Category: Reconsideration

V.S. v. Travelers Insurance Company of Canada (17-001670)

The claimant sought reconsideration that he was not entitled to treatment outside of the MIG. With the insurer having approved both treatment plans in dispute and removing the claimant from the MIG in advance of the reconsideration hearing, the single issue to be decided was whether the claimant was entitled to interest on the insurer’s payment of the outstanding benefits. Executive Chair Lamoureux held that it did. Pursuant to sections 51(1) and (2) of the SABS, an insurer is required to pay interest on any overdue payments of a benefit. The insurer had agreed that the amounts of the treatment were payable and therefore was required to pay interest in accordance with the SABS on any overdue payments.

P.R. v. Aviva Canada Insurance (16-002782)

The insurer requested reconsideration of the LAT’s decision to deny its request for costs, arguing that the claimant’s failure to address serious evidentiary issues throughout he proceeding amounted to frivolous and vexatious conduct warranting a costs award. Associate Chair Batty denied the request. While the LAT did not explicitly apply the definitions of frivolous and vexatious in its decision, the claimant’s actions did not amount to such conduct. The claimant’s application may have been weak, but he filed hundreds of pages of evidence in support of his position and based on that evidence, put forth some rational foundation to advance his position. He was not acting without reasonable or probable cause.

T.F. v. Peel Mutual Insurance Company (16-003316)

The claimant sought reconsideration of the Tribunal’s decision that she was barred from seeking entitlement to two treatment plans, arguing that the insurer’s denials did not provider the requisite medical reasons. Executive Chair Lamoureux agreed with the claimant and overturned the decision. She held that the insurer’s medical reasons had to engage the specific details about the claimant’s condition, and should be adequate enough to allow an unsophisticated person to understand them and make an informed decision. She reasoned that the insurer’s denials in this case failed to cite the specific documentation upon which the insurer was relying in denying the proposed benefits.

T.F. v. Peel Mutual Insurance Company (16-003316)

The claimant sought reconsideration of the Tribunal’s decision that she was barred from seeking entitlement to two treatment plans, arguing that the insurer’s denials did not provider the requisite medical reasons. Executive Chair Lamoureux agreed with the claimant and overturned the decision. She held that the insurer’s medical reasons had to engage the specific details about the claimant’s condition, and should be adequate enough to allow an unsophisticated person to understand them and make an informed decision. She reasoned that the insurer’s denials in this case failed to cite the specific documentation upon which the insurer was relying in denying the proposed benefits.

R.P. v. Wawanesa Insurance Company (16-002947)

The claimant requested reconsideration of the LAT’s decision in favour of the insurer’s denial of entitlement to certain medical benefits, expenses for prescription medication, and interest. He argued that the LAT violated procedural fairness by failing to either refer to or consider certain medical records in its decision. Executive Chair Lamoureux denied the request for reconsideration. She found that while the LAT’s decision did not explicitly refer to all of the documents, it did state that it considered all of the submitted documents and summarized those that were relevant to its findings. In any event, the records did not support a different result.

A.L. v. The Personal Insurance Company (17-002582)

The Tribunal initially decided that the claimant was precluded from applying to the LAT in light of his non-attendance at multiple insurer examinations. Associate Chair Batty initiated a reconsideration on his own initiative to remedy a breach of procedural fairness in the preliminary issue hearing. In its reasons, the LAT had described how the respondent’s submissions relied upon affidavit evidence which had not been filed. Counsel for the respondent subsequently provided proof that the affidavit in question had been filed. It was not provided to the adjudicator as a result of an administrative error. Associate Chair Batty held that the respondent had been denied procedural fairness and remitted the matter to be reheard on the LAT’s full record.

A.L. v. The Personal Insurance Company (17-002582)

The Tribunal initially decided that the claimant was precluded from applying to the LAT in light of his non-attendance at multiple insurer examinations. Associate Chair Batty initiated a reconsideration on his own initiative to remedy a breach of procedural fairness in the preliminary issue hearing. In its reasons, the LAT had described how the respondent’s submissions relied upon affidavit evidence which had not been filed. Counsel for the respondent subsequently provided proof that the affidavit in question had been filed. It was not provided to the adjudicator as a result of an administrative error. Associate Chair Batty held that the respondent had been denied procedural fairness and remitted the matter to be reheard on the LAT’s full record.

I.K. v. Primmum Insurance Company (16-001652)

The claimant sought entitlement to a number of medical benefits as well as attendant care benefits. The insurer argued the claimant was barred from proceeding with a LAT application for failing to attend a number of IEs, pursuant to section 55. The LAT agreed and dismissed the matter. On reconsideration, Executive Chair Linda Lamoureux upheld the decision. It was noted that IEs are an important tool for medical management. In this instance, the insurer’s requests were reasonable. The claimant raised an argument that section 55 should operate to bar a proceeding only for the benefits the IE is reviewing and allow all other claims to proceed. Executive Chair Lamoureux noted this argument was new and should have been raised at the Tribunal level and declined to exercise the discretion to hear fresh arguments at the reconsideration level.

J.R. v. Certas Home and Auto Insurance Company (16-003921)

The claimant sought entitlement to a number of medical benefits. The insurer denied the treatment plans based on IE reports and the LAT agreed with the denials. On reconsideration, however, Executive Chair Linda Lamoureux determined that the Tribunal arrived at the determination in a manner that was procedurally unfair to the claimant. At the Tribunal level, the claimant failed to submit the disputed treatment plans as evidence. Executive Chair Lamoureux determined that the Tribunal deciding in the absence of these documents, without asking the claimant’s counsel for the materials was a breach of procedural fairness and remitted the matter back to the Tribunal for a new determination.

I.K. v. Primmum Insurance Company (16-001652)

The claimant sought entitlement to a number of medical benefits as well as attendant care benefits. The insurer argued the claimant was barred from proceeding with a LAT application for failing to attend a number of IEs, pursuant to section 55. The LAT agreed and dismissed the matter. On reconsideration, Executive Chair Linda Lamoureux upheld the decision. It was noted that IEs are an important tool for medical management. In this instance, the insurer’s requests were reasonable. The claimant raised an argument that section 55 should operate to bar a proceeding only for the benefits the IE is reviewing and allow all other claims to proceed. Executive Chair Lamoureux noted this argument was new and should have been raised at the Tribunal level and declined to exercise the discretion to hear fresh arguments at the reconsideration level.