G. P. v. Unifund Assurance Company, 2017 CanLII 39702

Licence Appeal Tribunal

Date: 2017-06-12

Tribunal File Number: 16-003165/AABS

Case Name: 16-003165 v Unifund Assurance 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:

G. P.

Applicant

and

Unifund Assurance Company

Respondent

DECISION

ADJUDICATOR: Chris Sewrattan

APPEARANCES:

Counsel for the Applicant: Andrej Rondas

Counsel for the Respondent: Stefania Sdao

HEARD: Written Hearing: May 4, 2017

Overview

1The applicant was injured in a motor vehicle accident on April 14, 2014. She applied for benefits under the Statutory Accident Benefits Schedule – Effective September 1, 2010 (the “Schedule”). Unifund Assurance Company (“Unifund”) denied the applicant’s claims for three treatment plans and an examination. The applicant appeals to the Licence Appeal Tribunal (the “Tribunal”) for payment.

Issues in Dispute:

2The following issues are in dispute:

1. Is the applicant entitled to $1,835.20 for payment for physiotherapy submitted by Markham Pain Solutions on November 15, 2014?
2. Is the applicant entitled to $2,912.20 for payment for physiotherapy submitted by Markham Pain Solutions on November 13, 2015?
3. Is the applicant entitled to $2,626.80 for payment for physiotherapy submitted by Markham Pain Solutions on February 18, 2016?
4. Is the applicant entitled to payment for the cost of a chronic pain assessment submitted by Markham Pain Solutions on December 14, 2015?

Result:

3The applicant has not submitted any Treatment Plans. It is impossible to determine whether any of the treatment or examination sought is reasonable and necessary. The applicant’s claims are denied.

Discussion

4To receive payment, the applicant must prove that each of the three physiotherapy treatment plans and the chronic pain assessment is a reasonable and necessary expense. To prove that an expense is reasonable and necessary, the applicant must show me that the benefits sought are reasonable and necessary methods of treating injury or impairment that she suffered as a result of the motor vehicle accident.

5Markham Pain Solutions would have included a Treatment Plan each time it put a claim to Unifund. The Treatment Plans shed light on the services sought. For example, it would describe what type of treatment is sought, what the treatment goals are, and, perhaps, how the treatment will achieve those goals. This information is helpful in determining whether the treatment sought is reasonable and necessary.

6The applicant has not provided any of the Treatment Plans to me. She has provided 11-pages of submissions and a psychological report, dated September 16, 2015, from Dr. Leon Steiner. The submissions do not discuss the issue of reasonableness and necessity.

7I am unable to determine whether the four benefits she seeks are reasonable and necessary expenses for any injury that may have been incurred. As a result, I am unable to decide in her favour on any of the issues in dispute.

Conclusion

8The applicant’s three claims for physiotherapy services and a chronic pain assessment, respectively, are denied.