Category: Special Award

The claimant applied to the LAT requesting ongoing IRBs, removal from the MIG, various medical benefits, and a special award. Before the hearing, the insurer removed the claimant from the MIG, approved the four disputed treatment plans, and approved IRBs up to the 104 week mark. The claimant continued with the claim for post-104 week IRBs and a special award. Adjudicator Shapiro held that the claimant suffered a complete inability to engage in any employment, and awarded post-104 week IRBs. The claimant had been approved for CPP Disability Benefits and LTD benefits in relation to the same injuries. The claimant had limited formal education, worked in a physical job before the accident, and had only rudimentary English skills. The IEs the insurer relied on were form only four months after the accident, and failed to consider the psychological impairments that continued to worsen over time. The surveillance of the claimant did not demonstrate abilities in excess of what the claimant or her treatment providers were reporting. Adjudicator Shapiro also granted a special award of 30 percent on the medical benefits that had been denied based on the MIG. The insurer’s psychological IE had noted a psychological diagnosis, but also stated that it could be treated within the MIG. The insurer ought to have removed the claimant from the MIG once it was aware of the diagnosis. The IE assessor’s opinion about treatment being available within the MIG limits was a legal conclusion rather than a medical opinion, which the insurer should have known not to accept. No special award was given on IRBs as the medical evidence supporting post-104 week IRBs was only provided to the insurer close to the hearing date.

The claimant applied to the LAT disputing the quantum of IRBs he was entitled to. He also claimed the denied portions of two psychological treatment plans. The claimant was self-employed prior to the accident as a renovation contractor. He elected to use the 52 weeks of earnings prior to the accident rather than the last completed taxation year. Adjudicator Farlam accepted the accounting report of the insurer as it was based on the documentation provided by the claimant. The claimant’s own accountant used various assumptions and oral evidence from the claimant that was not supported by financial documentation. For example, the claimant did not provide purchase orders, invoices, sales summary, or time records. Adjudicator Farlam also denied the disputed portions of the psychological treatment plans. She accepted that the insurer’s decision to allow $99.75 per hour for psychotherapy was appropriate (rather than the $224.42 per hour claimed). She also held that the claimant failed to prove why “documentation support activity” was reasonable and necessary. The special award claim was also dismissed. The insurer’s delay in payment of IRBs was due to the claimant’s failure to provide financial documentation.

The claimant sought entitlement to post-104 week IRBs, physiotherapy, and a special award. Adjudicator Mather granted the claim for ongoing IRBs, but dismissed the claim for further physical therapy. She also granted a special award of 50 percent on IRBs. The claimant was a self-employed taxi driver for over a decade prior to the accident. He suffered a concussion in the subject accident which led to psychological impairments. He was also in a second accident and made a claim for accident benefits with the same insurer. The insurer denied IRBs based on IEs completed with regard to the subject accident (which concluded he did not have a psychological disorder) despite having IEs from the second accident in which the claimant was diagnosed with major depressive disorder, general anxiety, panic attacks, and vehicular phobia. The psychological IE in the subject accident ignored various relevant factors and cherry-picked evidence that was supportive of denying IRBs (such as the claimant attempting a return to work for a few hours per day). Given the claimant’s lack of other relevant job experience and poor English skills, there were no other potential types of employment that were suitable for him. Adjudicator Mather found the insurer’s denial of IRBs to be unacceptable. She held that the insurer failed in its adjusting of the claim by ignoring the psychological diagnoses in its own IEs related to the second accident. She also noted that the insurer continued to approve psychotherapy while taking the position the claimant did not have a psychological impairment preventing him from working. The claimed physiotherapy was dismissed as the claimant did not provide evidence of the need for further physical therapy. He also failed to provide evidence of treatment received to date or the progress that physical treatment provided.