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Application for dental benefits dismissed as applicant failed to prove TMJ impairment was accident-related.
The applicant sought statutory accident benefits for dental treatment plans totaling $4,310.00 following a motor vehicle accident.
The insurer denied the plans, arguing the applicant's temporomandibular joint (TMJ) issues were not caused by the accident.
The Licence Appeal Tribunal reviewed the medical evidence and found that the applicant had a pre-existing history of nocturnal teeth clenching and TMJ symptoms that were substantially similar to her post-accident complaints.
Applying the 'but for' test for causation, the Tribunal concluded the applicant failed to establish that her TMJ impairments were sustained as a result of the accident.
The application for medical benefits was dismissed.
Insurer ordered to pay for five of six disputed treatment plans for accident-related injuries.
The applicant was injured in a motor vehicle accident and sought various medical and rehabilitation benefits under the Statutory Accident Benefits Schedule, which the respondent insurer denied.
The adjudicator first determined that the applicant's shoulder and back injuries were caused by the accident, rejecting the insurer's argument that they were pre-existing.
The adjudicator then reviewed six disputed treatment plans.
Five plans for chiropractic, physiotherapy, dental splints, and active release treatment were found to be reasonable and necessary to treat the applicant's ongoing pain and impairments.
However, a treatment plan for extensive psychological services was deemed excessive, with the adjudicator preferring the insurer's psychological assessment that limited sessions were sufficient.
The applicant was awarded the approved treatment plans along with interest on the overdue amounts.
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