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Joseph v. ACE INA Insurance (19-010124)

  • February 7, 2022

The claimant was involved in a motor vehicle accident in 2018. He was later determined to be catastrophically impaired as a result of the accident. The claimant applied to the LAT seeking entitlement to numerous medical and rehabilitation benefits, including the cost of cancellation fees, home modifications totaling $262,619.50, the cost of a trip to Haiti, and provider travel time for a psychologist. The majority of the treatment plans in dispute had been partially approved. Both parties claimed costs of the hearing in relation to allegations of conduct resulting in a delayed and unnecessarily lengthy hearing. The insurer also sought judgment in relation to unspecified costs previously awarded in relation to two motions. Adjudicator Grieves found that the claimant was entitled to partial payment of the proposed cost of a trip to Haiti for therapeutic purposes (the claimant was from Haiti; the insurer had previously approved two trips and denied the third proposed trip; and in Haiti, the claimant reportedly participated in “family cultural practices and received alternative therapies.”) The claimant was not entitled to the remaining issues in dispute. The travel time of the psychologist was considered not reasonable and necessary because the claimant had access to approved transportation expenses and on several occasions had indicated a preference for receiving treatment at the therapist’s office. The insurer had previously approved home modifications in the amount of $30,670.75. Adjudicator Grieves found that the disputed amount was not payable because the modifications proposed in the claimant’s report were largely to address speculative future needs, not to address the claimant’s current disability. Neither party was awarded costs of the hearing. Adjudicator Grieves held that the standard for ordering costs was very high and found that both parties contributed to the delay and inefficiency of the hearing. The insurer was awarded $350 in costs in relation to two prior motions. Costs were awarded because the claimant’s “conduct interfered with the Tribunal’s ability to conduct a fair, efficient and effective process, and resulted in wasted resources and prejudice to the respondent.” In addition, Adjudicator Grieves found that the claimant’s “misconduct was serious in that it resulted in delay of the start of the hearing and wasted time for the parties in preparing and responding to a motion that the applicant succeeded on and then essentially requested to ‘undo’.”

Full decision here

TGP Analysis

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  • FILED UNDER Medical Benefits, Costs, Home Modification
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