Attendant care benefits for nursing home resident limited to copay amount plus reasonable family services.
The applicant was catastrophically injured in a motor vehicle accident and sought attendant care benefits of $6,000 per month while residing in a nursing home.
The insurer argued it was only required to pay the nursing home copay amount plus reasonable and necessary family care services, relying on section 60(2) of the Schedule.
The arbitrator agreed with the insurer, finding that paying the maximum benefit when the actual incurred nursing home costs were lower would amount to unfair enrichment.
The arbitrator calculated the reasonable and necessary family care services to be added to the copay amount.
The applicant's claim for a home renovation assessment was denied because prior approval was not obtained and there was no immediate risk of harm.
Interest was awarded on overdue amounts, but a special award was denied as the insurer had acted reasonably.
OFSCDRSOntario Financial Services Commission - Dispute Resolution ServicesMar 31, 2014
