Tribunal File Number: 17-001145/AABS
In the matter of an Application for Dispute Resolution pursuant to subsection 280(2) of the Insurance Act, RSO 1990, c I.8., in relation to statutory accident benefits.
Between:
A.D.
Applicant
and
Aviva Insurance Canada
Respondent
DECISION
ADJUDICATOR: Robert Watt
APPEARANCES:
For the Applicant: Lucy Lee, Counsel
For the Respondent: Ahmad Khan, Counsel
HEARD: Written Hearing: June 12, 2017
OVERVIEW
1The applicant was injured in an automobile accident on June 3, 2013, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (the ''Schedule'').
2The applicant submitted an application for dispute resolution services to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”).
3The parties participated in settlement discussions at the case conference held on April 25, 2017, but were unable to resolve all of the issues in dispute between them.
ISSUES IN DISPUTE:
4The case conference order dated May 5, 2017, indicated that the following issues were in dispute:
a. Is the applicant entitled to a rehabilitation benefit in the amount of
$2,200.00 for other goods and services recommended by Katie Schinkel of Bayshore Therapy & Rehab, in treatment plan dated March 15, 2016, denied by the respondent on June 22, 2016?
b. Is the applicant entitled to interest on the overdue amounts?
RESULT
5I find that the request for the rehabilitation benefit in the amount of $2,200.00 for other goods and services recommended by Katie Schinkel of Bayshore Therapy
& Rehab, in treatment plan dated March 15, 2016, denied by the respondent on June 22, 2016, is not reasonable or necessary.
6I find that there is no interest owing on overdue amounts.
7I find that the request for the rehabilitation benefit in the amount of $2,200.00, is not deemed automatically to be approved, under the SABS section 38 (11).
THE LAW EVIDENCE AND ANALYSIS
8The applicant‘s position is that the Treatment and Assessment Plan submitted was reasonable and necessary, and therefore should be paid by the respondent. The applicant also states in her written submissions that since the respondent failed to respond to the applicant’s Treatment and Assessment Plan within the required ten days under Section 38 of the SABS, the Treatment and Assessment Plan should be deemed to be approved automatically.
9The respondent’s position is that the Treatment and Assessment Plan is not reasonable and necessary, as required to be under section 15(1) of the SABS, and therefore should not be paid. The respondent also takes the position that as the expense asked for under the Treatment and Assessment Plan submitted wasn’t incurred, it doesn’t need to be paid under section 38 (11) of the SABS.
10Section 15(1) of the SABS requires an insurer to pay for all medical benefits that are reasonable and necessary.
11The only current independent evidence relating to the medical issues raised by the applicant, before me, is the Occupational Therapy Assessment Report dated May 26, 2016, and written by J.P.
12This report could not relate any current diagnosis of the issues to the accident, because of the length of time between when the accident occurred (June 3, 2013), and the date of evaluating the applicant. (May 26, 2016)
13This report also found that the applicant “demonstrated proficiency ambulating, and completing day to day tasks within her home environment…” and that “There are no home adaptations necessary to assist [the applicant] in functioning within her home environment…” and finally that ”actual functional limitations relating to the area of injury were not observed.”
14There is no evidence before me as to what additional requests have been made if any, by the applicant for ongoing treatment, or what medical treatment if any, the applicant is currently taking.
15The evidence before me shows that the applicant is not suffering from any alleged accident related impairments, and that she has not proven that the Treatment and Assessment Plan submitted to the respondent, is reasonable and necessary.
16The evidence before me shows that the respondent was beyond the ten day period permitted by the SABS (section 38(8)), in responding to the applicant’s treatment plan submission.
17There is no evidence before me however, showing that the applicant actually incurred expenses relating to the proposed Treatment and Assessment Plan, and had also submitted invoices to the respondent, as required under the SABS (section 38(15). Therefore, there is no entitlement to that amount from the respondent.
Released: November 28, 2017
__________________
Robert Watt
Adjudicator