Nursing home providing insured with adequate attendant care services

May 26, 2014, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

Heard Before:  Pamila Ahlfeld

Date of Decision: March 31, 2014

  

Quy Luong was injured in a car accident on February 13, 2010.  She was struck by an SUV and pinned beneath it. She suffered many injuries including broken hips, broken ribs, a collapsed lung, internal injuries, and a broken leg. She required numerous surgeries and blood transfusions. She was hospitalized for nearly three months. Prior to her discharge an OT had concerns regarding Mrs. Luong’s ability to live in her son’s home and recommended $6,825.00 in modifications required to make the home accessible which Allstate denied. Her son felt he could not adequately car for her at home and eventually she was placed in a nursing home. Approximately two years post-accident Mrs. Luong ‘s injuries were deemed to be catastrophic.  There is no dispute with respect to her catastrophic impairment. Allstate paid attendant care to Quy Luong in the amount of $6,000.00 per month while she lived at her son’s residence.  There is no dispute over the attendant care paid prior to May 2012.

 

Disputes arose between the parties over the amount of benefit to be paid. Is Quy Luong entitled to $6,000.00 per month even if the actual amount charged by the nursing home is less than that amount?

 

The issues in this hearing are:

  1. What is the amount of attendant care benefits that Quy Luong is entitled to from May 1, 2012 to present and ongoing?
  2. Is Quy Luong entitled to receive $6,825.00 for the cost of a home renovation treatment plan dated May 5, 2010?
  3. Is Quy Luong entitled to interest pursuant to section 46(2) of the Schedule?
  4. Is Quy Luong entitled to a special award pursuant to section 282(10) of the Insurance Act?
  5. Is either party entitled to expenses of the arbitration proceeding pursuant to section 282(11) of the Insurance Act?

 

Ms. Luong argues the Regulations should be interpreted broadly in the favour of the applicant. The Arbitrator reviewed the law in the case. He also reviewed two Form 1s prepared by the nursing home which both indicated her attendant care costs exceed $6000 per month. Ms. Luong argues that her family provides significant services beyond what the nursing home provides, and that the money should be paid to her to be distributed as she sees fit.

 

Allstate argued that the issue is the amount of expenses reasonably and necessarily incurred by or on behalf of Mrs. Luong, and that the amount payable to Mrs. Luong is the cost of reasonable and necessary services that are being provided by the family as per the Form 1 and the amount billed to her by the nursing home.

 

The Arbitrator reviewed all of the evidence and hearing submissions from the parties and found Allstate’s arguments to be more persuasive. Mrs. Luong has chosen to avail herself of the care of a nursing home where OHIP pays a portion of her stay and the family pays a co-pay. Her family in fact does provide many services and visits to her in the home, but the nursing home care is by and large adequately caring for her.

 

Result:

 

  1. Quy Luong is entitled to receive the following attendant care benefits:
    1. From May 22, 2012 to May 31, 2012 the copay amount of $612.30 plus an additional $345.47 for family services which totals $957.77.  The total amount of attendant care benefits for the month of May 2012 is $4,153.80 (prorated amount paid prior to Quy Luong moving to Kennedy Lodge)[2] plus $957.77 = $5,111.57.

 

  1. From June 1, 2012 to February 28, 2013, the copay amount of $1,862.41 plus an additional $1,070.98 for family services which totals $2,933.39 a month.

 

  1. From March 1, 2013 to March 19, 2013, the copay amount from Kennedy Lodge of $1,163.37 plus an additional $34.54/day x 19 days = $656.26; and from March 20, 2013 to March 31, 2013, the copay amount from Mon Sheong of $897.48 plus the family services of $381.60.  The total amount of attendant care benefits for March 2013 is $3,098.71.

 

  1. From April 1, 2013 to July 1, 2013, the copay amount from Mon Sheong of $2,274.86 plus the family services of $985.90 which totals $3,260.76.

 

  1. From July 1, 2013 and onwards, the copay amount of $2,308.32 plus the family services of $985.90 which totals $3,294.22.

 

  1. Quy Luong is not entitled to receive $6,825.00 for a home renovation treatment plan dated May 5, 2010.

 

  1. Quy Luong is entitled to be paid interest in accordance with section 46(2) of the Schedule on the amount owing for attendant care calculated as the difference between what has been paid monthly and the new rate set in this decision.

 

  1. Quy Luong is not entitled to a special award.
Posted under Accident Benefit News, Car Accidents, Catastrophic Injury, Fractures, Paraplegia, Treatment

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About Deutschmann Law

Deutschmann Law serves South-Western Ontario with offices in Kitchener-Waterloo, Cambridge, Woodstock, Brantford, Stratford and Ayr. The law practice of Robert Deutschmann focuses almost exclusively in personal injury and disability insurance matters. For more information, please visit www.deutschmannlaw.com or call us toll-free at 1-866-414-4878.

It is important that you review your accident benefit file with one of our experienced personal injury / car accident lawyers to ensure that you obtain access to all your benefits which include, but are limited to, things like physiotherapy, income replacement benefits, vocational retraining and home modifications.

Practice Areas

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  2. Motorcycle accidents
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  4. Catastrophic injury
  5. Brain or Head injury
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  5. Fractures or broken bone injury
  6. Pedestrian accidents
  7. Chronic pain
  8. Truck accidents
  9. Amputation and disfigurement
  10. Fibromyalgia
  11. Nursing Home Fatality Claims

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