C.T. v. RBC General Insurance Company (16-001142)

The claimant sought entitlement to a digital x-ray and mileage expenses. Adjudicator Treksler wrote that the claimant had not provided medical evidence in support of the need for an insurer-funded x-ray, and had failed to submit a treatment plan for the mileage expenses. Both claims were dismissed.

F.B. v. The Dominion of Canada General Insurance Company (16-002742)

The claimant sought entitlement to attendant care, non-earner, and medical benefits. On review of the medical documentation, as well as surveillance, Adjudicator Nicole Treksler found the claimant was not entitled to medical and attendant care benefits. The applicant was seen as independent with self-care making attendant care benefits not reasonable; similar analysis was conducted for the disputed medical benefits. The insurer submitted that non-earner benefits were not payable prior to a disability certificate. Adjudicator Treksler noted that per section 36, benefits are not payable prior to an OCF-3; moreover, on the merits the mere submission of an OCF-3 does not create an entitlement to non-earner benefits. Rather a disability certificate is a “a starting point for the [insurer] to investigate whether the applicant is entitled to the claimed benefit.” Costs were sought but not awarded.

J.D. v. The Dominion of Canada General Insurance Company (16-002745)

The claimant sought entitlement to attendant care, non-earner, and medical benefits. The insurer denied the benefits and had placed the claimant within the MIG. On review of the medical documentation, Adjudicator Nicole Treksler found the claimant was not entitled to any of the benefits claimed. It was noted that non-earner benefits are not automatic upon the submission of a disability certificate; indeed, an OCF-3 is a “a starting point for the [insurer] to investigate whether the applicant is entitled to the claimed benefit.” Adjudicator Treksler also concluded the applicant had not met the onus of demonstrating that his injuries were not minor.

J.M. v. Wawanesa Mutual Insurance Company (16-000258)

The claimant sought reconsideration of the Tribunal’s decision to deny psychological treatment. Executive Chair Lamoureux rejected the reconsideration request. She held that all of the grounds raised by the claimant were essentially a re-weighing of facts of findings made by the Tribunal.

M.G. v. Primmum Insurance Company (16-002951)

The claimant was a pedestrian knockdown. She claimed entitlement to two treatment plans; one psychological and the other for physiotherapy. The claimant also objected to the insurer placing her within the MIG. After reviewing the medical documentation of each party, Adjudicator Chris Sewrattan concluded the claimant suffered a psychological impairment. She was removed from the MIG and only the psychological treatment plan was awarded. The treatment plan for physiotherapy was denied as not being reasonable and necessary.

J.M. v. Wawanesa Mutual Insurance Company (16-000258)

The claimant sought reconsideration of the Tribunal’s decision to deny psychological treatment. Executive Chair Lamoureux rejected the reconsideration request. She held that all of the grounds raised by the claimant were essentially a re-weighing of facts of findings made by the Tribunal.

Optimum Insurance Company (16-000760)

The claimant sought entitlement to an in-home assessment and assistive devices. After weighing the evidence, Adjudicator Pay found the treatment plans reasonable and necessary. Although the insurer raised objections to the Reply submissions of the claimant, Adjudicator Pay stated: “Because these submissions of the applicant were not relevant to the determination of the dispute, I did not consider them. The issues in dispute focused on whether or not the two treatment plans were reasonable and necessary. In determining these issues, I considered the medical evidence. I did not consider telephone records or emails by the assessors. I also disregarded the allegation regarding production issues and the accusation of errors, misinterpretation and misleading facts. As a result, I do not need to consider the request to strike these portions of the applicant’s submissions, or to provide an opportunity to respond.”

P.K. v. Cumis General Insurance (16-001809)

The claimant sought entitlement to eight treatment plans, including prescription medication. Adjudicator Sewrattan found five of the treatment plans were not payable as the treatment was incurred before the submission of treatment plans. When interpreting section 38(2), it was noted that there was no “reasonable excuse” exception; therefore, if the claimant did not meet any of the expressed exceptions to incurring treatment before the submission of a treatment plan, the LAT cannot exercise any discretion to find treatment payable. The prescription medication, however, was found payable by operation of section 32(2)(c)(i). Because the accident necessitated the prescription medication, and the medication was reasonable and provided by a regulated professional, the medication was found payable. The remaining treatment plans, with one exception, were deemed reasonable and payable.

Applicant v. Wawanesa Mutual Insurance Company (16-001181)

This is a reconsideration decision under LAT Rule 18.2(b) wherein the original decision found the claimant not entitled to claim expenses related to a trip to Disney World. Executive Chair Lamoureux noted that there were no further submissions on the part of the claimant, and it appeared the Tribunal was merely “urged to discover the error.” Although Executive Chair Lamoureux did not entirely agree with the original Adjudicator’s analysis, it was concluded that the proper interpretation of section 16 of the SABS was conducted and the same result would have occurred. Executive Chair Lamoureux interpreted section 16(3) as a provision aimed to serve a rehabilitative purpose. The trip to Disney was seen as an event meant to be enjoyed as a result of the rehabilitation process, not for, or part of, the rehabilitation of the claimant. As a result, the original decision was maintained and the expenses claimed remained denied.

N.M. v. Certas Direct Insurance Company (16-001438)

The claimant sought entitlement to medical benefits. The insurer denied the benefits and held the claimant within the MIG. The claimant argued that a pre-existing condition of spina bifida warranted removal from the MIG. The claimant also advanced a chronic pain and psychological impairment argument. Adjudicator Rebecca Hines noted that the asserted pre-existing condition was not documented by a healthcare practitioner before the accident, per section 18(2). In any event, however, Adjudicator Hines noted that the conditions asserted were not proven to be barriers to recovery. The assertions of chronic pain and psychological impairment were found to be unsupported by medical evidence. The MIG was maintained and the treatment plans were denied.