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.
The claimant sought entitlement to non-earner and medical benefits. The insurer asserted a MIG defence. Adjudicator Truong considered the claimant’s testimony regarding her pre- and post-MVA life, which included an international flight to Norway and Sweden for approximately 2 weeks. Adjudicator Truong also reviewed surveillance footage and concluded that the claimant did not suffer a complete inability to carry on a normal life. Furthermore, on review of the medical evidence, the claimant’s injuries were said to be minor – the treatment plans were deemed not reasonable and necessary.
The claimant was catastrophically impaired. An assessment of attendant care needs yielded a monthly rate beyond the statutory maximum. The insurer agreed to pay up to the statutory maximum; however, invoices showed services incurred for less and therefore only the amounts on submitted invoices were paid. The claimant argued that once an economic loss was established, the entire value of the Form 1 was payable. Adjudicator Purdy concluded that the insurer is only liable to pay the attendant care amounts that have been incurred by the applicant. Additionally, treatment plans for both a neuropsychological assessment and neuropsychometric testing were, in fact, one large assessment that would produce two reports – it was therefore subject to the maximum $2,000.00 maximum cap for assessments.
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.
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.
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.
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.
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.
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.
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416.507.1850
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150 York Street, Suite 1800
Toronto, Ontario M5H 3S5
416.507.1850