Category: Medical Benefits

Optimum Insurance Company (16-000760)

Post author By tgp-admin
Post date March 31, 2017
No Comments on 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)

Post author By tgp-admin
Post date March 28, 2017
No Comments on 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)

Post author By tgp-admin
Post date March 23, 2017
No Comments on 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)

Post author By tgp-admin
Post date March 23, 2017
No Comments on 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)

Post author By tgp-admin
Post date March 16, 2017
No Comments on 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)

Post author By tgp-admin
Post date March 15, 2017
No Comments on 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)

Post author By tgp-admin
Post date March 14, 2017
No Comments on 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)

Post author By tgp-admin
Post date March 9, 2017
No Comments on 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)

Post author By tgp-admin
Post date March 9, 2017
No Comments on 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)

Post author By tgp-admin
Post date February 23, 2017
No Comments on 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.

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