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.
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.
The claimant sought entitlement to a number of medical benefits. The insurer asserted the treatment plans were not reasonable and necessary. Adjudicator Christopher Ferguson reviewed the medical evidence, and concluded that on a balance of probabilities the proposed treatment plans were reasonable and necessary. Interest on all incurred amounts was also found payable.
The claimant sought entitlement to various medical benefits; the insurer sought repayment of IRBs due to overpayment of the weekly quantum. Adjudicator Treksler held that the claimant failed to provide evidence that the claimed physical therapy and assessments were reasonable and necessary. She ordered the claimant to repay the overpayment in IRBs, stating that the insured had complied with all of the requirements of section 52 and the claimant had not shown that any exception to repayment applied.
The claimant sought entitlement to eight treatment plans for further assessments and treatment. Adjudicator Gosio rejected all of the claimed benefits, writing that the claimant had simply repeated the contents of the treatment plans as the justification as to why they were reasonable and necessary. On the other hand, the insurer had provided the opinions of four IE assessors, who each concluded that the proposed benefits were not reasonable and necessary.
The claimant sought entitlement to a number of medical benefits. In addition to a MIG position, the insurer asserted that the claimant was barred from bringing a claim as notice to claim accident benefits was not provided within seven days (or reasonably thereafter) of the MVA, pursuant to sections 32 and 55. Adjudicator S.F. Mather reviewed the circumstances leading up to the claimant providing an application for accident benefits three months following the MVA and determined that the time it took to bring the claim was not unreasonable. Although the application was incomplete, Adjudicator Mather ruled it was reasonable to obtain the missing information on review of the overall claim. With respect to the medical benefits claimed, Adjudicator Mather ruled that the notice letters did not take a position on the MIG and did not provide medical reasons for the denial. As a result, the insurer was precluded from taking a MIG position, and therefore must pay for the treatment plans claimed. No discussion of whether the treatment was reasonable was needed, since the provisions make it clear an insurer shall pay for treatment it fails to provide notice to, until the notice is cured. Therefore the treatment plans claimed were deemed payable.
The claimant sought entitlement to a number of medical benefits. The insurer asserted that the treatment plans were not reasonable and necessary and that one plan was partially approved in accordance with the Professional Service Guidelines. Adjudicator Therese Reilly, on review of the evidence, found none of the claimant’s claims payable. The PSGs were accepted as the appropriate cap on services and therefore the partial approval by the insurer was correct. The remaining claims were not substantiated by the claimant and deemed not reasonable and necessary.
The claimant sought entitlement to a number of treatment plans, both psychological and physical-based. The insurer asserted a MIG position. On review of the medical evidence, Adjudicator Paul Gosio determined the claimant established the injuries sustained were outside the MIG by virtue of a psychological report, which was not rebutted by the insurer. As a result, the psychological treatment plans were deemed reasonable and necessary, along with a chronic pain and one chiropractic plan.
The claimant sought entitlement to a number of treatment plans. The insurer asserted a MIG position and also raised a limitation defense to one of the treatment plans. Adjudicator Billeh Hamud reviewed the denial letter of the insurer and found it to be clear and unequivocal. However, Adjudicator Hamud also noted that the claimant established a pre-existing injury that prevented recovery within the MIG; namely chronic pain from a previous MVA. Accordingly, the non-limitation barred treatment plans were found payable.
The claimant sought entitlement to three additional assessments related to a catastrophic impairment determination. The insurer denied them as being duplicative and unreasonable. Adjudicator Johal held that the in order to be payable, the proposed catastrophic impairment assessment had to be reasonable and necessary. Each proposed assessment was to be examined on that standard. Adjudicator Johal held that two of the proposed assessments were reasonable and necessary, but that no evidence was provided supporting the third assessment. The adjudicator also held that a maximum of $2,000 was to be paid for each proposed assessment. She denied a special award, stating that the insurer had based its denial on two paper review IEs and that it was not unreasonable for the insurer to do so.
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Toronto, Ontario M5H 3S5
416.507.1850
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150 York Street, Suite 1800
Toronto, Ontario M5H 3S5
416.507.1850