The claimant sought entitlement to a number of medical benefits. On review, Adjudicator Christopher Ferguson determined that a number of treatment sought exceeded the monetary value claimed in the treatment plans, as well as in the Professional Service Guideline. Where the claims exceeded the PSGs, the treatment was not awarded. However, the remaining treatment plans, on review of the medical evidence were deemed reasonable and necessary.
The claimant sought entitlement to IRBs and a number of treatment plans. Adjudicator Jeffrey Shapiro, on review of the medical evidence, as well as surveillance and employment records, noted that the claimant’s self-reporting was unreliable and had “failed to timely, honestly and accurately disclose his multiple actual returns to work and his ability to work.” As it pertained to the treatment plans sought, Adjudicator Shapiro concluded the claimant had failed to establish removal from the MIG was warranted. All claims were dismissed.
The claimant sought entitlement to treatment in the form of physical rehabilitation and acupuncture services. Adjudicator Cezary Paluch reviewed the medical evidence and determined that the injuries asserted by the claimant were as a result of the accident. On further review, the treatment sought was also deemed reasonable and necessary; the claims were found payable with applicable interest.
The claimant sought entitlement to attendant care benefits and two treatment plans. Adjudicator Billeh Hamud reviewed the medical evidence and determined that the claimant was independent with his day to day activities and was functional to the point that attendant care benefits were not reasonable and necessary. In the alternative, Adjudicator Hamud also determined that the claimant did not satisfy that his wife, and reported service provider, suffered an economic loss. Moreover, the claimant failed to provide sufficient evidence to justify payment of the two treatment plans. All of the claimant’s claims were dismissed.
The claimant sought entitlement to three medical benefits for physiotherapy and chiropractic treatment. After reviewing the available medical evidence, Adjudicator Fricot held that the requested treatment plans were not reasonable and necessary. More specifically, the claimant’s accident-related injuries had largely resolved, and Adjudicator Fricot determined that further treatment was not warranted.
The claimant sought entitlement to an orthopedic assessment at a cost of $2,912.00. The insurer asserted the claim was governed by the MIG and that the maximum allowable fee for an assessment was $2,000.00. Adjudicator Blaine Baker determined that since the claimant had broken her arm, the MIG did not apply. On review of the fees for the treatment plan, Adjudicator Baker concluded that the proposed fees were all payable. While $2,000.00 is a cap on assessments, travel (in this case $400.00), the cost of preparing the treatment plan (in this case $200.00) and HST (in this case $312.00) were also recoverable above the assessment cap. The treatment plan was deemed reasonable and payable in full.
The claimant sought entitlement to two chiropractic treatment plans as well as an attendant care assessment. The insurer denied the claims and asserted none were reasonable and necessary. Adjudicator Marisa Victor determined that the claimant failed to provide sufficient medical evidence to establish the treatment plans were reasonable and necessary. Adjudicator Victor also favoured the medical evidence tendered by the insurer, and deemed an attendant care assessment not reasonable. The claims were dismissed.
The claimant sought entitlement to eight treatment plans for various physical and psychological treatment and assessments. Adjudicator White denied entitlement to all of the claims. She held that the claimant had sustained relatively minor injuries in the accident. She was critical of the claims for in-home treatment and the proposal for various assistive devices as not being supported by any evidence. She accepted the recommendations of the insurer’s assessors that further treatment was not reasonable and necessary.
The claimant sought entitlement to a number of medical benefits for physical and psychological treatment. The insurer asserted a MIG position. Adjudicator S.F. Mather, on review of the medical evidence, determined the claimant’s injuries fell outside of the MIG. The treatment plans that addressed the injuries removing the claimant from the MIG were found payable, while the remainder of the plans were dismissed. During the course of the proceedings, the claimant sought to add jurisprudence claiming the MIG was unconstitutional; however, Adjudicator Mather denied the adding of the case law to the book of authorities, since to do so would import a constitutional question without the proper notice to the Attorney General’s office.
The claimant sought entitlement to attendant care benefits and a number of treatment plans. Adjudicator Eleanor White reviewed the claimant’s submissions for attendant care and noted that no evidence was provided showing that attendant care had been incurred. Accordingly, Adjudicator White determined that regardless of a determination regarding the reasonableness and necessity of the claimant’s attendant care claim, it was “without effect as he cannot prove the care was incurred for the period in question.” The treatment plans claimed were also denied as the medical evidence tendered did not support entitlement.
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150 York Street, Suite 1800
Toronto, Ontario M5H 3S5
416.507.1850
© 2020 Thomas Gold Pettingill LLP