Prior to the written hearing, the respondent agreed to remove the claimant from the MIG and pay any invoices for incurred treatment. The claimant decided to proceed with the hearing and sought entitlement to a special award, costs, and interest on overdue payments. Adjudicator Sharma held that the claimant was entitled to the claimed interest only.
The applicant sought various medical benefits, as well as an award pursuant to section 10 of O. Reg 664. Adjudicator Truong held that the applicant was entitled to the balance of the treatment plan for a total body assessment and documentation, but was not entitled to medical benefits for physiotherapy. The adjudicator held that the diagnoses listed in the physiotherapy treatment plan were not accident related. The adjudicator also held that the applicant was entitled to an award in the amount of 50 percent of the amount payable plus interest due to: Aviva’s handling of the first treatment plan; Aviva specifically refusing to pay the fees for a progress report it approved; and not providing an updated notice with medical reasons for denying the total body assessment. Aviva had partially approved a treatment plan for documentation and two physiotherapy sessions, and further costs for a progress report as long as a copy would be provided to Aviva. The progress report was provided to Aviva, however, Aviva argued that the report was completed in contemplation of the second treatment plan in dispute. Adjudicator Truong held that it logically follows that a progress report would contemplate further treatment, and the approval letter was ambiguous about what a progress report should include. The adjudicator resolved the ambiguity in favour of the applicant. With respect to the total body assessment, Aviva argued that it was for the purpose of completing the treatment plan, and was subject to the $200 limit per the FSCO Guideline for the completion of an OCF-18. Adjudicator Truong held that no medical reasons were given for denying the total body assessment, thus Aviva was in non-compliance with subsection 38(8) and the assessment was payable pursuant to subsection 38(11).
Seven days prior to an in-person hearing, the claimant brought a motion requesting an Order to add a special award to the issues in dispute and an Order for leave to examine the insurer’s claims adjuster. Adjudicator Maedel granted both requests.
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.
The claimant sought entitlement to 15 treatment plans, non-earner and attendant care benefits. The insurer paid the non-earner and attendant care benefits for two years, before stopping both with IE reports. The insurer, in its written submissions, reversed its position on medical benefits, and ultimately approved the disputed treatment plans. However, Adjudicator Susan Sapin determined the withholding of the treatment amounted to a special award and awarded five percent of the disputed quantum, plus special award interest. On review of the medical documentation, as well as an analysis of the claimant’s pre- and post-MVA lifestyle, along with finding favour in the claimant’s subjective reports, it was held that the claimant suffered a complete inability to carry on a normal life and was therefore entitled to ongoing NEBs. As it pertained to the claim for attendant care benefits, Adjudicator Sapin determined that the claimant was entitled to a reduced Form 1 quantum, as the claimant failed to demonstrate proof of incurred expense necessary to claim the full amount. Although the insurer sought to quash the claimant’s ongoing attendant care benefits as premature, Adjudicator Sapin held that the claimant needed to dispute the denial of attendant care within the 104 week period, or else forfeit the claim beyond the 104 week due to a possible limitations deadline. On review, it was determined the claimant was entitled to an increased quantum beyond the 104 week cut-off; however, the claimant would first need to apply for, and be designated, catastrophically impaired. Interest on all payable benefits was also awarded.
The insurer sought an order for a number of documents (which the claimant undertook to provide during the Case Conference) and the particulars of the special award claim. Adjudicator Ferguson granted the insurer’s motion, and ordered the claimant to produce the requested documentation within seven days, and to provide the particulars of the special award claim.
The claimant sought entitlement to a special award. During the course of the medical management of the matter, the claimant required medical marijuana. The insurer requested that the claim be submitted via an OCF-18. However, Adjudicator Brian Norris noted that under section 38 a treatment plan is not needed if the drug is prescribed by a regulated health practitioner, as was the case here. Adjudicator Norris reviewed the correspondence between the claimant and the insurer and determined that although wrong to request a treatment plan, the insurer did not act unreasonably to delay a claim as there was other reasons needed for the treatment plan; namely, to determine the appropriate date of loss being claimed as the claimant was involved in multiple MVAs. As a result, no special award was provided.
The claimant sought entitlement to a number of medical treatment plans. The insurer asserted a MIG position. On review of the medical reports and evidence, Adjudicator Sandeep Johal concluded the claimant provided compelling evidence that the injuries sustained warranted removal from the MIG. The treatment plans were also considered reasonable and necessary. However, despite the claimant seeking a special award, Adjudicator Johal noted no evidence was tendered by the claimant to demonstrate the unreasonable withholding of benefits; the special award claim was dismissed.
The claimant sought entitlement to three treatment plans. The insurer asserted the plans were not reasonable and necessary. Adjudicator Paul Gosio reviewed the medical evidence and concluded the treatment plans were reasonable and necessary. Although the claimant sought a special award, Adjudicator Gosio denied the claim and noted that “an insurer will not face a special award just because an arbitrator finds that the insurer got it wrong.”
The claimant sought entitlement to IRBs and various medical benefits. Regarding IRBs, Adjudicator Bickley held that the claimant had failed to prove a substantial inability beyond three months, and also held that the claimant had failed to provide financial records supporting a higher weekly IRB quantum. The adjudicator made an adverse inference due to the claimant’s failure to provide requested financial records. In terms of the medical benefits, Adjudicator Bickley held that the claimant’s non-attendance at two IEs barred her from seeking a chronic pain treatment plan. Two other assessments were approved as being reasonable and necessary. The remaining treatment plans were denied. Finally, Adjudicator Bickley allowed the claimant to add a special award to her claim, but denied entitlement to such an award.
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150 York Street, Suite 1800
Toronto, Ontario M5H 3S5
416.507.1850
© 2020 Thomas Gold Pettingill LLP