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A.J. v. Aviva General Insurance (19-010794)

  • September 24, 2020

The claimant disputed entitled to two treatment plans for physiotherapy and chiropractic services. The insurer disputed the claimant’s entitlement based upon IE reports, and argued that new evidence was submitted in the claimant’s reply submissions were prejudicial. The insurer, by way of motion, requested that the new evidence was improperly submitted and requested it be struck from the hearing record. Adjudicator Grant partially agreed with the insurer regarding the striking of evidence. Adjudicator Grant noted that the right of reply was limited, and reply arguments were not the place to make new arguments or submit new evidence. The paragraphs containing new evidence or arguments were struck, and the paragraphs containing new medical claims (i.e., chronic pain) were struck as well as they were not supported by any previous evidence or arguments. The claimant argued that he was unable to include the new arguments in his original submissions due to COVID 19. Adjudicator Grant did not accept this argument, noting that the claimant could have communicated his inability to meet the submission deadline to the parties to ensure action was taken, and noted that the insurer was prejudiced by the late filing and new evidence as it was unable to mount a defence to the same or reply in kind. Adjudicator Grant determined that the disputed treatment plan for physiotherapy services was reasonable and necessary as both the claimant’s expert report and the IE assessor had reached similar conclusions regarding his physical status. The treatment plan for chiropractic services was not reasonable or necessary as it recommended an exercise bike and home exercises, which did not require the direct supervision of a chiropractor.

Full decision here

TGP Analysis

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  • FILED UNDER Medical Benefits, LAT Rules
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