Category: Medical Benefits

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.

H.C. v. Certas Direct Insurance Company (16-001285)

The claimant sought entitlement to income replacement benefits along with two treatment plans, costs, and a special award. Adjudicator Bass reviewed the medical evidence, along with surveillance submitted by the insurer. It was found that the claimant’s reports were “overly pessimistic in light of the surveillance evidence from only a few months later.” As a result, it was concluded that the claimant did not sustain a substantial inability to perform the essential tasks of his employment. The treatment plans claimed were also denied as Adjudicator Bass found the claimant’s injuries to be minor.

J.S. v. RBC Insurance Company (16-000576)

The claimant sought entitlement to eight treatment plans. The insurer maintained a MIG position. Adjudicator Makhamra found the claimant failed to meet the burden of proof to warrant removal from the MIG. The claimant holds the onus to prove removal from the MIG is justified. In doing so, Adjudicator Makhamra distilled the analysis to three questions: i. Are the claimant’s injuries predominantly minor? ii. Does the claimant suffer from a pre-existing medical condition that prevents him from reaching maximal recovery if he is subject to the $3500 cap in the Minor Injury Guideline? and, iii. Are the treatment plans necessary and reasonable for the claimant’s treatment? Adjudicator Makhamra was satisfied with the notice letters and said the insurer “explained that the applicant’s injuries were within the MIG; it described the diagnosis, and advised of its intention to schedule an insurer’s examination where applicable.” The treatment plans were found not payable.

Applicant v. Aviva (16-001144)

The claimant sought entitlement to income replacement benefits and an orthopaedic assessment. The insurer paid IRBs for four months and terminated them after a number of IE reports. The orthopaedic assessment was denied based on a MIG position. As a preliminary issue, the insurer sought to add the claimant’s LinkedIn page to show the claimant was working and therefore required IRB repayment. Adjudicator Treksler allowed the new evidence to be admitted, but found the page insufficient evidence to warrant repayment of IRBs. Adjudicator Treksler found that the claimant was entitled to IRBs and held that he should be removed from the MIG. The fact that the claimant did not return to his employment, but instead, went to school in a different field was seen as supporting the IRB claim.

F.V. v. Wawanesa Mutual Insurance Company (16-001811)

The claimant had sustained a catastrophic impairment and sought entitlement to rehabilitation benefits funding a trip to Florida and Disney World. Adjudicator Lester held that the proposed treatment did not fall within the scope of activities set out in section 16 of the SABS, and dismissed the claim.