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T.K. v. Unica Insurance Inc. (16-000372)

  • February 24, 2017

The claimant was involved in two accident and sought two years of attendant care benefits. She submitted a Form 1 fifteen months after the second accident. She had also submitted a Form 1 for her first accident in which she claimed similar needs. Adjudicator Shapiro rejected the entire claim for attendant care benefits. First, he did not accept that the claimant’s AC needs arose as a result of the second accident, noting that she had just completed a Form 1 for her 2013 accident claiming similar needs from that accident. Second, Adjudicator Shapiro held that retroactive ACBs were not always warranted following the submission of a late Form 1. He followed FSCO case law which permitted a late Form 1 to support ACBs prior to submission (Kelly and Guarantee). However, he distinguished that case (where the claimant had serious catastrophic injuries and could not complete a Form 1) to this case (where the claimant was slow in providing a Form 1). Third, Adjudicator Shapiro denied the ACBs claimed after the date of the Form 1 based on the claimant’s admissions to an IE doctor that she was independent in self-care. He also found that some of the claimed services were in fact for childcare assistance and housekeeping, rather than personal care for the claimant.

Full decision here

TGP Analysis

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  • FILED UNDER Attendant Care Benefits
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