Category: Medical Benefits

J.S. v. Aviva General Insurance Company (16-002529)

The claimant sought entitlement to a treatment plan. The insurer asserted the treatment plan was not reasonable a necessary. The insurer also objected to evidence supplied by the claimant’s OT, as it was not disclosed at the case conference. Adjudicator Sandeep Johal ruled that the inclusion of more documentation on the part of the claimant did not prejudice the insurer and allowed the testimony. However, on review of the evidence, the treatment plan was physical-based and the claimant’s aliments, psychological; the plan was deemed not reasonable and necessary and not payable.

R.B. v. Aviva Insurance Canada (17-001238)

The claimant sought entitlement to a number of treatment plans the insurer denied. On review of the medical evidence, Adjudicator Billeh Hamud held that some of the plans were payable. The treatment plans that were denied were denied due to a lack of evidence substantiating the plans as reasonable a necessary. While the claimant sought a special award, no award was granted given that no evidence was tendered to support the claim.

D.G. v. Allstate Insurance Company of Canada (17-001641)

The claimant sought entitlement to one treatment plan for physiotherapy services. The respondent relied upon the orthopaedic IE report of Dr. Yousif, in which he concluded that the claimant did not require further treatment. The claimant provided only two documents with his written submissions: the Motor Vehicle Accident Report prepared by the police and the OCF-18 in dispute, which provided no information with respect to the claimant’s prognosis. Adjudicator Maedel found the IE report more comprehensive and persuasive than the claimant’s evidence, given the scope and detail provided. The adjudicator concluded that the claimant was not entitled to the medical benefit, as he had not met his onus of establishing that the disputed treatment plan was reasonable and necessary.

Applicant v. Aviva Insurance (17-000760)

The non-MIG claimant sought entitlement to various medical benefits and examinations. Adjudicator Maedel rejected all of the claims. He accepted the opinions of the insurer’s assessors over the claimant’s assessors due to the specificity of testing and multiple examinations of the claimant. He also wrote that the claimant’s submissions often lacked specific evidence in support of the need for the claimed medical benefits.

Applicant v. Aviva Insurance (17-001023)

The claimant sought entitlement to IRBs and various medical benefits. Adjudicator Sewrattan held that the claimant did not suffer a substantial inability to engage in his pre-accident work (he admitted to being able to drive, which was a major component of his job). He also held that the claimant was not entitled to proposed assessment or psychological treatment, but that two treatment plans for physical therapy were reasonable and necessary. The insurer was denied costs despite the claimant providing materials late, ignoring the page limit on written submissions, refusing to provide relevant records, and failing to abide by the Tribunal’s timelines.

G.R. v. Aviva Insurance Canada (17-001146)

The claimant sought entitlement to a number of medical treatment plans. On review of the medical evidence, Adjudicator Chris Sewrattan determined that the claimant suffered from both physical and psychological impairments, and that a choice was available with respect to the modality of treatment to reduce pain. Pain relief and increasing strength were considered reasonable and necessary goals of the treatment. The treatment plans aimed at achieving these goals were awarded with interest in accordance with section 51.

Applicant v. Motor Vehicle Accident Claims Fund (17-000665)

The claimant sought removal from the MIG and entitlement to various medical benefits for physical therapy and psychological therapy. Adjudicator Markovits held that the claimant was suffering from an adjustment disorder with mixed anxiety and depressed mood, and that his injuries were therefore non-minor. In terms of the medical benefits sought, Adjudicator Markovits awarded all of the claimed physical therapy and orthopaedic assessment; he denied part of the proposed psychological treatment, a driving re-integration assessment, and a chronic pain assessment.

D.A. v. The Personal Insurance Company (17-001941)

The claimant sought a determination that his impairments were outside of the MIG and entitlement to various medical benefits and costs of examinations. As a preliminary issue, the claimant requested to know the number of reports that each of the IE assessors had provided to the respondent for the last three years and the cost of each report. Adjudicator Paluch denied the claimant’s request for production. He failed to see how information about how many times a particular assessor has been retained by an insurer or how much the report cost would be relevant in assisting the claimant in satisfying that his injuries are not minor or that the proposed treatments are reasonable and necessary. The more appropriate forum to impugn the objectivity of an expert is at a live hearing, not a written preliminary issue hearing.

Applicant v. Aviva Insurance Company of Canada (16-001934)

The claimant sought entitlement to a chronic pain assessment. The insurer denied the assessment. Adjudicator Chris Sewrattan referenced a previous decision in the same matter where it was held that it was reasonably possible the claimant suffered from chronic pain syndrome. Based on the medical evidence, Adjudicator Sewrattan reasoned that a chronic pain assessment was the only way to determine if the claimant indeed suffered from chronic pain and whether further treatment was needed. The assessment was deemed payable with interest in accordance with section 51 of the SABS.

Applicant v. Aviva Insurance Company of Canada (16-001934)

The claimant sought entitlement to a chronic pain assessment. The insurer denied the assessment. Adjudicator Chris Sewrattan referenced a previous decision in the same matter where it was held that it was reasonably possible the claimant suffered from chronic pain syndrome. Based on the medical evidence, Adjudicator Sewrattan reasoned that a chronic pain assessment was the only way to determine if the claimant indeed suffered from chronic pain and whether further treatment was needed. The assessment was deemed payable with interest in accordance with section 51 of the SABS.