Licence Appeal Tribunal
Tribunal File No: 17-001061/AABS
Case Name: 17-001061 v Yarmouth Mutual Fire
In the matter of an Application pursuant to subsection 280(2) of the Insurance Act, RSO 1990, c I.8., in relation to statutory accident benefits.
Between:
Applicant
Applicant
and
Yarmouth Mutual Fire
Respondent
DECISION
ADJUDICATOR: Christopher A. Ferguson
Counsel for the Applicant: Matthew D. Reid
Counsel for the Respondent: Shannon Mulholland
HEARD: Written Hearing May 26, 2017
REASONS FOR DECISION
Background
1The applicant was aged 9 years old when he was involved as a passenger in a motor vehicle accident (MVA) on October 5, 2015. He sought benefits pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 2010 (“the 'Schedule'').
2[The applicant] applied for dispute resolution services to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”).
3A case settlement conference held on April 18, 2017 failed to fully resolve the issues disputed by the parties. Accordingly, a written hearing was ordered to be conducted in this matter, commencing June 26, 2017.
4On consent, this matter was heard concurrently with another file, #17-001057/AABS as ordered by the Tribunal in orders dated May 3, 2017 and May 4, 2017 respectively.
5Concurrent hearings were ordered and conducted because the applicants are siblings who sustained injuries in the same MVA, and claim entitlement to benefits arising from the same MVA. In his orders, Adjudicator Johal noted that the applicants were attending the same treatment providers. I would further note that:
(i) The treatment and assessment plans disputed in both files are identical in cost and very similar in substance.
(ii) The responses by the respondent insurer to both applications are virtually identical.
6Despite the similarities between the two cases, I determined each application independently on its own merits with respect to disputed rehabilitation benefits.
7I handled the dispute over whether transport costs – “mileage” -- are payable by the respondent to a service provider jointly, because the same payment is claimed jointly by the two applicants. I elaborate on this below.
Issues
8The substantive issues for me to determine are:
Is [the applicant] entitled to receive a rehabilitation benefit in the amount of $3,700.00 for social worker support, recommended by Natalie Walters, occupational therapist, and Mei-ling Thiessen, registered social worker, of Novus Rehabilitation, in a treatment plan dated February 8, 2016, denied by the Respondent on February 26, 2016?
Is [the applicant] entitled to receive a rehabilitation benefit in the amount of $1,116.32 for in-home occupational therapy (“OT”) assessment, recommended by Natalie Walters of Novus Rehabilitation, in a treatment plan dated November 17, 2015, denied by the Respondent on December 1, 2015?
Is [the applicant], along with his sibling entitled to $598.50 for the travel costs of a service provider associated with an approved treatment plan for physiotherapy approved by the respondent on December 30, 2016 – the travel costs denied by the respondent on January 31, 2017?
Is [the applicant] entitled to interest on overdue payments from the respondent?
RESULT
Findings
9I find that the treatment plan for social work support (issue #1) is not reasonable and necessary.
10I find that the assessment plan for an OT in-home assessment is not reasonable and necessary.
11On the joint claim for travel costs, I find that the respondent is not required by the Schedule to pay it.
12[The applicant’s] application for interest is denied.
Analysis and Reasons: Issue 1 – Social Worker Support
13The parties agree that [the applicant] suffered psychological injuries from the MVA.
14To support [the applicant’s] recovery, the insurer approved a treatment plan for psychological therapy recommended by Dr. Nicole Reist, psychologist, on January 25,