Category: Medical Benefits

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

Post author By tgp-admin
Post date February 5, 2018
No Comments on 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)

Post author By tgp-admin
Post date January 31, 2018
No Comments on 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.

T.N. v. Aviva Insurance Canada (17-002971)

Post author By tgp-admin
Post date January 31, 2018
No Comments on T.N. v. Aviva Insurance Canada (17-002971)

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.

D.W. v. Heartland Farm Mutual (17-001508)

Post author By tgp-admin
Post date January 30, 2018
No Comments on D.W. v. Heartland Farm Mutual (17-001508)

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

N.H. v. Aviva Insurance Canada (17-001309)

Post author By tgp-admin
Post date January 30, 2018
No Comments on N.H. v. Aviva Insurance Canada (17-001309)

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.

Applicant v. Aviva Insurance Canada (17-001040)

Post author By tgp-admin
Post date January 29, 2018
No Comments on Applicant v. Aviva Insurance Canada (17-001040)

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.

T. T. v. Aviva Insurance Canada (17-002535)

Post author By tgp-admin
Post date January 28, 2018
No Comments on T. T. v. Aviva Insurance Canada (17-002535)

The claimant sought entitlement to a number of medical treatment plans. The insurer denied the treatment and asserted a MIG position. The insurer also tendered surveillance in support of its position, to which the claimant sought to exclude on the basis of bad faith. Adjudicator Avvy Go determined that the surveillance was in contravention of Rule 9.2 and was not served 10 days prior to the hearing. Moreover, a case conference Order stipulated timelines that the insurer was in contravention of without any explanation. Accordingly, the materials were excluded. Additionally, the insurer was ordered to pay costs on the motion to exclude. However, on the substantive merits of the claim, Adjudicator Go determined that the claimant had not tendered compelling evidence to demonstrate that recovery within the MIG was unavailable; as a result, none of the treatment plans were found payable.

Applicant v. Allstate Insurance Company of Canada (17-001523)

Post author By tgp-admin
Post date January 26, 2018
No Comments on Applicant v. Allstate Insurance Company of Canada (17-001523)

The claimant sought entitlement to a number of medical benefits, as well as attendant care benefits. The insurer denied the medical treatment asserting the claims were not reasonable and necessary. The insurer also denied the claimant’s attendant care claim and cited a lower attendant care rate commissioned by an IE assessor. Adjudicator Billeh Hamud reviewed the medical evidence and preferred the evidence of the insurer’s attendant care assessor, which was not rebutted. Accordingly, attendant care benefits were awarded at the rate of the insurer. Moreover, because only one of the attendant care providers was qualified, the award for attendant care was confined to the expenses of the one PSW. As it pertained to the medical benefits claimed, Adjudicator Hamud determined that fees attached to the submission of treatment plans were compliant with Superintendent Guideline No. 03/14 and therefore payable. The substantive treatment sought, with the exception of a progress report, was considered not reasonable and necessary on review of the medical evidence.

Applicant v. Certas Home and Auto Insurance (17-001228)

Post author By tgp-admin
Post date January 26, 2018
No Comments on Applicant v. Certas Home and Auto Insurance (17-001228)

The claimant sought entitlement to a number of medical benefits. The insurer denied the treatment asserting the claims were not reasonable and necessary. On review of the medical evidence, Adjudicator Eleanor White determined that the medical benefits sought were payable, with the exception of a neuropsychological examination. A gym membership and assistive devices were also found partially payable. Interest, pursuant to section 51, was also awarded.

Applicant v. TD Insurance (17-003356)

Post author By tgp-admin
Post date January 26, 2018
No Comments on Applicant v. TD Insurance (17-003356)

The claimant sought entitlement to medical benefits, including a number of prescription expenses. The insurer raised a causation argument as the claimant’s medical history was littered with previous MVAs and workplace injuries. The claimant countered by noting the insurer previously approved treatment, which would suggest the insurer accepted the subject motor vehicle accident as the cause of the claimant’s impairments. Adjudicator Christopher Ferguson reviewed the medical evidence and determined the MVA was the cause of the claimant’s injuries. Since the insurer did not object to the reasonableness of medication claimed, the medication was considered payable. The treatment sought, however, was consider not payable as the claimant failed to prove the treatment was reasonable and necessary.

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