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.
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.
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.
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.
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.
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.
The claimant sought entitlement to a number of medical benefits. The insurer denied the treatment and cited that the plans were not reasonable and necessary. Adjudicator Derek Grant reviewed the medical evidence and concluded that the claimant failed to establish the medical benefits sought were reasonable and necessary. The claims were dismissed.
The claimant sought entitlement to a number of medical treatment plans. The insurer asserted the claimant was barred from proceeding to the LAT due to a failure to attend IEs scheduled. On review of the Notices provided, Adjudicator Rupinder Hans found the requested IEs to be reasonable. Accordingly, because the claimant failed to attend, the LAT application could not proceed
The claimant sought entitlement to a medical treatment plan for optometrist services. The insurer denied the plan, citing the proposal to not be reasonable and necessary. Adjudicator Gemma Harmison noted that the applicant failed to submit the disputed OCF-18 as evidence and subsequently failed to meet the burden of proof. Additionally, Adjudicator Harmison went further to note that the treatment was also not reasonable and necessary on the merits.
The claimant sought entitlement to a number of medical treatment plans. The insurer denied each as not being reasonable and necessary. Adjudicator Eleanor White reviewed the medical evidence and found half of the treatment plans reasonable and necessary. Interest, in accordance with section 51, was awarded on the payable benefits.
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150 York Street, Suite 1800
Toronto, Ontario M5H 3S5
416.507.1850
© 2020 Thomas Gold Pettingill LLP