Our client was involved in a motor vehicle accident in February 2015 where she was rear ended at a red light, causing her to strike her head on the roof. That same day she was taken to the hospital. Shortly after she was diagnosed with a concussion and had complaints of headaches, nausea, reduced focus, increased fatigue, and other difficulties with mental processing, memory, word-finding and other cognitive related issues. In addition to her cognitive impairments, she also suffered from chronic neck pain, upper back pain, shoulder pain, depression and anxiety.
Due to her accident-related impairments, our client claimed for a variety of benefits from her accident benefits insurer, which were subsequently denied. As a result, we applied to the Licence Appeal Tribunal (LAT) to dispute the denied benefits. We also filed for an award arguing that the insurer inappropriately by unreasonably delaying or withholding payments.
Adjudicator Punyarthi overturned the accident benefits insurer’s denials and also granted an award to our client for the following reasons:
First, the adjudicator found that our client was entitled to medical benefits for physiotherapy. The adjudicator noted that we had disputed the insurer’s denial letter by referencing the report of Dr. Kopyto, who was a physician retained by the insurer in relation to the treatment plan. We also noted that Dr. Kopyto was incorrect about the type of physiotherapy treatment our client had received, the number of sessions she had attended and the benefits she was experiencing. While Dr. Kopyto issued an addendum, he did not appear to address our client’s concerns in any capacity. In addition, the accident benefits insurer did not appear to have reviewed clinical notes of records provided to Dr. Kopyto for the addendum when denying the second physiotherapy treatment plan.
Second, the adjudicator held that our client was entitled to assistant devices denied by the insurer. Again, the adjudicator noted that the insurer’s Occupational Therapist, Ms. Dhillon, provided tests that seemed “narrowly focused and de-contextualized.”
Third, the adjudicator found that our client was entitled to psychological treatment, finding that the Applicant’s treating psychologist, Dr. MacDonald, provided compelling explanations supported by evidence.
Fourth, the adjudicator concluded that our client was entitled to chiropractic treatment. The adjudicator noted that that the insurer’s chiropractor, Dr. Getsos, provided little justification for denying the treatment claimed.
Lastly, the adjudicator found that our client was entitled to an award because the insurer had unreasonably delayed or withheld payments to the Applicant. Specifically, the adjudicator highlighted that the accident benefits insurer was unable to explain why it omitted certain evidence when making its denials.