Category: Medical Benefits

Applicant v. Aviva Insurance Company (17-001173)

The claimant sought entitlement to IRBs and medical benefits. The insurer asserted the claimant’s impairments were as a result of an intervening factor, namely a slip and fall, rather than the MVA. Adjudicator Catherine Bickley found the claimant to be a credible witness and attributed her impairments to the MVA. It was also noted that the claimant was receiving CPP disability benefits. The record indicated that she attempted to work two different jobs post-MVA but was unable to continue due to pain. On review of the medical evidence, Adjudicator Bickley concluded that the claimant had met the disability test for income replacement benefits and awarded the benefits ongoing, with interest. However, little evidence was tendered to show entitlement to the claimed medical benefits, and therefore the treatment plans were deemed not payable.

E.D. v. Aviva Insurance Canada (17-002048)

The claimant was an elderly pedestrian knockdown and claimed entitlement to non-earner benefits, attendant care, and a number of medical treatment plans. Adjudicator Christopher Ferguson was critical of the evidence led by the claimant and remarked “The applicant made no submissions in this matter: she advanced no discussion or argument respecting the evidence that she provided, nor did she reply to the respondent’s submissions. Her evidence consisted of her personal affidavit, a chronic pain assessment, and treatment and assessment plans for medical benefits.” It was held that the claimant failed to provide sufficient evidence to justify entitlement to any of the benefits claimed.

Applicant v. Travelers Canada (17-002177)

The claimant sought entitlement to a number of medical treatment plans. The insurer asserted a MIG designation. Adjudicator Avvy Go reviewed the medical evidence submitted and concluded that the claimant had failed to meet the burden of proof necessary to remove a MIG designation from her claims. All of the claimed treatment plans were dismissed.

N.R. v. Pembridge Insurance Company (16-003776)

The claimant sought entitlement to NEBs, ACBs, and medical benefits. Adjudicator Hans rejected all of the claims. In terms of NEBs, the adjudicator wrote that the claimant failed to provide evidence of his pre-accident activities and that without such information, entitlement to NEBs could not be proven. In terms of ACBs, the adjudicator wrote that the claimant’s expense forms did not prove that the attendant care services were incurred. In particular, the adjudicator was critical of the lack of specificity or details as to the days or services provided, and the fact that the expense forms were completed months after the services were allegedly provided. Finally, the medical benefits for dental work were denied because the claimant had not proven that he sustained a dental injury in the accident.

S.H. v. Gore Mutual Insurance Company (17-002632)

The claimant sought entitlement to a medical treatment plan for optometrist services. The insurer denied the treatment plan and relied on an IE assessment which noted the claimant’s eye issues were not as a result of the MVA. Adjudicator Avvy Go reviewed the medical evidence and determined that the claimant’s eye impairment was a direct result of the accident. Accordingly, the treatment plan was found payable.

Applicant v. Aviva Insurance Canada (17-001822)

The claimant sought entitlement to IRBs and a chronic pain assessment. Adjudicator Hines accepted that the claimant suffered a substantial inability to perform the essential tasks of her pre-accident employment as a sales representative. She preferred the medical opinions of the claimant’s assessors over the insurer’s assessors due to inconsistencies and lack of analysis in the IE reports. The adjudicator was also unswayed by surveillance evidence showing the claimant working at a restaurant, reasoning that the claimant’s pre-accident work was dissimilar enough from the work at the restaurant. The insurer was entitled to deduct any post-accident earnings from the claimant’s IRB. Finally, the claimed chronic pain assessment was awarded as being reasonable and necessary.

Applicant v. Royal Sun Alliance (17-001315)

The claimant sought entitlement to a treatment plan, which the insurer denied due to a MIG determination. The claimant asserted the insurer failed to comply with the Notice provisions of section 38 and that the claimant’s pre-existing psychological impairments warranted removal from the MIG. Adjudicator Gemma Harmison determined that the insurer failed to comply with section 38, by not providing Notice within 10 business days. In reviewing the chronology of events, it was noted that despite the date of the correspondence from the insurer, the fact that it was mailed added an additional five business days, thus falling outside the prescribed timelines. Accordingly, the insurer was barred from taking a MIG position. However, because none of the disputed treatment was incurred during the period following, no amounts were found payable. Instead, the treatment plan was evaluated on whether it was reasonable. On review of the evidence, the plan was deemed not reasonable and necessary.

Applicant v. State Farm Mutual Automobile Insurance Company (16-004375)

This was an amended decision from a previous ruling in which the claimant sought entitlement to a number of medical treatment pans. On review of the medical evidence, Adjudicator Avvy Go determined the treatment plans were reasonable and necessary. Additionally, interest was awarded on the overdue payment of benefits.

Applicant v. Travelers Insurance (16-003313)

The claimant sought entitlement to a number of medical benefits. Adjudicator Paul Gosio, on review of the medical evidence, determined that the treatment sought was reasonable and necessary.

P.M. v. RBC General Insurance Company (16-001611)

The claimant suffered a finger fracture in the accident. He was new to Canada and did not understand the accident benefits system. He first applied for EI, which was denied; he appealed and lost again. He first applied for accident benefits eight months after the date of loss. The insurer argued that the claimant did not have a reasonable explanation for his delay and could not claim accident benefits. Adjudicator Gottfried followed FSCO case law regarding late applications and concluded that the claimant did have a reasonable explanation for his late application, and that he could claim accident benefits. He was found entitled to IRBs based on his injuries from the date of his first OCF-3 up to the 104 week mark. IRBs beyond that date were denied. Various medical benefits were paid by the insurer. Adjudicator Gottfried held that claims for HST on proposed medical benefits were also payable.