Category: Medical Benefits

Applicant v. TTC Insurance Company Limited (17-002561)

The claimant sought a declaration that she suffered a catastrophic impairment as a result of the accident, and entitlement to a psychological paper review. The claimant had submitted two OCF-19s – the first alleged a catastrophic impairment due to a 55 percent Whole Person Impairment; the second alleged a catastrophic impairment due to a Class 4 marked impairment. Adjudicator Bickley held that the claimant suffered a catastrophic impairment due to two Class 4 marked impairments, in social functioning and adaptation. She rejected the arguments regarding a 55 percent WPI, and held that the claimant’s injuries amounted to a maximum of 46 percent. In terms of the Class 4 marked impairments, Adjudicator Bickley preferred the evidence of the claimant’s experts due to the consistency and explanation in the report, and the expert’s consultation with the claimant’s family members. She also found that the surveillance tended to support the claimant’s submissions regarding social isolation and lack of independence. The claimed treatment plan was not awarded because it appeared to be proposed for the purpose of supporting the tort claim rather than the accident benefits claim.

Applicant v. Aviva Insurance Company (17-001007)

The claimant sought removal from the MIG and entitlement to two treatment plans for physical therapy. Adjudicator Watt held that the claimant’s injuries fell within the MIG and wrote that the claimant had not explained why her pre-existing obesity, hypertension, and sciatic nerve problems would prevent maximal recovery under the MIG. He favoured the opinions of the insurer’s assessors, and noted that the claimant had returned to work within five months of the accident. Adjudicator Watt also wrote that the proposed treatment plans were not reasonable and necessary because the description of the claimant’s injuries were inconsistent with the claimant’s actual injuries.

Applicant v. Aviva Insurance Canada (16-003323)

The claimant sought entitlement to non-earner benefits, as well as a number of medical treatment plans. The insurer denied entitlement to all claims. Adjudicator Rebecca Hines reviewed the medical evidence and determined the claimant failed to prove the treatment plans were reasonable and necessary, and also failed to establish a complete inability to carry on a normal life. All of the claims were dismissed.

C.W. v. Unifund Assurance Company (16-003336)

The insurer sought reconsideration of the Tribunal’s decision that the claimant’s injuries were non-minor due to a partial shoulder tear and pre-existing back pain. Executive Chair Lamoureux dismissed the reconsideration. She held that the Tribunal’s decision was based on the evidence before it and that the Tribunal was entitled to weight the contradicting evidence as it saw fit. Executive Chair Lamoureux was not satisfied that there was a significant error of fact or law.

Applicant v The Guarantee Company of North America (17-002558)

The applicant sought medical benefits for physiotherapy services. The respondent brought a motion to strike the applicant’s reply. The applicant filed a response to the motion to strike a day after the deadline. Adjudicator Goela held that despite being late, she would consider the applicant’s response as it did not prejudice the respondent. Adjudicator Goela further held that the applicant’s reply was struck because the applicant used the reply to introduce new information and arguments that should have been addressed in her initial submissions. The adjudicator also held that the applicant was also not entitled to the medical benefits sought as the treatment plans were related to injuries from a previous accident.

C.W. v. Unifund Assurance Company (16-003336)

The insurer sought reconsideration of the Tribunal’s decision that the claimant’s injuries were non-minor due to a partial shoulder tear and pre-existing back pain. Executive Chair Lamoureux dismissed the reconsideration. She held that the Tribunal’s decision was based on the evidence before it and that the Tribunal was entitled to weight the contradicting evidence as it saw fit. Executive Chair Lamoureux was not satisfied that there was a significant error of fact or law.

A.R. v. Wawanesa Mutual Insurance Company (17-000149)

The claimant sought entitlement to two proposed orthopaedic assessments. Adjudicator Msosa denied both assessments. He first wrote that without the treatment plans before him, he could not determine whether they were reasonable. He also accepted the opinion of the insurer’s expert that the claimant had not sustained orthopaedic injury in the accident and there was no medical or rehabilitative value to an orthopaedic assessment for the claimant’s soft tissue injuries.

A.R. v. TD General Insurance Company (16-003487)

The claimant sought interest on re-instated IRBs and entitlement to an orthopaedic mattress. The insurer opposed paying interest, arguing that the claimant had not provided evidence earlier in her claim supporting IRB entitlement. Adjudicator Maedel held that once the insurer re-instated IRBs, the claimant was entitled to interest for the period IRBs had not been paid. He rejected the claim for a mattress because the claimant had not provided any explanation how the mattress related to her specific injuries, and had not provided the Tribunal with the treatment plan itself.

Applicant v. Traditional Mutual Insurance Company (17-002734)

The claimant sought entitlement to a psychological assessment. Adjudicator Norris held that the proposed assessment was reasonable and necessary. He relied upon the claimant’s consistency of reporting, prescription for antidepressants, and more than one medical practitioner opining that the claimant may suffer a psychological disorder.

Applicant v. Allstate Insurance Company (16-004309)

The claimant sought entitlement to ongoing NEBs and two proposed treatment plans for physiotherapy. Adjudicator Baker denied entitlement to NEBs but awarded the treatment plans. In terms of NEBs, Adjudicator Baker wrote that the claimant had submitted only limited evidence about his pre-accident and post-accident life, which did not support entitlement to NEBs. He also wrote that the activities set out in the insurer’s IE (as reported by the claimant) suggested that the claimant did not suffer a complete inability to live a normal life. In terms of the treatment plans, Adjudicator Baker held that further physical therapy was reasonable and necessary for the claimant’s soft tissue pain particularly given that it allowed the claimant to be more active in her day to day tasks.