Category: Medical Benefits

J.C. v. Certas Direct Insurance Company (16-000940)

The claimant sought entitlement to two medical benefits. Adjudicator Sewrattan dismissed the claim. He wrote that reports in favour of a treatment plan failed to provide sufficient detail explaining why the specific treatment request was reasonable and necessary. Simply showing a treatment is “necessary” was not enough. More was required to discharge the claimant’s onus.

N.C. v. RBC General Insurance Company (16-000282)

Following an accident, the self-employed claimant stopped operating his business in January 2016. Adjudicator Sewrattan concluded that the IRB calculation could not take into account business losses, as the claimant did not have business losses (as calculated by the Income Tax Act) after he ceased operations of his business. In terms of medical benefits, the adjudicator concluded that the claimant’s injuries did not fall in the MIG and wrote that pain reduction is a valid goal when assessing whether a treatment plan is reasonable and necessary.

L.W. v. The Co-operators General Insurance Company (16-000536)

The claimant sought entitlement to six treatment plans. Adjudicator Sewrattan adopted FSCO case law on the legitimacy of pain relief being a reasonable and necessary goal of treatment, and awarded all six treatment plans. The adjudicator also rejected the insurer’s position that surveillance could accurately capture the sensation of pain.

D.J. v. Aviva Insurance Canada (16-000098)

The claimant sought removal from the MIG and entitlement to various treatment plans. Adjudicator Theoharis concluded that the claimant suffered from depression and anxiety, which entitled her to benefits above the MIG limits. However, Adjudicator Theoharis concluded that all treatment plans for physical treatment were not reasonable and necessary, as the claimant had met maximum medical improvement from a physical perspective.

J.H. v. Intact Insurance Company (16-000009)

The claimant sustained a catastrophic impairment and sought mileage expenses for his service providers. Adjudicator Pay held that the SABS did not require the insurer to pay for the mileage expenses of the service providers (the insurer was already paying for the hourly rate of the service providers, which included their transportation time).