16-000872 v Certas Home and Auto Insurance Company
Tribunal File Number: 16-000872/AABS
Case Name: 16-000872 v Certas Home and Auto Insurance Company
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:
Y.C.T-T.
Applicant
and
Certas Home and Auto Insurance Company
Respondent
REASONS FOR DECISION AND ORDER
ADJUDICATOR: Claudette Leslie
Written Arguments/Evidence Provided By:
The Applicant: Y.C.T-T.
Paralegal for the Applicant: Philip Kai Kwong Yeung
Counsel for the Respondent: Nathalie Rosenthall
Heard: Written Hearing: December 14, 2016
Overview:
The applicant Y.C. T-T. was injured in a motor vehicle accident on November 27, 2013. Following the accident, she applied for and received benefits under the Statutory Accident Benefits Schedule – Effective after September 1, 2010 (the “Schedule”) from the insurer, State Farm Insurance.
She was the passenger in a car driven by her husband on November 27, 2013 when another vehicle collided with and “t-boned” their vehicle.
The airbag deployed and the applicant described being thrown forward and backward. She was taken to hospital by ambulance with complaints of chest pains. She underwent x-ray(s) which revealed there were no fractures. She was released with Tylenol pain relief after several hours at the hospital. The day after the accident, she visited her family doctor complaining of chest and neck pain. The doctor assessed, among other things, tenderness including at 3rd and 7th costal (rib) cartilage.
The applicant continued to experience what she describes as severe pain, and in December 2013, within 1 week of the accident, with the respondent’s approval, she started receiving physiotherapy treatments twice per week. She continued to receive treatment for pain reduction, approved by the respondent, up to March 2014 when the respondent denied approval of further treatment.
At the time of denial, it was the respondent’s position that the applicant had sustained predominantly minor injuries as that term is defined in s. 3 of the Schedule; and subject to a limitation of $3,500.00 for medical and rehabilitation benefits in keeping with s. 18 of the Schedule.
The Schedule refers to a treatment protocol for the treatment of minor injuries; the Minor Injury Guideline (MIG) and a person with minor injuries being treated under the MIG are referred to as being in the MIG. I will use the term MIG to refer to minor injuries hereafter.
In August 2014 the respondent determined that the applicant’s injuries qualified for treatment above the MIG limit of $3,500.00. Despite this change in position, the respondent declined payment of treatment plans dated March 11, 2014, June 21, 2014, expenses which were submitted March 15, 2016; costs submitted May 2016 in the amount of $100.00 for replacement of eyeglasses, and attendant care services assessment costs of $921.22, submitted April 3, 2014.
The applicant disagrees with the insurer’s decision and applied to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”) for an order requiring the insurer to pay the outstanding benefits claimed; as well as applicable, accrued interest. The respondent submits she is not entitled to the benefits claimed.
Issues in dispute:
- The issues as set out before me are:
a. Is the applicant entitled to receive a medical benefit in the amount of $1,386.32 for physiotherapy services, recommended by Mon Sheong Court Physio & Rehab Centre in a treatment plan dated March 11,2014, and denied by the respondent on March 31, 2014 ?
b. Is the applicant entitled to receive a medical benefit in the amount of $2,100.60 for chiropractic services, recommended by Dr. Georgia Palantzas of Mon Sheong Court Physio & Rehab Centre in a treatment plan dated June 21, 2014, and denied by the respondent on July 8, 2014?
c. Is the applicant entitled to receive a medical benefit in the amount of $500 for physiotherapy and acupuncture services, provided by Perfect Physio on January 15 and April 14, 2015, submitted in an expense form on March 15, 2016; and denied by the respondent?
d. Is the applicant entitled to payment for eyeglasses in the amount of $100.00 submitted in an expense form?
e. Is the applicant entitled to payment for the cost of examination in the amount of $921.22 for an Attendant Care Assessment (Form 1), recommended by Mon Sheong Court Physio & Rehab Centre in a treatment plan dated April 3, 2014, and denied by the respondent on April 14, 2014?
f. Is the applicant entitled to interest on any outstanding payment of benefits?
g. Is the applicant entitled to costs?
Preliminary issue:
The submissions provided raise a preliminary issue as to whether the applicant can retroactively be considered to be entitled to treatment plans submitted, before she was taken out of the MIG regime.
In this case, the applicant submitted treatment plans to the respondent in March and April 2014. The insurer made the decision that, pending the outcome of the insurer’s examinations, her injuries fell within the MIG and as such, she qualified for treatment of up to $3,500.00.
Later, in August 2014, the insurer decided that the applicant’s injuries were outside of the MIG, and instead they fell under the non-MIG regime. The insurer’s change of mind was due solely to the outcome of an insurer’s examination conducted in July 2014.
Section 18 of the Schedule makes it clear that the $3,500.00 MIG limit does not apply in a case, such as this, where a health practitioner determines that a person’s accident-related injuries no longer meets the MIG classification, and requires treatment that goes beyond the amount allowed under the MIG limit. In such cases, the legislation allows the insured person to seek treatment outside the scope of the MIG, of up to $50,000.00, if their impairment is not of a catastrophic nature.
I must interpret the legislation in a reasonable fashion. Clearly the respondent’s denial of the treatment plans at the time, was based on a belief that the applicant`s injuries fell within the MIG; until such time as the insurer had medical evidence that determined otherwise.
Based on medical proof obtained by way of an insurer’s examination, the insurer was satisfied that as of July 2014 the applicant’s injuries had progressed beyond those classified under the MIG. As a result, the applicant’s injuries qualified for treatment beyond the $3,500.00 MIG limit. The insurer could not then continue to maintain its denial of the treatment plans, on the basis of its initial belief for two reasons.
Firstly, in the spirit of the overall benefit scheme, and at least as of the date the insurer found the applicant’s injuries no longer met the MIG classification, it was obligated to re-consider the submitted treatment plans under the non-MIG regime. To do otherwise, or to maintain its denial of the treatment plans based on its initial belief of the classification of the applicant’s injuries and in light of proof to the contrary, would undermine the purpose of the benefit scheme to allow access to appropriate treatment.
Secondly, the totality of the evidence before me leads me to believe that the applicant’s impairments should not have been classified as being within the MIG at the time of submission of the treatment plans in March and April 2014. For example: a March 2014 MRI showed degenerative injuries of a “chronic nature”; a physiatrist’s May and July 2014 clinical notes and records indicate “chronic pain syndrome”; and in a June 2014 treatment plan a chiropractor observed that the applicant`s impairment
objectivelyanddemonstrablywarranted treatment outside of the MIG limits. The fact that respondent’s medical examiners came to the same conclusion just months later, supports the conclusion that her injuries were likely outside of the MIG classification in March and April 2014; as it is unlikely that she developed chronic pain, which moved her out of the MIG classification, the week of the insurer’s examination.Consequently, it would be unreasonable to deny consideration of the treatment plans, or of the applicant’s injuries under any other than the non-MIG regime. The only issue I need to consider in this decision is therefore whether the plans are reasonable and necessary.
Result:
- Considering all of the relevant evidence, I have determined that the applicant is entitled to:
a. The treatment plans dated March 11, 2014($1,386.32), June 21, 2014($2,100.60), for physiotherapy and chiropractic services recommended by Mon Sheong Court Physio & Rehab Centre;
b. The cost of an examination in the amount of $921.22 for an Attendant Care Assessment form, recommended by Mon Sheong Court Physio & Rehab Centre in a treatment plan dated, April 3, 2014; and
c. Interest on all outstanding benefit payments as per the Schedule.
d. I have determined that the applicant is not entitled to costs of $100.00 for eyeglasses claimed in January 2016; and
e. The applicant is not entitled to out of pocket expense submitted on March 15, 2016 in the amount of $500 for physiotherapy and acupuncture services provided by Perfect Physio.
- I also find no reasonable grounds that would require the insurer to pay the application filing fee/costs.
Background:
Starting on the day after the accident the applicant began seeing her family doctor, Dr. Kwok, with complaints of pain in various parts of her body. She saw Dr. Kwok on December 2, 9, 27, 2013; several times in 2014 and 2015 including October 25, 2015 and December 22, 2015; and again in January 2016.
On the December 2, 2013 visit, 5 days after the accident, the applicant complained to Dr. Kwok of tingling in her right hand, pain at the right neck, forearms, left side chest wall, lower back and join on both sides. Dr. Kwok continued to treat the applicant for ongoing pain complaints, and he also referred her to specialists for other physical treatments.
She began receiving physiotherapy treatment from Dr. Daniel Wong, to reduce pain in her chest wall, neck, back and lower back pain and sleeping disturbances in December 2013. On March 21, 2014, Dr. Kwok referred the applicant to Physiatrist, Dr. Joseph Wong.
On May 1, 2014, approximately 5 months after the accident, Dr. J. Wong examined the applicant and found her accident-related injuries included, “myofascial injury of neck, upper back, buttock, insomnia, anxiety” and chronic pain syndrome. On her follow up visit on July 11, 2014 he found the applicant still required physiotherapy treatment; and he notes in his October 27, 2016 affidavit submitted for this hearing, at that time, “She still has not reached pre-accident status…”
A bone scan and an MRI for cervical spine ordered by the applicant’s family doctor were conducted in February and March of 2014. The MRI showed degenerative changes of different severity at various, levels of the spine, and “very mild spondylitic changes can be seen at C5-C6 and especially C6-C7 of a chronic nature.”
Subsequent to further medical assessments, recommendations and Insurer’s Examinations (IE) conducted on May 24, 2014 and July 19, 2014, on August 13, 2014, the insurer approved the applicant for treatment outside of the maximum allowed for treatment under the MIG.
Claim for Attendant Care benefits. The applicant also submitted a treatment plan for attendant care benefits on April 3, 2014. The plan included costs for examination/assessment, for an Attendant Care Assessment form which was submitted on April 8, 2014. The request was declined by the insurer on the grounds that she did not qualify for such benefits because treatment of her injuries fell under the MIG regime.
However, after the applicant was removed from the MIG scheme, starting with a November 29, 2014 claim, the insurer approved and paid the applicant’s attendant care benefits from January 2015 to June 2015 (6 months). The respondent did not pay the the previously submitted, April 3, 2014 cost of examination ($921.22) for an Attendant Care Assessment (Form 1), one of the issues disputed in this application.
Evidence/Analysis:
Medical/Rehabilitation Benefits:
- To determine the applicant’s entitlement to the claims for medical/rehabilitation benefits, the applicant must prove that on a balance of probabilities, the recommended treatment plans are reasonable and necessary.
Issues 1 & 2: Are the treatment plans of March 11, 2014 for physiotherapy services and June 21, 2014 for chiropractic services reasonable and necessary?
All considered, I conclude that the treatment plans in question, are reasonable and necessary. The applicant provided persuasive evidence to support this finding.
The evidence indicates that the applicant developed pain which persisted over a long period of time; longer than the estimated 9-12 weeks recovery period indicated in her disability certificate of December 9, 2013, by her family doctor. The doctor notes in the certificate that the applicant was unable to conduct household activities. On the recommendation of her family doctor the applicant secured on-going pain reduction treatments; and the evidence indicates that she continued to visit her doctor and specialists well after the accident due to persistent pain discomfort.
Her family doctor, Dr. Kwok’s, clinical notes and records indicate that he treated the applicant for pain complaints, including referrals to a physiotherapist and a physiatrist, approximately 4 times after the accident in 2013; 5 times in 2014; 5 times in 2015; and several times in 2016.
Neither party disputes the contents of a February 21, 2014 bone scan which indicates,
There is loss of normal cervical lordosis…A Scarborough Hospital Magnetic Resonance Imaging(MRI) of March 19, 2014 indicates, “Very mild spondylitic changes can be seen at C 5-C6 and especially C6-C7 of a chronic nature.” Following his examinations of the applicant on May 1 and July 11, 2014 respectively, Physiatrist, Dr. Joseph Wong’s hand-written notes state, “chronic pain syndrome.”The above indicates that approximately 12 weeks after the accident there was clear evidence of , changes of a
chronic natureas noted in the MRI report of March 19, 2014. Furthermore, on May 1, 2014 and July 11, 2014, Physiatrist, Dr. J. Wong, supports this finding in his assessment of the applicant`s complaint as beingchronic pain syndrome.As well, in the treatment and assessment plan (OCF-18) of June 21, 2014 Chiropractor, Georgia Palantzas classifies the applicant’s injuries as, “not M.I.G…due to objective, demonstrable, definable, and clinically relevant neurological signs such as weakness (muscle resistant test)…” She goes on to state, “Based on evidence of significant impairment/injury, radiculopothy, psychological/emotional issues, and marked decrease in pre-accident capacity, the patient's condition is not presently considered to be minor. More involved multi-disciplinary treatment outside a minor injury framework (according to biopscyhosoclal models) is recommended in order to avoid long-term chronicity.”
I have assigned significant weight to the evidence provided in the comprehensive findings, opinion or test results reported in the treatment plan of June 21, 2014, recommended by Chiropractor, Dr. Georgia Palantzas. She indicates that the applicant`s impairment
objectivelyanddemonstrablywarranted treatment outside of the MIG limitsAn IE conducted by general practitioner T. Levy on May 24, 2014, approximately 2 months after the first treatment plan was submitted, reports that the applicant had sustained injuries treatable under the MIG limits; and that she had achieved “maximum medical improvement.
Considering Dr. Levy’s report and notwithstanding the applicant’s constant pursuit of medical/rehabilitative relief from her injuries and clinical notation of chronic pain syndrome in May 2014, the insurer did not concede that the applicant’s injuries were severe enough to warrant treatment outside of the MIG until Psychiatrist Dr. Leslie Kiraly IE report of July 19, 2014.
The respondent submits that the treatment plans in question were not reasonable and necessary. The respondent points out that the applicant had been receiving physiotherapy treatment from Pro-Physiotherapy, which had been approved up to the MIG limit. After utilizing $2,340.26 of the maximum allowed, the applicant began receiving treatment at another facility. It is the insurer’s position that a negative inference should be drawn from the fact that the applicant did not traverse the remaining $1,159.74 towards treatment at the new facility, Mon Sheon Court Physiotherapy.
I accept the applicant’s evidence that she was last treated at Pro-Physiotherapy on March 6, 2014; and that she left because she was dissatisfied with their service. She began receiving treatment at Mon Sheon Court Physiotherapy instead, and submitted the above 2 treatment plans in question.
I also find no reason to believe that the applicant acted unreasonably or in bad faith. Firstly, the evidence indicates that she did not abandon treatment, but rather that she continued to pursue pain reduction treatment elsewhere. Secondly, there is no evidence that the insurer was billed or likely to be billed for any part of the $3,500.00 that was not incurred. Nor is there any indication that the insurer was prejudiced because the subsequent treatment plans to which the applicant was entitled came from a different treatment facility.
Considering the serious nature of the accident which involved a deployed airbag on the applicant
s body, coupled with the applicants numerous visits to her family doctor and the diagnosis of chronic pain syndrome, I find that the treatment in question was reasonable and necessary.
Issue 3: Is the applicant entitled to replacement costs of $100.00 for prescription eyeglasses?
The applicant provided no reasonable grounds or evidence that would lead me to make a finding that her glasses were damaged in the accident of November 27, 2013, or that she is entitled to the amount claimed for replacement.
On May 20, 2016, the applicant submits that in keeping with section 24 of the Schedule, which requires an insurer to pay for “all reasonable expenses incurred in repairing or replacing…prescription eyewear…that were lost or damaged as a result of the accident,” she claimed expenses for glasses in the amount of $100.00. The claim was denied by the insurer on May 27, 2016 on the basis that it needed clarification to support the claim. The respondent indicates that no such clarification was provided to show how the cost was related to the accident.
The applicant relies on the following evidence to support her claim. A Manulife Financial statement provided indicates that in December of 2015 the applicant had her prescription glasses replaced, as part of a biennial allowance under her Extended Health Plan (EHP). The replacement cost is noted as $350.00; $250.00 of which was paid under the EHP. The applicant submitted an expense form to the insurer claiming the remaining $100.00 for her glasses, without explanation.
To determine whether the applicant is entitled to payment of $100.00 towards replacement of her glasses, I must consider firstly, whether the glasses were damaged in the accident; and secondly whether the claim is reasonable/necessary.
Other than evidence that she replaced her glasses a few years after the accident, the applicant provides no indication as to how her glasses were allegedly damaged, or if they were damaged in the accident. I agree with the insurer, that if the glasses were damaged in the accident of November 27, 2013, it would have been immediately apparent on the day of the accident, or shortly thereafter.
As well, it is unlikely that the applicant would have waited close to 3 years later to submit a claim for her glasses if they had been damaged in the accident. There is no indication that the applicant’s glasses were damaged.
I find no merit in the applicant’s claim that the replacement of her glasses was connected to the accident, and therefore I find no need to consider reasonableness or any other claims made by the applicant in regards to this issue.
Issue 4: Is the applicant entitled to out of pocket medical expenses for physiotherapy and acupuncture services totalling $500.00 from Perfect Physio Rehab Centre; denied by the insurer on May 24, 2016?
The applicant bears the burden of proving that on a balance of probabilities, she is entitled to the cost of the medical/rehabilitation treatments of January and April 2015, more than 12 months after the accident. The applicant must also prove that the treatments, which were not submitted by way of a treatment and assessment plan, or recommended by a health practitioner, meet the test of being reasonable and necessary. In this case, the applicant submits that in keeping with section 15(1) of the Schedule the insurer is required to pay all reasonable and necessary expenses incurred on her behalf as a result of the accident.
I find the applicant is not entitled to the out of pocket expenses claimed for physiotherapy and acupuncture services. The evidence before me does not establish that on a balance of probabilities, the services she received were as a result of any documented, accident-related assessment or recommended in a treatment plan by a health provider.
The applicant relies on the following. She submits that she saw her family doctor, Dr. Kwok on October 25, 2014 and again on January 3, 2015. Due to chest pain complaints, the doctor, among other things, ordered a chest x-ray. Results of a December 22, 2015, bilateral chest x-ray indicate, “subacute fracture deformity of the right distal 8th rib with some degree of callus formation but incomplete healing likely due to sequelae of post traumatic change.”
Based on the results of the above x-ray and upon her family doctor’s advice, the applicant states she paid for the physiotherapy and acupuncture treatments in question; for which she now seeks compensation. The applicant’s evidence includes an expense form (OCF-6), supported by receipts for the following medical treatments at Perfect Physio Rehab Centre: physiotherapy on January 15, 2015 and acupuncture on April 14, 2015, each in the amount of $250.00.
The insurer declines the applicant’s claim, on the grounds that the expenses claimed do not comply with any exemptions allowed, they are not connected to the accident, and because of the applicant’s failure to comply with the requirements of section 38(2) of the Schedule. Section 38 essentially stipulates that an insurer is not liable to pay medical/rehabilitation expenses that were “incurred before the insured person submits a treatment and assessment plan”; and unless the insurer indicated to the insured person that they will pay the expense without a treatment and assessment plan.
The insurer maintains that the applicant is not entitled to the costs incurred as she did not submit the required treatment and assessment plan, completed by a health practitioner before undergoing the treatments; and the insurer did not waive this requirement.
The accident benefit scheme clearly requires an insured person to submit a treatment and assessment plan when claiming medical/rehabilitation benefits such as those claimed here, unless otherwise directed. The fact that the Schedule (section 38) further details the information that must be included in a treatment plan, including: evidence it is commissioned by a regulated health professional and a statement as to whether the treatment and assessment plan “is in respect of an accident…;” underscores its necessity to an insurer for reasonably assessing an insured person’s benefit claim.
The respondent maintains it did not waive this requirement and the applicant has not provided the necessary documents to reasonably assess whether, the applicant’s condition, more than a year later, was as a result of the accident; and whether the medical/rehabilitation treatments she pursued were reasonable and necessary.
In keeping with the provisions of section 38 I find no reasonable grounds that would require the insurer to pay the cost of the treatments unilaterally, initiated by the applicant, with no indication as to how they relate to the accident. The applicant has not provided me with evidence to prove otherwise.
Issue 5: Is the applicant entitled to payment for the cost of examination in the amount of $921.22 for attendant care assessment by Mon Sheong Court Physio & Rehab Centre, submitted on April 3, 2014, and denied by the respondent on June 17, 2014?
The Schedule authorizes attendant care benefits to pay for reasonable and necessary expenses incurred to hire someone to help with self-care activities that an insured person is unable to perform, as a result of accident related injuries. Of note, attendant care benefits are not available to individuals whose injuries fall under the MIG regime. It has already been determined that treatment of the applicant’s injuries fall outside the MIG regime. Therefore, I find no need to consider the part of the respondent’s denial that is based on its position that she was not entitled to treatment outside of the MIG.
The process for claiming attendant care benefits entails the insured person submitting a treatment and assessment plan (OCF-18) and an attendant care needs assessment form, (Form 1). The costs outlined in the documents include the amount charged for the assessment/examination. In this case, the applicant is claiming the cost of the examination.
For the following reasons, I find that the applicant is entitled to payment of the cost of examination in the amount of $921.22 for attendant care benefits assessment as claimed (providing it is incurred).
The applicant submitted a treatment and assessment plan for Attendant Care benefits to the insurer on April 3, 2014. It included the cost of the assessment/examination in the amount of $921.22. The required Attendant Care Assessment form (Form 1), dated April 8, 2014, and was completed by nurse Li Jing followed.
The applicant submits that the insurer is obligated to begin payment of the attendant care benefit within 10 business days of receipt of the assessment/plan, and pending IE results, as provided in section 42(6) of the Schedule. The applicant maintains that the amount claimed for examination is reasonable, as it is inclusive of transportation by the nurse to and from the applicant’s home, completion of the form, as well as planning and assessment activities conducted by the nurse.
The insurer submits that $921.22 is an excessive amount for completing an Assessment of Attendant Care Needs (Form 1). The insurer further claims that the amount has not been incurred and the form was not accompanied by a supporting report; and therefore the applicant is not entitled to the benefit.
Supporting documentation/assessment cost: The insurer’s denial form/letter submitted, indicates the claim was denied on the basis of MIG classification. The document makes no mention of the respondent’s concern regarding the amount of the examination cost. The insurer’s dispute regarding the cost is only raised in its submissions for this hearing, as is the issue of supporting documents.
Coupled with the fact that the respondent later approved and paid similar amounts for two subsequent attendant care assessment forms; which were also submitted without supporting reports; and the insurer’s silence on the amount of the examination costs in its denial, in my view, is reasonably understood to mean that it had no concerns about the amount and that it had in fact accepted the cost for the attendant care assessment at face value. I therefore find no need to make any further determinations regarding the quantum claimed for cost of examination, or the issue of supporting reports.
Reasonableness/necessity: In determining eligibility, I must consider whether the subject assessment was reasonable and necessary. In my view, the evidence provides a compelling indication that on a balance of probabilities, the applicant’s need for attendant care assessment and the cost involved was warranted.
The applicant’s evidence demonstrated a pattern of on-going pursuit for treatment of her injuries following the accident. Additionally, detailed medical notes and records provided indicate that she was forced to take time off work and was unable to perform household activities at one point and that she developed chronic pain syndrome (May 1, 2014 and July 11, 2014, Physiatrist, Dr. J. Wong). Even more persuasive that the assessment was likely warranted in April 2014, 5 months after the accident, is the evidence that more than a year after the accident, the applicant submitted to attendant care assessments. For the above reasons, I find the cost of examination claimed here is warranted on the grounds of reasonableness and necessity; and payable by the insurer, if incurred. I therefore find no need to consider the issue further on the basis of procedural non-compliance grounds raised by the applicant.
Issue 6: Is the applicant entitled to interest on any outstanding payment of benefits?
- Having established, on the basis of the evidence provided, that the applicant is entitled to the treatment plans of March 11, 2014 ($1,386.32), June 21, 2014($2,100.60); and the cost of an attendant care examination in the amount of $921.22; I also find that the applicant is entitled to interest, calculated according to the Schedule, on any outstanding amounts incurred in the said treatment plans and for the attendant care examination..
Issue 7: Is the applicant entitled to costs related to this application?
Tribunal Rule 19.1 allows parties to request costs, if they believe that the other party in a proceeding has acted unreasonably, frivolously, vexatiously, or in bad faith. Rule 19.4 further sets out the requirements for that request, which must include the reasons for the request and the particulars of the alleged conduct.
The applicant seeks to have the respondent pay costs and unspecified expenses for filing this application. Cost awards are not meant to compensate parties for bringing or defending claims. I find the respondent’s costs and expenses request to be unwarranted and contrary to the Rule and spirit of the dispute resolution process.
Conclusion:
- The applicant has established on a balance of probabilities that she is entitled to the following:
- Treatment plan of March 11, 2014 for physiotherapy services;
- Treatment plan of June 21, 2014 for chiropractic services; and
- Cost of examination in the amount of $921.22 for an attendant care assessment.
The applicant’s evidence did not establish that, on a balance of probabilities, her eyeglasses were damaged in the accident; or that the insurer should be held liable for the self-directed, out-of-pocket expenses she incurred for physiotherapy and acupuncture treatments in January and April of 2015, without the provision of any reasonable, supporting evidence/documentation as to how they relate to the accident.
The applicant failed to provide any particulars that would warrant the awarding of costs and expenses related to the filing of the application.
Based on the relevant evidence provided, and for the reasons contained herein, the following order is issued.
The Tribunal orders that:
- The respondent shall pay to the applicant:
a. Medical benefits in the amounts of $1,386.32 for physiotherapy services, $2,100.60 for chiropractic services recommended by Mon Sheong Court Physio & Rehab Centre less any amounts already paid for the above services; plus, accrued interest on any outstanding balance of benefit payment;
b. $921.22 representing incurred cost of examination for Attendant Care Assessment Form less any amounts already paid for the above services; plus, accrued interest on any outstanding balance of benefit payment.
The applicant’s claims for cost of $100.00 for eyeglasses; and for out of pocket expenses incurred for physiotherapy and acupuncture services in the amount of $500.00, are dismissed.
The applicant’s claim for costs and expenses related to the filing of the application is dismissed.
Released: June 8, 2017
___________________________
Claudette Leslie, Adjudicator