Category: Medical Benefits

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.

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.

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.

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.

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.