Applicant v. Certas Direct Insurance Company (17-005290)

The claimant sought removal from the MIG and entitlement to three medical benefits. Adjudicator Parish concluded that the claimant’s injuries fell within the MIG. She held that the claimant did not suffer psychological injuries or chronic pain. She noted that the claimant’s assessors did not adequately consider objective findings and relied upon subjective reporting without appropriate testing. Further, the chronic pain assessor did not connect the claimant’s reported impairments to the accident. Finally, there was very little reporting to the family doctor regarding pain complaints.

Applicant v. Aviva General (17-004847)

The claimant sought entitlement to various medical benefits, the costs of a chronic pain assessment, treatment outside of the MIG, and interest. Upon weighing the medical evidence, Adjudicator Boyce determined that the claimant’s chronic pain warranted treatment outside of the MIG. Moreover, Adjudicator Boyce found the requested chronic pain assessment was reasonable and necessary. Adjudicator Boyce further held that one of the requested benefits was partially reasonable and necessary, but denied another treatment plan for being duplicative. As the claimant was found to be entitled to some of the benefits sought, he was also entitled to interest.

Applicant v. Aviva Insurance Canada (17-003724)

The claimant sought removal from the MIG and entitlement to psychological treatment. Adjudicator Grant concluded that the insurer failed to respond to the treatment plan within 10 days. Even though the treatment plan was denied on HCAI, no letter with the medical and other reasons for the denial was sent to the claimant until two months later. The insurer was therefore prohibited from relying upon the MIG. However, Adjudicator Grant held that the claimant failed to prove that the proposed psychological treatment was reasonable and necessary.

Applicant v. Certas Home and Auto Insurance Company (17-004519)

The claimant sought removal from the MIG and entitlement to seven disputed medical benefits. He argued that he suffered psychological injuries and chronic pain. Adjudicator Ferguson rejected the claims. He held that the claimant failed to provide evidence of psychological impairment. He also held that claimant failed to prove that his pain symptoms were not clinically associated sequelae to his minor injuries.

Applicant v RBC General Insurance Company (17-005285)

The claimant argued that his injuries fell outside the MIG and sought medical benefits. Adjudicator Mazerolle held that the claimant’s injuries fell within the MIG. Adjudicator Mazerolle preferred the insurer’s psychological assessment that noted the claimant exhibited adjustment reactions which were mild symptoms and treatable within the MIG. The insurer’s report relied on seven psychometric tests, whereas the claimant’s report relied on three tests. Additionally, the insurer’s report found validity issues which demonstrated potential over-reporting of symptoms, whereas the claimant’s report exclusively used self-reporting measures. With regard to chronic pain, Adjudicator Mazerolle held that the claimant failed to demonstrate that it was not clinically associated sequelae to the soft tissue injuries caused by the accident.

Applicant v. Royal and Sun Alliance (17-003732)

The minor claimant sought entitlement to NEBs, and four treatment plans. The insurer argued that the claim for NEBs was time barred, and that the claimant’s injuries fell within the MIG. Adjudicator Hines held that the two year limitation period did not apply to the minor claimant until she hit the age of majority. She also held that the claimant’s mother was not deemed a litigation guardian by virtue of filling out SABS forms for the claimant. In terms of NEB entitlement, Adjudicator Hines held that the claimant failed to prove a substantial change in her life following the accident, and raised concerns about many inconsistencies in the claimant’s reporting. In terms of the medical benefits, Adjudicator Hines concluded that the claimant’s injuries were minor in nature, and that the treatment plans were therefore not payable.

Applicant v. Aviva Insurance Canada (17-002957)

The claimant sought entitlement to treatment outside of the MIG, attendant care benefits, medical benefits, the costs of three examinations, and a special award. After a review of the medical evidence, Adjudicator Anwar preferred the reports of the claimant’s specialists and held that the claimant’s injuries warranted treatment outside of the MIG. Adjudicator Anwar further concluded that the claimant was entitled to the medical benefits sought, as they were reasonable and necessary, but that attendant care benefits were not warranted nor were any expenses incurred.  Moreover, Adjudicator Anwar held that the insurer did not unreasonably withhold payments from the claimant to necessitate a special award.

V.A. v. Wawanesa Mutual Insurance Company (17-002948)

The claimant disputed his MIG status; entitlement to payment for treatment; entitlement to payment for examinations and completion of OCF-3s; and entitlement to IRBs. Adjudicator Sewrattan denied all of the claims. The claimant, allegedly suffering from chronic pain, failed to prove that he suffered from an injury not predominantly minor in nature. The expert reports relied upon by the claimant were scant in their descriptions of methodologies used to reach the diagnoses made. The claimant was self-employed at the material time and failed to provide an intelligible basis upon which IRB could be calculated. Although he may be entitled to an IRB, he failed to prove what the weekly rate of the benefit should be. As a result, Adjudicator Sewrattan held his IRB entitlement to be $0 per week.

F.H. v. Certas Direct Insurance Company (17-003735)

The claimant sought entitlement to treatment outside of the MIG, five treatment plans, and a special award. Adjudicator Sewrattan found that the claimant suffered from Chronic Post Traumatic Pain Syndrome and was entitled to treatment outside of the MIG. Adjudicator Sewrattan preferred the claimant’s expert report over the insurer’s, as the insurer’s report failed to address the claimant’s pre-existing carpal tunnel syndrome and the issue of chronic pain.  Adjudicator Sewrattan found that all of the treatment plans in dispute were reasonable and necessary. Adjudicator Sewrattan held that the claimant was not entitled to a special award as the insurer had not acted unreasonably.

Applicant v. Certas Home and Auto Insurance Company (17-005008)

The claimant sought removal from the MIG and one treatment plan. Adjudicator Kepman concluded that the claimant’s back spasm were clinically associated sequelae to a soft tissue injury, and that the claimant was therefore restricted to MIG-level benefits.