Category: Medical Benefits

Applicant v. TD Insurance Meloche Monnex (17-000640)

The claimant sought entitlement to NEBs, removal from the MIG, and two treatment plans. Adjudicator Neilsen first exclude one report submitted by the claimant because it was given to the insurer 10 days prior to the hearing. In terms of the benefits in dispute, the adjudicator concluded that the claimant failed to adduce sufficient evidence supporting a pre-existing condition, psychological impairments, or chronic pain. She noted that chronic pain was not the same as chronic pain syndrome, and that pain does not take a person out of the MIG unless it is functionally disabling. The adjudicator also concluded that the claimant did not suffer a complete inability to live a normal life.

Applicant v. Wawanesa Mutual Insurance Company (16-002633)

The claimant sought removal from the MIG and two medical benefits. The insurer argued that the claim was time barred. Adjudicator Maedel held that the claimant had applied to the LAT within 90 days of receipt of the FSCO Report of Mediator, and was therefore within the limitation period. He concluded that the claimant’s injuries were minor in nature and that the claimant’s evidence did not support removal from the MIG.

D.N. v. Aviva Insurance Company (17-004104)

The claimant sought entitlement to two assessments, and argued that the treatment plans were denied more than 10 days after submission. The insurer argued that the claimant failed to attend IEs. Adjudicator Norris agreed with the claimant that the treatment plans had been denied more than 10 days after submission due to the deeming provision at section 64(18) of the SABS relating to mail. However, the adjudicator also concluded that the insurer sent a proper denial before the proposed goods and services were completed, and they were therefore not payable. He also found that the claimant failed to attend a scheduled IE, and therefore could not dispute his entitlement to one of the proposed assessments. The other assessments was denied as being not reasonable and necessary.

M.H.E. v. Aviva Insurance Company (17-002624)

The claimant sought removal from the MIG and entitlement to six treatment plans. Adjudicator Mather concluded that the claimant suffered from chronic pain, which was a non-“minor injury.” The adjudicator accepted that pain relief was a valid treatment goal, and awarded four of the claimed treatment plans. Two of the treatment plans were denied due to being too similar to earlier treatment plans without consideration for new modalities and anticipated improvement.

Applicant v. Aviva Insurance Company (17-002907)

The claimant sought removal from the MIG and entitlement to four medical benefits. Adjudicator Lester held that the claimant’s disc bulges, degenerative changes, and chronic pain disorder were not minor injuries, and removed the claimant from the MIG. She also awarded the cost of a chronic pain assessment, chronic pain treatment plan, and a psychological assessment. She denied entitlement to an orthopaedic assessment because it was unclear why it was warranted.

J.D. v Aviva General Insurance (17-002713)

The claimant sought the cost of an orthopaedic assessment. Adjudicator Goela held that the respondent’s denial letter did not provide a medical reason why an orthopedic examination was not reasonable or necessary pursuant to section 38(8) of the SABS. The denial letter stated that pursuant to the physiatrist report, further physical intervention would not affect the recovery of the claimant’s shoulder, and that cortisone injections could be more beneficial. The denial letter did not elaborate any further. Adjudicator Goela also concluded that even if she did not find that the respondent failed to provide a medical reason for denying the benefit, the orthopedic assessment was reasonable and necessary. Adjudicator Goela further held that the cost of completing the OCF-18 in the amount of $200.00 and HST were not subject to the $2,000.00 limit.

J.N. v. Aviva General Insurance Company (17-000518)

The claimant sought entitlement to NEBs and the cost of an in-home assessment. Adjudicator Truong dismissed the claim for NEBs, but awarded the in-home assessment. She found the reports by the claimant’s assessors to be contradictory and unhelpful in supporting the NEB claim. There were also injuries that the claimant’s assessor tried to link to the accident, but for which no persuasive evidence was put forward. There were also inconsistencies in the claimant’s evidence regarding her functionality. In terms of the in-home assessment, Adjudicator Truong found it payable because the claimant had been removed from the MIG.

Applicant v. TD Insurance (17-003496)

The claimant sought entitlement to six assessments to address his potential catastrophic impairment. Each assessment was in excess of $2,000. The insurer denied the assessments on the basis that the claimant had failed to prove causation (i.e. the accident was minor, and the claimant suffered psychological difficulties before the accident). Adjudicator Sewrattan granted the claimant’s request for all six assessments, but limited the total payable to $2,000 per assessment, $200 for the form fee, and HST. The adjudicator did not decide whether section 25 automatically entitled the claimant to the assessments, but held that even on a “reasonable and necessary” standard, it was appropriate for the claimant’s psychiatric impairments to be tested and to determine whether they were accident related. He also noted that the insurer has a total of 13 IE assessments, while the claimant had no assessment funded, and that the insurer’s catastrophic IE assessors did not offer opinions on the psychiatric impairment as part of a WPI measurement.

Applicant v. The Sovereign General Insurance Company (16-004501)

The claimant sought entitlement to various denied catastrophic impairment assessments, and the cost of x-rays. The insurer had approved some of the catastrophic impairment assessments, but denied others. At the time of the hearing, the claimant had been declared catastrophically impaired. Adjudicator Sewrattan awarded the cost of the physiatry assessment, even though an orthopaedic assessment had been approved. He reasoned that it was an appropriate assessments as part of an overall determination. The adjudicator denied the cost of a File Review and a Whole Person Impairment Analysis, reasoning that both assessments were duplicative of services that had been approved (the file review as part of the $2,000 assessment fee, and the WPI analysis as part of an approved “Overall Assessment”). The cost of the x-ray was denied because it was reasonably available through OHIP.

Applicant v. Aviva General Insurance (17-004357)

The claimant sought entitlement to a psychological assessment, as well as a number of psychological treatment plans. Adjudicator Christopher Ferguson reviewed the denial letter for the psychological assessment, and determined that the Notice failed to provide medical reasons for the denial. Accordingly, by operation of section 38, the assessment was deemed payable. However, based on the medical evidence, it was determined that the psychological treatment was not reasonable. Only interest on the assessment was found payable.