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.
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.
The claimant sought entitlement to further medical benefits and removal from the MIG. Adjudicator Sewrattan concluded that the claimant had not proven an ongoing psychological injury or physical injury that fell outside of the “minor injury” definition. There was also insufficient evidence submitted by the claimant to prove that injuries arising from an earlier motor vehicle accident would prevent maximal recovery under the $3,500 minor injury limits. Entitlement to the claimed medical benefits was denied.
The claimant sought entitlement to one psychological treatment plan. The insurer denied the plan and cited the excessive progress report fees as one of the reasons the plan was not reasonable and necessary. Adjudicator Lori Marzinotto evaluated the Ontario Psychological Association Guidelines for Assessment and Treatment in Insurance Claims and agreed that the treatment plan was not reasonable and therefore not payable.
The claimant sought entitlement to a number of treatment plans. The insurer asserted a MIG defense. On review of the evidence, Adjudicator Nicole Treksler ruled the claimant’s injuries, including chronic pain, were outside of the MIG. The treatment sought was deemed payable. The claimant also sought costs for the insurer failing to provide log notes as requested. Costs were denied as the claimant did not sufficiently substantiate the claim under Rule 19.1.
The claimant sought entitlement to three medical benefits, including a vocational assessment. She was not employed at the time of the accident. Adjudicator Anwar awarded all three medical benefits on the basis of medical evidence showing potential lumbar spine injuries. He also awarded the vocational assessment reasoning that it was appropriate for the claimant to identify limitations and evaluate potential future career prospects.
The claimant sought entitlement to two treatment plans. The insurer denied the plans and cited insurer’s examination reports as justification. Adjudicator Christopher Ferguson reviewed the medical reports on both sides and noted contradictions in the claimant’s self-reporting. Additionally, one of the treatment plans sought was not included as evidence. The insurer’s evidence was considered more credible and the claims were deemed not payable.
The claimant sought removal from the MIG and entitlement to medical benefits. Adjudicator Ferguson held that the claimant suffered a concussion and post-concussion syndrome, which were not minor injuries. The claimant was therefore removed from the MIG. The sought medical benefits were denied because the claimant and his treatment providers had not explained how the proposed treatment would address and treat the concussion and post-concussion injuries.
The claimant sought entitlement to a psychological treatment plan. The insurer denied the treatment plan and cited a psychological insurer’s examination report as justification. Adjudicator Christopher Ferguson reviewed the medical reports on both sides and noted contradictions in the claimant’s self-reporting. The insurer’s evidence was considered more credible and the treatment plan was deemed not payable.
The primary issue in dispute was whether the claimant sustained a predominantly minor injury as a result of the accident. Adjudicator Neilsen explained that ongoing pain alone was insufficient to remove the claimant from the “minor injury” definition. Rather, she had to prove chronic pain syndrome. The ongoing pain had to be accompanied by some functional impairment. She wrote that a diagnosis of chronic pain without any discussion of the level of pain, its effect on the person’s function, or whether the pain is bearable without treatment will not meet the claimant’s burden to show that the chronic pain is more than mere sequelae of the “minor injury” sustained in the accident. The medical evidence submitted by the claimant was insufficient to prove a non-minor injury, and Adjudicator Neilsen held that the claimant’s pain was mere sequelae of the minor injury. Adjudicator Neilsen also rejected the allegations of psychological injury based on the inconsistencies in the medical report and the claimant’s self-reporting. The only benefit awarded was $215 for a psychological assessment, which is provided for in the Minor Injury Guideline.
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416.507.1850
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150 York Street, Suite 1800
Toronto, Ontario M5H 3S5
416.507.1850