Category: Medical Benefits

Applicant v. Echelon (16-003221)

The claimant had suffered a catastrophic impairment in the accident and sought entitlement to rehabilitation benefits from an OT. The insurer denied the services on the basis of IEs that had concluded that the claimant had recovered from a physical perspective. Adjudicator Mather awarded the claimed benefits, and held that the claimant continued to suffer psychological impairments that necessitated further intervention with an occupational therapist. The adjudicator also wrote that surveillance provided by the insurer was of no assistance as it did not provide evidence that further occupational therapy was not required from a psychological perspective.

Applicant v. Echelon (16-003223)

The claimant was involved in a serious accident in which his daughter was fatally injured. The claimant was deemed to have sustained a catastrophic impairment. The claimant sought entitlement to occupational therapy assistance. The insurer denied the treatment plan and stated there was no rehabilitative goal of consuming the treatment. On review of the medical evidence, Adjudicator Mather concluded the treatment plan was reasonable and necessary and awarded the benefit. The claimant sought costs and asked that a negative inference be drawn of the insurer’s behaviour due to its refusal to produce log notes. Costs were denied and no inference was made regarding the non-production of log notes, since the notes were considered not relevant to the issues in dispute.

K.L. v. Aviva Insurance Company of Canada (16-002397)

The claimant sought removal from the MIG and entitlement to five treatment plans based on a spinal compression fracture identified two years after the accident. The insurer argued that the claimant had not proven that the compression fracture was related to the accident. Adjudicator Shapiro agreed with the insurer and concluded that the claimant had not met his onus of proof in demonstrating that the fracture was accident-related.

V.H.T. v. Certas Home and Auto Insurance Company (16-000874)

The claimant sought entitlement to IRBs and further medical benefits. A preliminary motion was first heard to address the admissibility of late documents. Adjudicator Sapin held that the late documents were admissible, that the insurer had sufficient time to review the new documents, and that the insurer should have requested an adjournment if it believed prejudice would result. In terms of the benefits in dispute, Adjudicator Sapin held that the claimant was entitled to post-104 week IRBs due to ongoing psychological issues, chronic pain, and inability to use his right hand. The medical benefit sought were not awarded because the claimant did not provide evidence that they were reasonable and necessary, or were not on a treatment plan.

L.S. v. Royal & Sun Alliance Insurance Company of Canada (16-002381)

The claimant sought entitlement to a medical treatment plan. In addition to the issues outlined in the Case Conference Order, the claimant also sought a lump sum payment of $35,000.00 for 5 years of future medical treatment. Adjudicator Truong noted that issues not codified by the Case Conference Order were not properly before the Tribunal and therefore could not be determined. On review of the medical evidence, the treatment plan in dispute was found not reasonable and necessary. It was noted that a treatment plan alone is not sufficient evidence to establish entitlement – corroborating evidence is also required.

P.W. v. Aviva Canada Inc. (16-001097)

The claimant sought entitlement to a medical treatment plan. The insurer relied on IE reports and denied the benefit. On review, Adjudicator Norris preferred the evidence of the claimant and determined the treatment plan was reasonable and necessary.

Applicant v. Aviva (16-000775)

The claimant had been involved in two accidents. He had been removed from the MIG due to pre-existing back injuries and sought entitlement to a treatment plan proposing psychological therapy in relation to the first accident. The treatment plan was submitted after the second accident occurred. Adjudicator White took issue with the treatment provider’s failure to mention to the second accident and failure to review the clinical notes and records of the family physician, as well as the claimant’s failure to seek out psychological treatment on his own. Surveillance was also considered by the adjudicator. The treatment plan was denied as being not reasonable and necessary.

Applicant v. Unifund Assurance Company (16-002818)

The claimant sought entitlement to a number of medical benefits. The insurer asserted a MIG defence. On review of the evidence, Adjudicator Sewrattan determined the claimant’s psychological injury was as a result of the accident and not predominantly minor. The psychologically-based treatment plans were found payable, and the physically-based treatment plans were denied as not reasonable and necessary.

G.P. v. Unifund Assurance Company (16-003165)

The claimant sought payment for various clinic balances for medical treatment. Adjudicator Sewrattan ruled that the claimant failed to submit the treatment plans as evidence and therefore the issue as to whether the treatment was reasonable and necessary was not at issue. The claims were dismissed.

Y.C.T-T. and Certas Home and Auto Insurance Company (16-000872)

The claimant was originally placed within the MIG. During that period, the insurer denied medical benefits as well as an assessment of attendant care needs. The insurer later removed the claimant from the MIG, but did not approve the previously denied treatment plans. The claimant sought entitlement to the previous plans. Adjudicator Leslie found the treatment and assessment plans payable. Adjudicator Leslie confirmed that insurers have an ongoing duty to assess and reassess files in the course of medically managing a claim. On review of the claimant’s injuries and medical documentation, Adjudicator Leslie concluded the treatment plans were reasonable and necessary.