Category: Medical Benefits

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.

M.N.K.A. v. State Farm Mutual Automobile Insurance (16-001592)

The claimant sought entitlement to NEBs and two medical benefits. Adjudicator Bass denied all claims as not meeting the requisite test for entitlement.

Applicant v. Unifund Assurance Company (16-000879)

The claimant sought an order for NEBs, and medical benefits. As a preliminary issue, the insurer sought the exclusion of documents not produced in accordance with the Case Conference Order. Adjudicator Truong held that the Tribunal could set deadlines that were more stringent than those in the LAT Rules. The documents were excluded and the claims for NEBs and medical benefits were dismissed.

R.H. v. TD Insurance Meloche Monnex

The claimant sought entitlement to medical benefits and removal from the MIG. Adjudicator Leslie concluded that the insurer had not complied with section 38 of the SABS in the denial timeline, and that the insurer was therefore prohibited from taking the position that the MIG applied. One of the claimed treatment plans was awarded.

E.S. v. Unifund Assurance Company (16-000691)

The claimant sought entitlement to further medical benefits. Adjudicator Bass concluded that no further passive therapy was reasonable and necessary, and that the claimant did not require further psychological treatment.

M.J. v. Pembridge Insurance Company (16-000583)

The claimant sought IRBs and medical marijuana. The adjudicator dismissed the IRBs claim because the claimant had refused to provide post-accident income records. The claim for medical marijuana was dismissed because the claimant did not provide a proper “medical document” supporting the need for medical marijuana. The term “medical document” is defined in the federal Marihuana for Medical Purposes Regulations.

J.B. v. Meloche Monnex Financial Services Inc. (16-000766)

The claimant sought entitlement to three medical benefits. As a preliminary issue, the insurer sought exclusion of the claimant’s submissions due to late filing. Adjudicator Treksler held that a large and liberal interpretation of Rule 3.1 allowed the late filing of submissions in this case. The adjudicator found the disputed treatment plans reasonable and necessary.