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J.M. v. Wawanesa Mutual Insurance Company (18-006148)

  • February 27, 2020

The insurer sought reconsideration of the Tribunal’s award of $6,000 per month in ACBs. The claimant was involved in an accident in 2015 and deemed catastrophically impaired three years later. The claimant’s Form 1 recommended $8,467.65 worth of ACBs per month; the insurer’s Form 1 supported $1,583.45 in ACBs per month. The insurer argued that the Tribunal erred in its decision, and that the evidence showed that the claimant was largely independent at the time the Form 1 was submitted, that the Tribunal did not properly apply the “but for” test, that the Tribunal incorrectly admitted late evidence, and failed to apply the proper law in relation to ACBs. Adjudicator Lester reiterated the exhaustive list of reasons why such a high quantum of ACBs were warranted and rejected the reconsideration request. She further commented that, although the claimant’s Form 1 was not included in the evidence brief prior to the hearing, the insurer had a chance to object to it being admitted into evidence at the hearing and did not, it was also a key piece of evidence that caused no prejudice to the insurer as it was aware of it prior to the hearing. Although the claimant and her treating therapists did not specifically elaborate on a precise breakdown of each line of the Form 1 in dispute, Adjudicator Lester was satisfied that it was reasonable on the grounds of the claimant’s psychological injuries requiring a higher level of assistance, such as cueing.

Full decision here

TGP Analysis

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  • FILED UNDER LAT Rules, Attendant Care Benefits, Reconsideration
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