3 total
Application for accident benefits dismissed; ongoing pain attributed to pre-existing obesity rather than the accident.
The applicant sought entitlement to statutory accident benefits for chiropractic, physiotherapy, and other goods and services following a motor vehicle accident.
The respondent denied the treatment plans, arguing the ongoing pain symptoms were driven by unrelated medical issues or pre-existing conditions, specifically obesity.
The Tribunal found that the applicant had not demonstrated the treatment plans were reasonable and necessary, noting a lack of progress despite significant prior facility-based treatment.
The Tribunal accepted the evidence of the respondent's section 44 assessors over the applicant's treating practitioners.
The application was dismissed.
Application for accident benefits dismissed; applicant failed to prove treatment plans were reasonable and necessary.
The applicant was injured in a motor vehicle accident and sought payment for three physiotherapy treatment plans and one psychological treatment plan under the Statutory Accident Benefits Schedule.
The respondent denied the physiotherapy plans on the basis that the applicant's soft tissue injuries had resolved and she had reached maximum medical recovery, and partially approved the psychological plan.
The Tribunal found that the applicant failed to prove the physiotherapy plans were reasonable and necessary, preferring the evidence of the respondent's section 44 assessors.
The Tribunal also upheld the respondent's partial approval of the psychological plan as a reasonable approach given the applicant's uncertain prognosis.
Insurer's non-compliant notices regarding treatment plan denial and examinations render the plan payable and warrant a 10% award.
The applicant sought statutory accident benefits for a physiotherapy treatment plan following a motor vehicle accident.
The respondent insurer denied the plan and required the applicant to attend insurer examinations.
The Tribunal found that the respondent's notices denying the plan and requiring the examinations did not comply with the requirements of sections 38(8) and 44(5) of the Schedule, as they failed to provide meaningful medical and other reasons.
Consequently, the applicant was not required to attend the examinations, and the treatment plan became payable under section 38(11)2 upon proof that the expenses were incurred.
The Tribunal also awarded interest and a 10 percent award under section 10 of O. Reg. 664, finding the respondent's prolonged failure to provide meaningful reasons to be stubborn and unyielding.
