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A.M. v. Certas Home and Auto Insurance (19-002869)

  • August 11, 2020

The claimant disputed entitlement to numerous treatments plans and ACBs in the amount of $6,142.59 per month from November 29, 2018 and ongoing. The claimant was diagnosed with Parkinson’s Disease and Dementia pre-accident, as well as headaches and ear pain. The insurer argued that the benefits claimed were for the claimant’s pre-existing conditions, and that he had only sustained minor soft tissues injuries as a direct result of the subject accident, and were therefore not reasonable or necessary. Adjudicator Watt noted that a review of the pre-accident medical records showed that the claimant was suffering from all of the alleged accident-related complaints long before the subject accident, that the claimant’s own expert reports were often contradictory and lacked compelling arguments as to why the proposed treatments were reasonable and necessary as a result of the accident. further, some of the disputed benefits were available to the claimant through OHIP. The claimant’s own statement’s that he was independent with personal care, along with a lack of evidence that any proposed ACBs would be as a result of the accident, and not his pre-existing conditions, resulted in the claim for attendant care being dismissed along with the rest of the Application.

Full decision here

TGP Analysis

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  • FILED UNDER Medical Benefits, Attendant Care Benefits
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