Category: Special Award

The claimant applied to the LAT seeking entitlement to a treatment plan for physiotherapy and sought a special award. Adjudicator Boyce found the claimant was entitled to the treatment plan, plus interest, and given a special award in the amount of $250.00. Adjudicator Boyce found that the insurer’s denial letter did not comply with section 38(8), as the insurer did not provide adequate medical reasons for its denial. In particular, the insurer noted in its letter that there was “”no compelling evidence”” to support treatment, however, the insurer had medical documentation in its possession where medical professionals recommended the precise treatment in dispute. Adjudicator Boyce found that per section 38(11), the treatment plan was payable. Adjudicator Boyce also found that the insurer unreasonably withheld the payments as it did not provide a proper denial. Adjudicator Boyce awarded a special award in the amount of $250 representing approximately 10 percent the cost of the disputed treatment plan.

The claimant sought a medical benefits in the amount of $12,341.56 proposing that the insurer pay the cash difference between her old vehicle, a 2016 Volkswagen Jetta, and a new vehicle, a 2017 Hyundai Tucson, which was a larger and more spacious SUV. The claimant and her treating OT argued that the new vehicle was necessary as the claimant’s job as a coffee shop newspaper producer and distributor required her to drive to over one hundred locations in the province over the course of two days every week to deliver papers. They noted that her old vehicle was smaller and lower to the ground which caused a strain on her hips while driving, made it more difficult to get in and out of the vehicle, and that the lower trunk height caused a strain on her back. The insurer denied the treatment plan on the grounds it was not reasonable or necessary as a result of the accident. The insurer noted in its denial letter that an IE would be arranged, but did not follow-up up on this and had no competing medical opinion. The claimant ended up purchasing the Hyundai. Vice-Chair Boyce noted that the claimant submitted two reports by the OT in support of the new vehicle, an original report from 2017, and an addendum report from 2020. Both the claimant and the OT took measures to find cheaper alternatives when selecting vehicles. Because the insurer did not arrange an IE, the claimant made the decision to purchase the Hyundai after a lengthy delay as it was necessary for her continued employment. Vice-Chair Boyce ruled in the claimant’s favour and found the medical benefits payable. A special award in the amount of $1,200.00 was also granted for the insurer’s withholding and delay.

The claimant sought payment for a housing accessibility assessment in excess of the $2,000 approved by the insurer, and sought a special award on cognitive training sessions that had been denied in 2017 but approved shortly before the hearing. Adjudicator Grant held that the $2,000 limit for assessments in section 25 applied to housing accessibility assessments, and that there was no carve out created by any Guidelines. He granted a special award of $200 on the cognitive training because the insurer had approved it shortly before the hearing, and had approved a similar treatment plan only months after denial of the subject treatment plan. The insurer had not set out a clear rationale for refusing the denied fees in the first place, and its approval of similar fees a few months later suggested that the fees were reasonable and necessary.