entitlement to one medical treatment plan. Adjudicator Anita Goela, on review of the medical evidence, determined that the treatment plan was not reasonable and necessary. The matter was dismissed.
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Toronto, Ontario M5H 3S5
416.507.1850