Category: Medical Benefits

The Applicant v. Aviva General Insurance (17-004239)

The claimant sought entitlement to one treatment plan for chiropractic treatment. Adjudicator Treksler concluded that although the claimant had been diagnosed with whiplash as a direct result of the accident, she had not provided any objective medical opinion to support that the chiropractic treatment would improve or resolve her injuries. The claimant was not entitled to payment of the treatment plan, as she had not shown that the treatment plan was reasonable and necessary.

Applicant v. Allstate Insurance Company (16-003204)

The claimant sought entitlement to a number of medical treatment plans. The insurer denied the plans based on IE reports. Adjudicator Brian Norris reviewed the medical evidence and determined that the treatment plans were not reasonable and necessary. The application was dismissed.

N.N. v. Allstate Insurance Company (17-000006)

The claimant sought entitlement to IRBs and three medical benefits. Adjudicator Hans concluded that as a result of the claimant’s physical impairments, he was substantially unable to perform the essential tasks of his employment as a marble shop worker. The Adjudicator was not persuaded by the respondent’s argument that the claimant was able to work as a taxi driver, as the analysis must focus on the claimant’s pre-accident employment as a marble shop worker. The medical benefits for physiotherapy and assistive devices were found not reasonable and necessary.

Applicant v. The Co-operators General Insurance Company (16-003478)

The claimant and the insurer disagreed on the amount payable to a case manager. The claimant sought $150 per hour; the insurer argued that the Professional Services Guideline capped the hourly rate at $89.07. Adjudicator Maedel concluded that the PSGs applied to the services provided to the claimant, and that $89.07 was the maximum payable. Central to the decision was the determination that the claimant’s case managers were “qualified case managers” despite also being Registered Social Workers. Although the case managers had such professional designations, the services provided were in the nature of case management.

J.M. & N.M. v. RBC General Insurance Company (17-001227 & 17-001283)

The claimants, two adult children whose mother was seriously injured in a motor vehicle accident, sought entitlement to one treatment plan each for social work assessments. The claimants failed to attend IEs. The claimants took the position that they were not required to attend the IEs because the treatment plans were automatically payable on the basis that RBC did not approve or deny the OCF-18s within 10 business days. Adjudicator Sewrattan concluded that the respondent was not required to pay for the assessments incurred by each of the claimants, as the claimants had incurred the expense prior to the expiry of the 10 day period. The expenses were thus incurred before the respondent could reasonably approve or deny the expense, and the claimants were precluded from applying to the LAT pursuant to section 55 of the SABS.

S.Y. v .Aviva General Insurance Company (16-004549)

The claimant sought entitlement to medical benefits. Some of the treatment plans were not included as original issues in dispute, others were already paid by the insurer. Adjudicator Anna Truong reviewed the medical evidence and determined that two treatment plans were reasonable, while a psychological treatment plan was not. Other treatment plans were denied due to limitations. Interest was awarded on the two reasonable treatment plans, if there was any overdue payment.

C.F. v. Aviva Insurance Canada (16-002373)

The claimant sought entitlement to a number of treatment plans. The insurer asserted a MIG position and noted one treatment plan to be limitations barred. Adjudicator Avvy Go noted the burden rested with the claimant and that the evidence tendered did not tie any specific impairment to the MVA. Moreover, the impairments were described as “mild or degenerative” in nature. The MIG was said to govern. The insurer noted that one treatment plan, while approved, lacked information requested under section 33 regarding a collateral benefits payer and as such was not payable until complied with. The claimant sought payment; however, Adjudicator Go noted the timing of the LAT application was beyond the 2 year period. The claimant was limitations barred from seeking payment.

F.P. v. Aviva Insurance Company (16-002861)

The claimant sought entitlement to further medical benefits and a special award; the insurer argued that the claimant had failed to attend IEs and that the benefits were not reasonable and necessary. Adjudicator Treksler concluded that the insurer’s request for IEs was not reasonable given that only one year had passed since the last IEs in this decade-long claim. She also concluded that the medical benefits sought were reasonable and necessary to treat the claimant’s chronic pain. Adjudicator Treksler also held that a special award was payable because the insurer had delayed payment of the claimed medical benefits by ignoring the potential pain relief that the treatment would provide the claimant and that requested assessments could provide further recommendations for pain relief.

M.H. v. Certas Direct Insurance Company (16-003657)

The claimant sought entitlement to non-earner benefits and a lone treatment plan. Adjudicator Rebecca Hines, on review of the medical evidence and surveillance, determined the claimant had not met the burden of proof to establish entitlement to non-earner benefits. The lone treatment plan was deemed payable as evidence did suggest the claimant was still dealing with MVA injuries.

S.S. v. RBC Insurance Company (17-000782)

The claimant sought entitlement to a medical treatment plan for physiotherapy. The insurer denied the plan as not reasonable and necessary. The insurer also noted that while the claimant was removed from the MIG on psychological grounds, the restrictions of the MIG applied to the physical treatment sought. Adjudicator Therese Reilly reviewed the medical evidence and determined the treatment plan claimed was not reasonable and necessary. The applicability of the MIG was therefore not considered. The claimant also sought a special award, which was not granted given the ruling on the benefits claimed.