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K.W. v. Aviva Insurance Company (18-006959)

  • January 27, 2020

The claimant applied to the LAT seeking entitlement to IRBs, the benefits proposed in two treatment plans, and a special award. The insurer conceded that the claimant qualified for IRBs during the disputed period but contested the quantum of IRBs being claimed. Adjudicator Watt held that post-accident “passive” income earned by a claimant was to be included as a deduction in any calculation under s. 4 and 7 of the SABS, and found that the self-employed claimant was entitled to IRBs in the amount calculated by the insurer’s expert accountant. The claimant was not entitled to a psychological assessment, psychological treatment, or a special award. The psychological assessment was not reasonable and necessary as the claimant had already undergone two assessments. Adjudicator Watt found that the services proposed in the OCF-18 for psychological treatment were not reasonable and necessary, including costs for consultation, communication with the treatment providers, periodic administration, scoring and interpretation of psychological tests, review of external file materials and preparation of status reports and overseeing supervision of another psychologist.

Full decision here

TGP Analysis

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  • FILED UNDER Income Replacement Benefits, Medical Benefits
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