The claimant sought entitlement to non-earner and medical benefits. On review of the evidence, Adjudicator Brian Norris concluded the claimant failed to meet the burden of proof for NEBs. After reviewing each treatment plan, it was held that all but one were not reasonable and necessary. The claims, with the exception of the one treatment plan, were dismissed.
The insurer appealed a ruling in which the claimant was awarded an orthopaedic assessment. The insurer argued that the assessment was available through OHIP, and therefore not payable under the SABS. Executive Chair Lamoureux rejected the reconsideration. She held that the obligation was on the insurer to advance evidence establishing that a benefit at issue was available through a collateral source (such as OHIP), and could not rely upon bare assertions. No evidence was presented about what benefits OHIP covered or the speed at which the claimant could obtain such an assessment through OHIP.
The claimant sought entitlement to various medical benefits. Adjudicator Sewrattan dismissed all of the claims, holding that the claimant had not demonstrated that the proposed treatment was reasonable and necessary. He also noted that the claimant had refused to provide her collateral benefits entitlement information and that he was unable to determine if any of the benefits would have been payable by the insurer. Finally, the adjudicator ruled that one proposed assessment was barred by the two-year limitation period.
The insurer appealed a ruling in which the claimant was awarded an orthopaedic assessment. The insurer argued that the assessment was available through OHIP, and therefore not payable under the SABS. Executive Chair Lamoureux rejected the reconsideration. She held that the obligation was on the insurer to advance evidence establishing that a benefit at issue was available through a collateral source (such as OHIP), and could not rely upon bare assertions. No evidence was presented about what benefits OHIP covered or the speed at which the claimant could obtain such an assessment through OHIP.
The claimant’s husband sought reimbursement for mileage incurred while visiting the claimant and transporting the claimant. Adjudicator Reilly held that the husband was, in fact, an aide because he transported the claimant, and that the proper mileage rate for him as an aide was $0.40 per kilometer per the Transportation Expense Guideline.
The claimant sought entitlement to various medical benefits and assessments. Adjudicator Harmison rejected all of the claims. In general, she preferred the evidence of the IE assessors, and noted that the family doctor’s records did not comport with the position put forward by the claimant’s assessors. She also wrote that the claimant had approved treatment that he had not consumed, and that the request for further treatment plans was inconsistent with his cessation of treatment.
The claimant sought entitlement to a treatment plan that had not been submitted through HCAI. Adjudicator Watt concluded that the treatment plan was not payable because the claimant had failed to submit the plan in accordance with the Superintendent’s Guideline.
The claimant sought entitlement to one treatment plan for rehabilitation therapy. The claimant argued that the treatment plan was reasonable and necessary, and that as the respondent had failed to respond to the treatment plan within the required ten days under the SABS, it should be deemed paid under section 38(11) of the SABS. The respondent argued that the treatment plan was not reasonable and necessary, and that as the expense sought under the treatment plan was not incurred, it was not payable. Adjudicator Watt agreed with the insurer, and concluded that the treatment plan was not reasonable and necessary as the claimant was not suffering from any accident related impairments. The adjudicator also noted that given the lack of evidence to show that the claimant actually incurred the expenses relating to the proposed treatment plan, he had no entitlement to that amount from the respondent.
The insurer approved a portion of the cost of a proposed psychological assessment based on an IE assessor’s view on the appropriate hourly rate to conduct the assessment. The claimant sought the remainder of the proposed amount. Adjudicator Ferguson accepted the insurer’s arguments and held that the remainder of the treatment plan was not payable. He further held that the insurer’s late denial did not result in the automatic payment of the assessment, because a proper denial was provided to the claimant prior to the assessment taking place.
The claimant sought entitlement to a chronic pain program and an orthopaedic assessment. Adjudicator Hans awarded both benefits and wrote that he preferred the evidence from the claimant’s experts over the opinions of the insurer’s experts. In particular, he found the claimant’s experts’ reports to be more thorough in analysis and recommendation. He also did not find the surveillance persuasive as it was taken more than six months after IE assessments.
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150 York Street, Suite 1800
Toronto, Ontario M5H 3S5
416.507.1850
© 2020 Thomas Gold Pettingill LLP