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L.D. v. Gore Mutual Insurance Company (18-011978)

  • June 27, 2023

The claimant sought entitlement to IRBs and a special award relating to a three year prior where she did not attend IEs. The Tribunal dismissed the claim, holding that the insurer had given proper IE notices, and that the claimant did not have a reasonable explanation for failing to attend the IEs. The claimant raised multiple arguments regarding the IE notices and the IE assessors. The adjudicator rejected all arguments. Adjudicator Neilson found that the notices contained sufficient medical and other reasons, as there was specificity to the claimant’s conditions and treatments. The notices properly referred to the benefit being assessed. The number and type of assessments was not excessive, given that the claimant was alleging physical, psychological, and neuropsychological injuries. Further, many of the assessors withdrew from conducting IEs due to aggressive communications from claimant’s counsel, leading to the insurer needing to retain further assessors and make additional IE requests. The scope of the insurer’s requests were similar to the assessments proposed and completed by the claimant’s section 25 assessors. The insurer’s use of assessment centres was not unreasonable, and is permitted by the Insurance Act. There was no violation of the Human Rights Code in the nature or format of the assessments, and the claimant failed to advise on any further accommodations she required (if any). Because the claimant did not have a reasonable excuse for failing to attend IEs, there was no unreasonable delay in the payment of IRBs, and no special award was given. Additionally, Adjudicator Neilson found that the claimant’s arguments were not proven. The insurer was not engaged in criminal harassment in using an investigator to conduct surveillance. The allegations that the insurer’s OT injured the claimant were not proven, and there was no evidence that the OT was made aware of any restrictions the claimant had. The claimant failed to prove that the insurer was selective in its review of the evidence. Furthermore, to the extent that the claimant believed that the assessors were not aware of her medical conditions, the SABS required the claimant to advise of any relevant information. Multiple procedural issues were considered by the adjudicator. The requests for contempt orders against IE facility directors were dismissed, and certain summons were not properly served. The claimant’s attempt to use summons to obtain production of records from assessors and assessment facilities was improper; the claimant was obliged to make the production requests through the insurer’s counsel, and to seek a Case Conference Order if disputes arose about the scope of production and relevance.

Full decision here

TGP Analysis

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  • FILED UNDER LAT Rules, IE Non-Attendance, Special Award
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