Category: Medical Benefits

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 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.