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S.M. v. Unica Insurance Inc. (18-010164)

  • June 25, 2020

The Tribunal had found the claimant entitled to (among other things) $6,000 per month in ACBs and granted a 25 percent special award. The insurer sought reconsideration. Adjudicator Boyce granted the reconsideration and reduced the payable ACBs and concluded that no special award was payable on ACBs or an awarded home modification. With regard to the ACBs award, the claimant was only entitled to payment for service incurred but in the amount provided for by the hourly rates set out in the Guidelines (as opposed to the amount actually incurred). The Tribunal erred by awarding the claimant “up to $6,000” for whatever was incurred at whatever rate the service provider charged. With regard to the special award, Adjudicator Boyce held that the Tribunal imposed a greater burden on the insurer than was appropriate. It was unreasonable to expect an adjuster to micromanage the assessments of qualified professionals, and the adjuster was entitled to rely upon their expert opinions.

Full decision here

TGP Analysis

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  • FILED UNDER Attendant Care Benefits, Special Award, Reconsideration
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