Category: Medical Benefits

Applicant v. RSA Insurance (17-000233)

The claimant disputed his entitlement to income replacement benefits (IRBs), medical benefits and the MIG. Adjudicator Treksler concluded that the claimant’s injuries fell outside of the MIG due a post-accident psychological impairment and diagnosis of chronic pain syndrome. In her reasons, Adjudicator Treksler noted that she preferred the evidence of the claimant’s family physician to the IE assessors and concluded that there was sufficient evidence in the claimant’s clinical notes and records of a psychological impairment and chronic pain syndrome to warrant the claimant’s removal from the MIG. Adjudicator Treksler also found that the disputed psychological assessment was payable. With respect to his dispute over IRBs, Adjudicator Treksler concluded that the claimant met the pre-104 week IRB disability test. Adjudicator Treksler noted that the claimant’s pre-accident employment was physical in nature and concluded that she preferred the s. 25 assessors’ conclusions that the claimant could not return to work to the opinions of the s. 44 assessors.

A.M. v. State Farm Mutual Automobile Insurance Company (16-003519)

The claimant sought entitlement to two treatment plans for dental work. Adjudicator Gosio rejected both claims. He held that the claimant had not submitted medical evidence in support of the claim (such as clinical notes and records, medical reports, or the treatment plans themselves) and that his counsel’s submissions were not evidence. Adjudicator Gosio also noted that the claimant’s dental pain appeared to have started four years prior to the motor vehicle accident.

C.R. v. Scottish & York Insurance Company (16-002077)

The claimant sought removal from the MIG and entitlement to one treatment plan. Adjudicator Anwar held that the claimant’s suffered pre-existing conditions that would prevent maximal recovery under the MIG and development of chronic pain. He relied upon the expert reports completed for the claimant, which detailed pre-existing injuries. The insurer argued that the Tribunal could not remove the claimant from the MIG without actually receiving and reviewing the clinical records from the claimant’s physician (which had not been provided to the insurer either). Adjudicator Anwar disagreed with the insurer, and wrote that the claimant’s experts had sufficiently detailed the pre-existing issues. He also noted that the insurer had not made any attempt to obtain the claimant’s clinical notes and records at any point (including the Case Conference). The adjudicator did not award the claimed treatment plan because the claimant did not explain what made the passive treatment reasonable and necessary, particularly given the claimant’s failure to respond to earlier passive treatment.

Applicant v. Aviva Insurance Canada (17-002689)

The claimant sought entitlement to a medical treatment plan. Adjudicator Derek Grant reviewed the medical evidence and noted that the mere submission of a treatment plan is not enough to establish entitlement. Rather, supporting medical documentation, recommending the treatment sought is critical. In this matter, the claimant failed to provide the necessary supporting evidence and as a result, the treatment plan was found not payable.

Applicant v. Certas Direct Insurance Company (16-004675)

The claimant sought removal from the MIG and entitlement to two treatment plans. Adjudicator Sewrattan concluded that the claimant suffered minor injuries in the accident. He wrote that neither of the claimant’s experts had diagnosed the claimant with a psychological disorder or chronic pain. He also held that the insurer’s denials satisfied the requirements of section 38 of the SABS. Adjudicator Sewrattan went on to state that he would not have awarded the claimed treatment plans because the claimant did not suffer a psychological disorder, and the treatment plan for chronic pain did not specify what the goals of the proposed treatment were.

A.P. v. Dominion Insurance (17-001651)

The claimant sought entitlement to a treatment plan. The insurer denied payment and asserted a MIG designation. The claimant countered and argued the insurer failed to respond to the treatment plan within the prescribed time. Adjudicator Brian Norris reviewed the chronology of events and determined the insurer had responded to the treatment plan in time. Adjudicator Norris also determined that the claimant’s impairments were minor and that no pre-existing conditions warranted removal from the MIG. The claims were dismissed.

Applicant v. State Farm Insurance Company (16-004031)

The claimant sought entitlement to income replacement benefits as well as psychological treatment plans. The insurer denied IRBs and asserted the claimant’s inability to resume working was due to a pre-existing injury and not an MVA-related impairment. The psychological treatment was denied by the insurer as being not reasonable and necessary. Adjudicator Deborah Neilson reviewed the medical evidence and noted that neither party tendered evidence from medical practitioners that addressed the claimant’s pre-existing conditions. Moreover, the claimant did not testify. Accordingly, it was held that the claimant failed to establish her impairments were directly as a result of the accident and prevented her from working. In the alternative, Adjudicator Neilson determined that the claimant failed to establish that she was substantially unable to resume working. As it pertained to the claim for psychological treatment, Adjudicator Neilson found that the treatment plan was necessary to address the claimant’s issues; however, based on the fees listed by the provider the plan was deemed unreasonable and therefore not payable.

Applicant v. Wawanesa Mutual Insurance Company (17-002337)

The claimant sought entitlement to a number of medical benefits, as well as income replacement and attendant care benefits. The insurer denied entitlement and also asserted a MIG position. Adjudicator Christopher Ferguson reviewed the medical evidence and determined that no compelling evidence was tendered by the claimant to support entitlement to any of the benefits claimed. The MIG was said to govern the claimant’s impairments and the matter dismissed.

Y.B. v. Aviva Insurance Canada (17-003257)

The claimant sought entitlement to two treatment plans. The insurer denied the plans and asserted neither was reasonable and necessary. The claimant also asserted that the IEs commissioned should have been paper reviews, and therefore not applicable to the insurer’s determination. Adjudicator Christopher Ferguson, on review of the medical evidence, determined that neither treatment plan was reasonable and necessary. The assertion that a paper review IE should have been commissioned, rather than in-person examination, was also rejected.

B.T. v. St. Paul Fire and Marine Insurance Company(17-000086)

The claimant sought entitlement to IRBs and costs of examinations. As a preliminary issue, the respondent argued that the claimant was barred from appealing her claims as she had not followed the procedures for claiming accident benefits under section 32 of the SABS. The claimant did not file a claim for accident benefits until July 2016, two and a half years after the subject accident. No explanation for the delay was provided. Adjudicator Ferguson concluded that the respondent was not required to pay the claimant’s claim for IRBs, as she did not comply with the prescribed procedures for claiming accident benefits. However, the amounts incurred with respect to the costs of examinations were payable pursuant to section 38(11). The claimant filed two assessment plans in June 2016 which the respondent did not deny.