Category: Medical Benefits

Catic v. Aviva General Insurance (19-005572)

The claimant requested reconsideration of a decision in which the Tribunal found that the claimant was not entitled to the cost of a psychological assessment because it was not reasonable and necessary, despite the insurer’s denial not complying with section 38. The claimant argued that the applicable consequences set out in section 38(11) required the insurer to pay for all assessments and examinations described in the treatment plan starting on the 11th business day and ending on the day the insurer gives a notice described in section 38(8). Further, the claimant argued that evidence of services being incurred was not required, as stated in P.M. v. Aviva General Insurance, where the adjudicator held that s. 38(11)2 does not include a requirement for any services to be “incurred.” The section only states “that relate to.” Adjudicator Grant set aside the Tribunal’s decision and held that the claimant was entitled to the disputed psychological assessment even though it had not been incurred prior to the insurer delivering a section 38 compliant denial.

Kyrylenko v. Aviva Insurance Canada (2021 ONSC 4929)

The claimant appealed the Tribunal’s decision that he was not entitled to payment for benefits related to two treatment plans that the insurer had failed to respond to within 10 business days. Despite the language of section 38(11), the Tribunal considered whether the medical benefits were reasonable and necessary, and whether the MIG applied and barred entitlement to the claimed in-home assessment. The Divisional Court granted the appeal and held that the insurer was liable for all amounts on the treatment plans related to the 11th business day onwards until the treatment plan was properly denied. The Tribunal erred in considering the “”reasonable and necessary”” test for the entitlement when section 38(11) applied, and the Tribunal erred in considering the prohibition on in-home assessments under section 25(2) for MIG claims, given that section 38(11) required payment. The Court ordered the insurer to pay the treatment amounts that relate to the period after the 11th business day following submission of the treatment plan. The Court returned to matter to the Tribunal for a decision on the claim for a special award.

Ali v. Aviva Insurance Company of Canada (19-013677S)

The claimant submitted that the insurer failed to comply with its obligations under section 38(8) regarding its notices that denied the disputed treatment plans. Adjudicator Lake found that the insurer’s response letter failed to provide any specific details about the claimant’s condition that formed the basis of its decision, and failed to provide an explanation for why the insurer concluded that the treatment plan was not reasonable and necessary. Adjudicator Lake stated that simply attaching an IE report to an Explanation of Benefits letter with a bare statement that the treatment plan was not reasonable and necessary was not sufficient enough to allow an unsophisticated person to make an informed decision to either accept or dispute the decision at issue and certainly does not serve the Schedule’s consumer protection goal.

S.B.S. v. Wawanesa Mutual Insurance Company (17-006935)

The claimant filed a request for reconsideration arising out of Adjudicator Neilson’s decision that he was not entitled to IRBs or the cost of a psychological treatment plan. Adjudicator Neilson dismissed the request. At the initial hearing, the claimant brought a motion to exclude the insurer’s experts’ reports on the basis that the insurer failed to comply with an order to produce the clinical notes and records of its IE experts, in particular the raw test data from the IE psychologist. Adjudicator Neilson had dismissed the motion on the basis that the insurer had provided proof of best efforts to obtain these records. Then, the claimant sought an adjournment so that the IE psychologist could produce the data to the claimant’s treating psychologist. Adjudicator Neilson dismissed that adjournment request, but the hearing was adjourned for other reasons. At the hearing, the claimant’s treating psychologist testified that she did not interpret the raw data as did not pay the fee to obtain this data through a computer program. Ultimately, Adjudicator Neilson agreed with the IE psychologist and on reconsideration, found that the raw data results would not have changed her opinion with respect to the IRB dispute or entitlement to the disputed psychological treatment plan.

Liao v. Aviva General Insurance (19-004856)

The claimant applied to the LAT seeking entitlement to IRBs and a treatment plan proposing chiropractic treatment. The claimant submitted that she attempted to return to work after the April 2016 accident but ceased working in August 2016 due to accident-related impairments. The insurer argued that the claimant was not entitled to IRBs because she did not comply with requests for documents to complete her IRB application and calculation until November 2019, and therefore she was not entitled to IRBs prior to November 2019. Alternatively, the insurer argued that the claimant had not shown that she satisfied the test for pre- or post-104 IRBs. Adjudicator Chakravarti found that the insurer provided proper (although late) s. 33 requests in December 2016 following receipt of the OCF-3 and the insurer was able to rely on the s. 33(6) consequences for the claimant’s non-compliance with s. 33 requests. The claimant did not produce requested income information until January 2018 and did not produce the requested OCF-2 until November 2019. Adjudicator Chakravarti found that the claimant did not provide a reasonable explanation for the delay in providing the requested documentation and the insurer was entitled to withhold payment of IRBs for the period of non-compliance. Adjudicator Chakravarti found that the insurer’s s. 33 request was made more than 10 days after receipt of the OCF-3 (contrary to the requirements in s. 36(4)) and IRBs would therefore be payable for the period from receipt of the OCF-3 until the s. 33 request was made if the claimant met the substantial inability test for pre-104 week IRBs during this period. Adjudicator Chakravarti found that the claimant failed to prove that she met the test for pre- or post-104 IRBs and was not entitled to IRBs for any period before the s. 33 requests were made or after the s. 33 requests were complied with. The claimant also failed to meet her onus of demonstrating that the proposed chiropractic treatment was reasonable and necessary. The application was dismissed in its entirety.

Kane v. Aviva Insurance Company (20-006995)

The insurer partially approved a treatment plan for psychological treatment because the recommendation was made by a psychotherapist, who was an unregulated provider under the Professional Services Guideline, and therefore was subject to the hourly rate of $99.75 as opposed to the $149.61 per hour rate claimed. Adjudicator Boyce found that the claimant was not entitled to the remainder of the treatment plan as the proposed rate was outside of the hourly fee provided by the Guideline. The Guideline provides that, for non-catastrophic impairments, the maximum hourly rate for psychologists and psychological associates is higher than that for psychometrists and counsellors (being family, rehabilitation, vocational). For services provided by health care professionals, unregulated providers and other occupations not listed in the Guideline, the amounts payable by an insurer related to services not covered by the Guideline are to be determined by the parties involved. Adjudicator Boyce agreed with the insurer that the individual’s CV in question confirmed that his practice was as a psychotherapist or psychometrist, which is not listed in the Guideline. Further, there was no evidence that the individual possessed specialized training. As a result, Adjudicator Boyce determined that the claimant had not provided support for the contention that they were entitled to the balance of the treatment plan.

Rodionova v. Aviva Insurance Company (19-012116)

The insurer initially denied four treatment plans because it believed that the MIG applied and the treatment plans proposed treatment outside of the MIG. Section 38(5) provides that the insurer may refuse to accept a non-MIG treatment plan during the period that the claimant is entitled to receive treatment under the MIG. The claimant submitted that section 38(5) did not apply because she sustained an accident-related injury that fell outside of the MIG. The insurer submitted that it was not obligated to accept the injuries listed on an OCF-18 without compelling medical evidence. Adjudicator Norris found that the insurer’s denial were proper. The injuries described in the treatment plans were predominantly soft-tissue injuries and the claimant failed to provide compelling evidence of a pre-existing injury or non-minor injury with any of the four treatment plans. Considering this, the insurer’s denial was valid pursuant to section 38(5) of the Schedule and the claimant was obligated to submit a treatment confirmation form pursuant to section 40(2). Accordingly, pursuant to section 38(6), the insurer’s decision was not subject to review. According to section 38(5), the claimant must treat her injuries within the MIG until she provides compelling evidence of a non-minor injury or a pre-existing medical condition which would preclude her recovery if she is subject to the MIG.

Green v. Intact Insurance Company (19-013031)

The claimant sought reconsideration of the Tribunal’s decision that the SABS did not provide for funding of multidisciplinary IRB reports. Vice Chair McGee rejected the reconsideration, finding no error in law. She noted that nothing prevented the claimant from responding to the insurer’s IE reports, but that he had to do so at his own expense. Vice Chair McGee rejected the argument that section 25 did not specifically bar expenses for IRB reports and that such reports should therefore be payable, noting that section 25 is clear and unambiguous as to the types of reports an insurer must fund. Additionally, Vice Chair McGee reiterated that stabilizing costs was one of the goals of the SABS, and that restricting the types of assessment an insurer was required to fund aligned with the Legislature’s policy goal.

Cargnelli v. Aviva Insurance Company (20-001892)

The claimant applied disputed his entitlement to NEBs, two medical benefits, interest, and a special award. Adjudicator Boyce dismissed the NEBs claim, awarded the two medical benefits plus interest, and awarded a 10 percent special award with respect to the medical benefits. With respect to NEBs, Adjudicator Boyce noted that while according to Heath a total disability is not required, the NEB test is a stringent one. Aviva relied on its IE reports and the claimant’s self-reporting. Adjudicator Boyce noted that the claimant reported that he had resumed self-care tasks and basic housekeeping activities, mowed his lawn, attended social events, and could drive his vehicle and motorcycle. Adjudicator Boyce found that the claimant’s pain did not practically prevent him from engaging in his most valued pre-accident activities. As for the medical benefits, Adjudicator Boyce found that both disputed treatment plans were reasonable and necessary to help him reduce pain and improve his recovery and that pain reduction is a legitimate goal for treatment. As for the special award, Adjudicator Boyce agreed with the claimant’s submissions that it was difficult to reconcile Aviva’s denial of medical benefits during the same period it had paid a NEBs.

Munro v. Belair Direct (19-013690)

The claimant suffered a catastrophic impairment in an accident that resulted in the death of his son. He sought entitlement to various medical benefits, including nursing services, a meditation system, a portable modulation stimulator device, naturopathic treatment, an ozone generator device, and an infrared sauna. Some of the claimed services were submitted on an OCF-6. Adjudicator Boyce awarded the cost of an eye exam on the OCF-6. All other claims were denied. In terms of the OCF-6 expenses, the claimant failed to submit the proposed expenses on an OCF-18, so the claims were barred by section 38(2). Similarly, the other claimed benefits which were incurred before submission of an OCF-18 were also not payable. The mediation system and portable modulation stimulator were experimental in nature and not payable due to section 15(2).