Category: Medical Benefits

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.

H.A.J. v. Aviva Insurance Canada (16-001418)

The claimant sought entitlement to a treatment plan for occupational therapy. Adjudicator Sewrattan awarded the claimed treatment plan based on the theory that the treatment would provide potential pain management or reduction, which was a reasonable goal for the claimant’s physical impairment.

A.T. v. Aviva Insurance Canada (16-001934)

The claimant sought entitlement to a treatment plan for physiotherapy and another treatment plan for a chronic pain assessment, as well as costs. On review of the medical evidence, Adjudicator Sewrattan found the chronic pain assessment reasonable.

S.S. v. Northbridge Personal Insurance Corporation (16-000960)

The claimant sought entitlement to various medical benefits. Adjudicator Theoharis accepted that the proposed treatment plans provided pain relief to the claimant, which allowed him to engage in his daily activities. She concluded that the medical benefits were reasonable and necessary.

A.A. v. State Farm Mutual Automobile Insurance Company (16-000448)

The claimant sought entitlement to social rehabilitation counseling services. The insurer denied the claim asserting (i) the limitations period barred the claim and (ii) the claim was already adjudicated at FSCO under a different date of loss. Adjudicator Sewrattan cited section 23 of the Statutory Powers and Procedures Act in precluding a party from proceeding with a claim if it is to prevent an abuse of process. Adjudicator Sewrattan found that the claimant had litigated the disputed treatment plan at FSCO. As a result, the claimant’s LAT claim would amount to an abuse of process and was therefore barred. The insurer, citing that the matter was an abuse of process sought costs. However, Adjudicator Sewrattan cited access to justice reasons, as well as the fact that the claimant was self-represented and genuinely believed the matter could proceed, as reason not to award costs.

J.J. v. Aviva Insurance Canada (16-001031)

The claimant was involved in two accidents and sustained a heart attack months after the second accident. A treatment plan for assistive devices was denied by the insurer with the assistance of a GP IE report. The insurer objected to the inclusion of documents not disclosed 10 days before the service and filing of written submissions, pursuant to LAT Rule 9. Adjudicator Theoharis ruled that since the insurer’s response submissions afforded it 10 days, the materials were properly disclosed. On the merits, Adjudicator Theoharis determined that the treatment plan for assistive devices was reasonable and necessary and that the treatment undertaken by the claimant had to be cognizant of the heart condition suffered afterwards.

D.O. v. TD Insurance Meloch Monnex (16-000142)

The claimant was a fetus at the time of the accident. The mother was 6 months pregnant at the time. After the MVA, the mother gave birth 2 months premature. 3 weeks after birth the claimant was discharged from the hospital; however, following the discharge she experienced difficulty swallowing and encountered choking episodes. As a result, the claimant, through her litigation guardian/mother, sought attendant care benefits. The insurer asserted the MVA did not cause the premature birth and the subsequent GERD syndrome (digestive condition) was not as a result of the MVA. Adjudicator Leslie concluded that the claimant failed to meet the burden that the MVA caused her condition and denied entitlement.

S.L. v. Pembridge Insurance Company (16-000393)

The claimant sought entitlement to medical treatment plans. The claimant asserted a chronic pain diagnosis to justify the treatment plans. The insurer asserted that the chronic pain diagnosis was as a result of a pre-existing injury and not the MVA. Adjudicator Derek Grant ruled that although “but for” is the default test for causation, “material contribution” was needed since the argument was that the MVA triggered pre-existing conditions, resulting in chronic pain. It followed that the claimant had to prove that the MVA was more than a minimal contribution to the chronic pain diagnosis. Adjudicator Grant found the claimant suffered from chronic pain as a result of the MVA. All of the claimed treatment plans, with the exception of a brain electrical activity scan, were deemed reasonable.

L.C. v. Aviva Insurance Company of Canada (16-001387)

The claimant sought removal from the MIG and entitlement to a series of treatment plans.  Adjudicator Flude concluded that the applicant had suffered a predominantly minor injury. A post-accident MRI identified degenerative changes and nerve root compression. The applicant argued that the condition was pre-existing and entitled him to removal from the MIG. Adjudicator Flude disagreed and noted that the diagnosis was not made until 3 years after the accident and failed the requirement to be identified prior to the accident.