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.
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.
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.
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.
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.
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.
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.
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.
The claimant sought entitlement to the form fee and HST associated with an assessment plan. The insurer indicated that the treatment plan was subject to the monetary cap under section 25(5). The claimant asserted the form fee was a separate cost, not subject to the cap. Adjudicator Christopher Ferguson referred to Superintendent’s Guideline No. 03/14 which noted the form fee is a separate expense, payable above the monetary cap. Reference was also made to correspondence from the insurer which suggested it adhered to the Guideline in the past. With respect to HST, Adjudicator Ferguson applied the same Guideline, despite being referred to Superintendent’s Guideline No. 03/16. HST was also found payable above the monetary cap.
The claimant sought entitlement to medical benefits; the insurer argued that the claimant had not complied with section 33 requests and that the claimed benefits were not reasonable and necessary. Regarding the section 33 argument, Adjudicator Ferguson held that the information requested by the insurer was not “reasonably necessary” to determine entitlement as the insurer had already rejected the claims prior to making the section 33 requests. Regarding the medical benefits claimed, Adjudicator Ferguson held that the medical evidence did not support that the treatment was reasonable or necessary.
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416.507.1850
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150 York Street, Suite 1800
Toronto, Ontario M5H 3S5
416.507.1850