Category: Medical Benefits

Applicant v. Aviva Insurance (16-002568)

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.

M.T.R. v. Aviva Insurance Canada (17-001721)

The claimant sought entitlement to non-earner and a number of medical benefits. On review of the claimant’s evidence, Adjudicator Christopher Ferguson determined that claimant did not meet the onus to prove a complete inability to carry on a normal life. Moreover, the treatment plans claimed were considered not reasonable and necessary.

Z.A. v. Aviva Insurance Canada (16-001928)

The claimant sought entitlement to physiotherapy. The insurer denied the treatment plan and asserted the treatment was not reasonable and necessary. Adjudicator Sandeep Johal reviewed the medical evidence and held that the claimant failed to meet the onus of proof. The treatment plan was deemed not reasonable and necessary.

Applicant v. RBC Insurance Company (16-002047)

The claimant sought entitlement to a number of medical treatment plans. The insurer asserted a MIG position. On review of the medical reports and evidence, Adjudicator Sandeep Johal concluded the claimant provided compelling evidence that the injuries sustained warranted removal from the MIG. The treatment plans were also considered reasonable and necessary. However, despite the claimant seeking a special award, Adjudicator Johal noted no evidence was tendered by the claimant to demonstrate the unreasonable withholding of benefits; the special award claim was dismissed.

Applicant v. Unifund Assurance Company (16-002346)

The claimant sought entitlement to three treatment plans. The insurer asserted the plans were not reasonable and necessary. Adjudicator Paul Gosio reviewed the medical evidence and concluded the treatment plans were reasonable and necessary. Although the claimant sought a special award, Adjudicator Gosio denied the claim and noted that “an insurer will not face a special award just because an arbitrator finds that the insurer got it wrong.”

Applicant v. Aviva Insurance (17-000612)

The claimant sought entitlement to a treatment plan for physical therapy. The insurer tendered medical evidence for the proposition that the claimant did not need further facility-based treatment. On review of the medical evidence, Adjudicator Derek Grant noted that while the claimant still experienced effects from the accident, the proposed treatment plan was not reasonable and necessary.

Applicant v. Certas Home and Auto Insurance Company (16-001905)

The claimant sought entitlement to IRBs and various medical benefits. Regarding IRBs, Adjudicator Bickley held that the claimant had failed to prove a substantial inability beyond three months, and also held that the claimant had failed to provide financial records supporting a higher weekly IRB quantum. The adjudicator made an adverse inference due to the claimant’s failure to provide requested financial records. In terms of the medical benefits, Adjudicator Bickley held that the claimant’s non-attendance at two IEs barred her from seeking a chronic pain treatment plan. Two other assessments were approved as being reasonable and necessary. The remaining treatment plans were denied. Finally, Adjudicator Bickley allowed the claimant to add a special award to her claim, but denied entitlement to such an award.

Applicant v. Wawanesa Mutual Insurance Company (16-001732)

The claimant sought entitlement to a number of medical treatment plans. The insurer asserted a MIG position. Adjudicator Robert Markovits reviewed the evidence and determined that there was compelling evidence of a pre-existing medical condition preventing recover within the MIG. The treatment plans were considered reasonable and necessary, with a psychological assessment capped at $2,000.00 pursuant to section 25(5)(a). However, an additional $200.00 was also payable for the completion of the OCF-18 pursuant to Superintendent’s Guideline No. 03/14.

B.C. v. Aviva Insurance Canada (17-001340)

The claimant sought entitlement to psychological treatment. Adjudicator Go agreed that it was reasonable and necessary. She was critical of the insurer’s IE report which did not specifically reference or review a psychological report provided by the claimant.

H.L. v. Co-operators General Insurance Company (17-006816)

The claimant sought entitlement to a medical treatment plans. The insurer was previously successful in a prior hearing and obtained a decision in which the claimant’s injuries were said to be governed by the MIG. The claimant further appealed that decision and a Divisional Court upheld the previous ruling. Accordingly, the insurer sought a preliminary motion to preclude the claimant’s new claim on the grounds of res judicata. Adjudicator Cezary Paluch reviewed the new claims of the claimant and determined that the claims were different than the previous arbitration. While it was acknowledged that the MIG was decided previously, Adjudicator Paluch noted that the claimant may have new grounds to warrant removal and thus it was too early to rule whether res judicata applied. As a result, the claimant was allowed to continue with the new claims.