D.T. v. Wawanesa Mutual Insurance Company (16-000266)

The claimant sought reconsideration of the Tribunal’s decision to deny medical benefits above MIG limits and IRBs. The Tribunal had denied the claimant’s entitlement to these benefits based on its review of the available medical evidence. The claimant made multiple arguments: first, that the Tribunal did not consider evidence indicating she suffered from a pre-existing condition; second, that the Tribunal considered improper surveillance footage; and, lastly, that the Tribunal erred in refusing her requests for an oral hearing and for the hearing to be recorded. Executive Chair Lamoureux denied the reconsideration request. She held that the Tribunal had properly reviewed the entire medical record when it determined that the claimant fell within the MIG. She noted that claimant’s counsel had provided the Tribunal with little guidance regarding the evidentiary record, and had failed in its duty to best present the claimant’s position. She further held that the Tribunal had properly addressed the claimant’s objections to the surveillance footage, and any new concerns raised in the reconsideration request were not permissible. Moreover, Executive Chair Lamoureux held that the claimant’s rights to procedural fairness were not affected by the Tribunal’s decisions to deny her requests for an oral hearing and for the hearing to be recorded.

D.T. v. Wawanesa Mutual Insurance Company (16-000266)

The claimant sought reconsideration of the Tribunal’s decision to deny medical benefits above MIG limits and IRBs. The Tribunal had denied the claimant’s entitlement to these benefits based on its review of the available medical evidence. The claimant made multiple arguments: first, that the Tribunal did not consider evidence indicating she suffered from a pre-existing condition; second, that the Tribunal considered improper surveillance footage; and, lastly, that the Tribunal erred in refusing her requests for an oral hearing and for the hearing to be recorded. Executive Chair Lamoureux denied the reconsideration request. She held that the Tribunal had properly reviewed the entire medical record when it determined that the claimant fell within the MIG. She noted that claimant’s counsel had provided the Tribunal with little guidance regarding the evidentiary record, and had failed in its duty to best present the claimant’s position. She further held that the Tribunal had properly addressed the claimant’s objections to the surveillance footage, and any new concerns raised in the reconsideration request were not permissible. Moreover, Executive Chair Lamoureux held that the claimant’s rights to procedural fairness were not affected by the Tribunal’s decisions to deny her requests for an oral hearing and for the hearing to be recorded.

Applicant v. Security National Insurance Company (16-003024)

The claimant sought entitlement to medical benefits and removal from the MIG. He also argued that the insurer’s denials did not comply with section 38 of the SABS. Adjudicator Belanger-Hardy dismissed the claims. She held that the insurer’s denials provided sufficient information to comply with the SABS. She also held that the evidence submitted supported a finding of minor physical injuries, and insufficient evidence was submitted to support an accident-related psychological injury.

C.A. v. The Dominion of Canada General Insurance Company (16-004033)

The claimant sought further medical benefits and removal from the MIG. Adjudicator Hines concluded that the claimant’s injuries were minor injuries, and rejected the expert opinion of his assessors. Adjudicator Hines was critical of the claimant’s assessors for failing to be provided with full medical documentation, for relying largely upon the claimant’s self-reporting, and for ignoring contradictions. She also noted that the bulk of medical evidence supported a diagnosis of soft tissue injuries, and that the claimant had not sought treatment for over one year.

C.J. v. The Personal Insurance Company of Canada (16-002815)

The claimant sought entitlement to medical treatment plans. The insurer denied payment and maintained a MIG defense. On review of the evidence, Adjudicator Rebecca Hines determined the claimant did not provide compelling evidence to warrant removal from the MIG. It was also noted the claimant did not consume treatment previously approved. Accordingly, the treatment plans were found not payable.

C.J. v. The Personal Insurance Company of Canada (16-002815)

The claimant sought entitlement to medical treatment plans. The insurer denied payment and maintained a MIG defense. On review of the evidence, Adjudicator Rebecca Hines determined the claimant did not provide compelling evidence to warrant removal from the MIG. It was also noted the claimant did not consume treatment previously approved. Accordingly, the treatment plans were found not payable.

G.K. v. Wawanesa Mutual Insurance Company (16-004479)

The claimant sought entitlement to medical benefits. The insurer asserted a MIG designation. On review, Adjudicator Sewrattan determined that the pre-existing back pain of the claimant would not prevent recovery under the MIG. The claimant’s injuries were deemed minor and the treatment plans were denied.

K.K. v. Aviva Insurance (16-000863)

The claimant sought entitlement to four medical treatment plans. At the hearing the claimant also sought to add a claim for a special award and interest. On review, Adjudicator Bickley refused to allow the additional issues. After examining the medical evidence, one treatment plan was found reasonable and necessary. Because the treatment plan was originally partially approved up to MIG limits, the subsequent removal from the MIG precluded the insurer from taking the position the plan was unreasonable. The rest of the claims, however, were dismissed on the merits.

M.R. v. Aviva Insurance Company of Canada (16-00216)

The claimant sought a determination that his impairments were outside of the MIG and entitlement to attendant care benefits. As a preliminary issue, the respondents sought to exclude the supplementary report of Dr. El-Hage, psychologist, and the sworn affidavit of the occupational therapist. Adjudicator Nemet granted the motion, as the material was written less than 30 days before the hearing and was clearly generated to address evidentiary deficiencies in the claimant’s case as set out in the respondent’s submissions. Further, the respondent would not have the chance to cross-examine the expert, as neither were being called by the claimant. The adjudicator found that the claimant’s psychological injuries fell outside of the MIG. The claimant’s evidence was that she required 45 hours per week of attendant care assistance, and that these services were provided by various family members. The adjudicator found that there was no reliable evidence by way of invoices, logs or any other corrobative evidence to what services, when, by whom and for how long were provided. He was not satisfied that the claimant had “incurred” the expenses as required by section 3(7)(e), noting that the evidence was consistent with the notion that the family members volunteered to help and that discussion about payment did not occur until much later. The adjudicator concluded that the claimant was not entitled to attendant care benefits, and dismissed the application.

K.L. v. Aviva Insurance Company of Canada (16-002397)

The claimant sought removal from the MIG and entitlement to five treatment plans based on a spinal compression fracture identified two years after the accident. The insurer argued that the claimant had not proven that the compression fracture was related to the accident. Adjudicator Shapiro agreed with the insurer and concluded that the claimant had not met his onus of proof in demonstrating that the fracture was accident-related.