Category: Section 57

Jama v. Unifund (20-005328)

The insurer brought a preliminary issue hearing seeking an order that the claimant was not entitled to receive an IRB pursuant to section 57, which outlines an insured person’s responsibility to pursue reasonable, necessary, and available forms of treatment if the insured person continues to receive a weekly benefit, such as an IRB. Adjudicator Mazerolle held that the insurer did not provide proper notice of its intention to cease payment of the claimant’s IRB and dismissed the insurer’s motion. Adjudicator Mazerolle found that the insurer did not provide proper notice per section 57(5) as the insurer did not make any specific mention of the IRB payment nor did the insurer advise the claimant of an intention to stop paying benefits in its notice letter. Adjudicator Mazerolle held that it was the insurer’s obligation to adhere to notice requirements if it was going to stop benefits.

P.M. v. Aviva General Insurance (18-009518)

The insurer was paying the claimant IRBs for over a year after the accident when it suspended IRBs due to the claimant’s failure to obtain necessary treatment and in providing relevant information under section 33 (the status of recommended psychological treatments and the updated clinical notes and records from the family physician). IRBs were reinstated after the claimant submitted a treatment plan for psychological treatment and remain ongoing. She applied to the LAT regarding the IRBs withheld for nine months. Adjudicator Makhamra concluded that the claimant was entitled to payment of the withheld IRBs. First, she held that while the claimant was in breach of section 33, the claimant had a reasonable explanation because she believed she was making best efforts and was complying with her family physician’s recommendations. She also believed the insurer had the ability to obtain the medical records with her consent. Second, the adjudicator held that the claimant was not in breach of section 57 as the claimant was receiving help for her psychological symptoms from her family physician and a social worker during the period of suspension.

R.S. v. Wawanesa Mutual Insurance Company (17-000513)

In this preliminary decision relating to IRBs, the insurer argued that the claimant had failed to provide documents requested under section 33 of the SABS, and that the claimant failed to seek medical treatment as required under section 57 of the SABS. Adjudicator Norris held that the claimant had failed to provide relevant documents over the period of approximately 5 months, and that the insurer was not required to pay IRBs for that period. In terms of the requirement to treat, Adjudicator Baker held that the claimant’s medical records show that he was attending medical treatment and therefore section 57 did not justify discontinuing IRBs.