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R.M. v. Certas Home and Auto Insurance Company (18-007521)

  • August 6, 2020

The claimant disputed entitlement to the cost of CAT assessments in the amount of $22,400. The claimant argued that the proposed assessments were reasonable and necessary to determine whether or not she sustained a catastrophic impairment because “it is possible [she] may be catastrophically impaired, either under s. 3.1 of the Schedule, criteria 7 (whole person impairment) or criteria 8 (marked impairment in there or more areas of function).” The claimant further pleaded that she did not have the means to fund the assessments herself, nor was she personally required to fund the assessments under section 25 (1) 5. In Response, the insurer pleaded that first, the each assessment must be reasonable and necessary, and second, that the fees charged for each assessment must themselves be reasonable. The insurer further noted that the claimant had the burden to show that each constituent element that makes up the CAT assessment is itself reasonable and necessary on a balance of probabilities. Adjudicator Farlam agreed that the onus of proof was on the claimant, and that the associated fees must also be proven to be reasonable and necessary. Adjudicator Farlam dismissed the claimant’s case, noting a lack of medical evidence in the records reviewed, including a lack of explanation by the claimant’s treating practitioners as to how the specific conditions alleged by the claimant were related to the subject accident. Adjudicator Farlam was extremely critical of the claimant’s CAT assessors, in particular, Dr. Igor Wilderman, a general practitioner with a focus on chronic pain. Dr. Wilderman diagnosed the claimant with PTSD, despite seemingly not having a licence to practice psychology or psychiatry; his failure to note in his report that he reviewed key evidence, including psychiatric reports on record, or explain in sufficient detail how any of the 14 diagnoses he made were actually caused by the subject accident. Of note, Dr. Wilderman listed “female sex” as one of the claimant’s barriers to recovery. Adjudicator Farlam gave this report little weight.

Full decision here

TGP Analysis

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  • FILED UNDER CAT Assessments
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