O.A. v. TD Insurance Meloche-Mennox, 2020 CanLII 87965

1O.A. was injured in an accident on June 30, 2017 and sought various benefits from the respondent, TD, pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (''Schedule''). Over time, O.A.’s condition has deteriorated to the point that he now seeks a determination of whether he is catastrophically impaired (“CAT”) under the Schedule.

2On July 12, 2018, O.A. submitted to TD a Determination for Catastrophic Impairment (OCF-19) form that opined that he met the criteria for CAT impairment. In response, TD scheduled multi-disciplinary assessments in order to determine whether O.A. was CAT. On December 7, 2018, TD notified O.A. that, based on the findings of its assessments, it had determined that O.A. was not CAT. O.A. exhausted his non-CAT funding limits shortly after.

3On December 19, 2018, O.A. submitted a Treatment and Assessment Plan (OCF-18) and accompanying report that sought funding for his own multi-disciplinary CAT assessments in the amount of $25,093.24.

4On January 29, 2019, TD provided notice to O.A. that it agreed to fund $12,000.00 plus HST of the proposed OCF-18 that it determined was reasonable and necessary and in line with what it paid for its own CAT determination assessments. TD also disclosed to O.A. the total amount it paid to its assessors for its multi-disciplinary assessments. TD denied payment of the remaining balance of the OCF-18, being $11,533.24, on the basis that it was not reasonable and necessary and