T.S. v. Aviva General Insurance (17-000835)

The primary issue in dispute was whether the claimant sustained a predominantly minor injury as a result of the accident. Adjudicator Ferguson rejected the claimant’s allegations of psychological injury. He also rejected the submission that the claimant’s chronic pain was not covered by the definition of “minor injury.” Adjudicator Ferguson accepted that the claimant did suffer chronic pain syndrome as a result of the accident. However, Adjudicator Ferguson concluded based on the medical evidence that the claimant’s chronic pain was a clinically associated sequelae of his minor injuries. He was therefore restricted to $3,500 in medical benefits. The claimed treatment plans were denied

Applicant v. Jevco Insurance Company (16-002000)

The claimant was involved in a serious accident and had sustained ongoing physical, psychological, and cognitive impairments. He had returned to doing some work on a part-time basis, but was unable to engage in full time work or retraining. Adjudicator Truong held that the claimant was entitled to post 104-week IRBs based on a holistic analysis of the claimant’s post-accident abilities and impairments. It was also noted that the claimant had been approved for CPP Disability Benefits. In terms of the catastrophic impairment, Adjudicator Truong determined that the claimant suffered a combined 56 percent whole person impairment, which qualified as a catastrophic impairment. The difference of opinion between the parties had been based on whether it was appropriate to combine the impairment rating for mental status impairment rating under Chapter 4 of the AMA Guides with the mental and behavioural impairment rating from Chapter 14 of the AMA Guides, or whether doing so amounted to “overcounting”. Adjudicator Truong held that it was appropriate to combine the ratings from both Chapters 4 and 14 in this case, because the claimant had suffered a cerebral impairment (which was counted under Chapter 4), and a psychological impairment (which was counted under Chapter 14). In terms of the medical benefits claimed, Adjudicator Truong held that the claimant had not submitted sufficient evidence to prove that the claims were reasonable and necessary.

C.L. v. Wawanesa Mutual Insurance (16-002085)

The claimant sought entitlement to a number of treatment plans. The insurer asserted the plans were not reasonable and necessary. Adjudicator Derek Grant determined the injuries complained of by the claimant were as a result of the accident; however, on review of the medical evidence, the treatment plans were deemed not reasonable and necessary.

Applicant v. Security National Insurance Company (16-003024)

The claimant sought entitlement to medical benefits and removal from the MIG. He also argued that the insurer’s denials did not comply with section 38 of the SABS. Adjudicator Belanger-Hardy dismissed the claims. She held that the insurer’s denials provided sufficient information to comply with the SABS. She also held that the evidence submitted supported a finding of minor physical injuries, and insufficient evidence was submitted to support an accident-related psychological injury.

R.R. v. Aviva Insurance (16-001627)

The claimant sought entitlement to treatment plans requesting assistive devices and psychological treatment. The insurer denied the plans as not being reasonable and necessary. Adjudicator Chris Sewrattan reviewed the medical evidence and determined that the claimant did not provide sufficient evidence to show the devices were reasonable. However, the psychological treatment was considered payable. No costs were awarded to either party.

Applicant v. Yarmouth Mutual Fire (17-001061)

The minor claimant sought entitlement to medical benefits and mileage. Adjudicator Ferguson dismissed all claims. He held that proposed social worker services were duplicative of approved treatment; further the claimant was completing self-care and school tasks as expected for someone of his age. In terms of OT services, the claimant did not explain what in-home barriers were being addressed. Finally, the mileage was not payable based on the Guidelines.

Applicant v. Yarmouth Mutual Fire (17-001057)

The minor claimant sought entitlement to medical benefits and mileage. Adjudicator Ferguson dismissed all claims. He held that proposed social worker services were duplicative of approved treatment; further the claimant was completing self-care and school tasks as expected for someone of his age. In terms of OT services, the claimant did not explain what in-home barriers were being addressed. Finally, the mileage was not payable based on the Guidelines.

A.H. v. Belair Direct Insurance Company (16-001063)

The claimant sought entitlement to a number of treatment plans and attendant care benefits. Adjudicator Lori Marzinotto noted that some of the treatment plans sought were not submitted as evidence, nor specifically addressed in the claimant’s submissions; those plans were denied. Other treatment plans sought mileage beyond the Professional Service Guidelines. Adjudicator Marzinotto highlighted no evidence was tendered to support exceeding the PSG; those previously partially approved plans were accordingly maintained. With respect to attendant care benefits, Adjudicator Marzinotto noted no evidence was provided to satisfy economic loss for much of the period claimed; therefore attendant care benefits were not payable for that time. However, the claimant was entitled to attendant care benefits from February 2016 onwards, as the evidence supported it was reasonable and necessary, and incurred, but that the rate charged by the service provider was in excess of the FSCO Guidelines.

L.F. v. Unifund Assurance Company (16-001020)

The claimant sought entitlement to IRBs and two treatment plans for a social emotional assessment and a functional abilities evaluation. The respondent initially paid weekly IRBs of $209.61. Payments were stopped when the claimant failed to attend three IEs in March and April 2016. After the claimant attended IEs in August 2016, the respondent denied IRBs entitlement based on the IE reports. Adjudicator Bickley concluded that as a result of the claimant’s psychological impairments, she was substantially unable to perform the essential tasks of her employment. Having found her entitled to IRBs, the Adjudicator determined that she was ineligible to receive IRBs between April 21, 2016 and July 18, 2016 due to her failure to provide a credible reason for her non-attendance at the March and April 2016 IEs. With respect to the disputed treatment plans, Adjudicator Bickley concluded that they were not reasonable and necessary. The proposed social emotional assessment was duplicative of the previously approved psychological assessment, and the claimant had submitted no evidence to support her position that the unpaid portion of the functional abilities evaluation was reasonable.

K.S. v. The Dominion of Canada General Insurance Company (16-002099)

The claimant sought entitlement to attendant care benefits and multiple treatment plans. A preliminary issue was whether late submitted medical records should be excluded from the hearing. Regarding the late records, Adjudicator Treksler admitted the records reasoning that third parties had control over the records and that the claimant could not control the date of disclosure. She also reasoned that the insurer had not suffered any prejudice. In terms of the attendant care benefits, Adjudicator Treksler awarded four months of attendant care benefits and held that the use of a professional service provider met the incurred requirements in the SABS. No attendant care benefits were awarded beyond the date the claimant was observed to be fully functional on surveillance. Five of the 12 claimed treatment plans were awarded.