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Walcott v. Aviva General Insurance (19-007910)

  • January 15, 2021

The claimant sought entitlement to three treatment plans for chiropractic services, one treatment plan for psychological services, and a catastrophic impairment assessment. Adjudicator Grieves noted that given the time elapsed before the claimant reported any accident-related complaints, and that there were only three entries relating to the accident despite seeing her family physician very frequently, the lack of objective evidence of ongoing injuries, and no recommendation from the neurologist, the claimant had not met her burden of proof. Therefore, the claimant was not entitled to the chiropractic services. With regards to the psychological services, the claimant’s family physician made referrals for psychotherapy, she was engaging in treatment which had been helpful, and the insurer’s assessors concluded that she met the criteria for an adjustment disorder with depressed mood and anxiety. Adjudicator Grieves concluded that the proposed treatment and associated cost were reasonable and necessary. Further, a treatment plan was submitted proposing various catastrophic assessments. The claimant relied on a report stating that the claimant’s psychosocial sequelae were causing challenges and disruptions to her life and normal activities such as being an effective spouse, mother and preventing her from returning to work. The claimant also submitted that there was a reasonable possibility that she was catastrophically impaired because her serious psychiatric conditions prevented her from returning to work or care for her children. Adjudicator Grieves found that the catastrophic assessments were partially reasonable and necessary. Adjudicator Grieves agreed that the claimant sustained serious psychological issues as a result of the accident, however, she had not established why each component of the multidisciplinary assessment was reasonable and necessary. A total of $8,400 of the claimed $16,272 was approved.

Full decision here

TGP Analysis

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  • FILED UNDER Medical Benefits, CAT Assessments
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