Tribunal File Number: 16-003564/AABS
Case Name: 16-003564 v The Co-operators General 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:
Applicant
Applicant
And
The Co-operators General Insurance Company
Respondent
DECISION
Adjudicator: Lori Marzinotto
Appearances:
Counsel for the Applicant: Jerzy Cootauco & Kevin Lin
Counsel for the Insurance Company: Lindsey Cutler
HEARD in writing on: March 7, 2017
OVERVIEW
1[ ](the “applicant”) was involved in an automobile accident on June 19, 2014, and sought benefits pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 2010 (the “Schedule”).
2The applicant applied for medical and rehabilitation benefits but was denied by the respondent. The applicant disagreed with the denial and submitted an application to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”).
3The matter proceeded to a Case Conference but the parties were unable to resolve the issue in dispute and a written hearing was scheduled.
ISSUE TO BE DECIDED
4The issue to be decided is as follow:
i) Is the applicant entitled to a medical benefit in the amount of $698.83, representing the outstanding balance for psychological services recommended in a treatment plan by Dr. Jon Mills of Synoptic Medical Assessments Inc., dated November 13, 2015; denied by the respondent on November 25, 2015 (the “OCF-18”)? 1
RESULT
5Based on the totality of the evidence before me, I find that the applicant is not entitled to the proposed treatment plan.
ANALYSIS
6As noted above, the $698.83 at issue is for the two denied portions of the partially approved OCF-18: i) the “Documentation support activity” for $250; and, ii) 3 Progress Evaluations.
7Section 14 and 15 of the Schedule provides that an insurer is liable to pay for all reasonable and necessary medical and rehabilitation expenses that are incurred. The applicant bears the onus of proving on a balance of probabilities that the treatment plan is reasonable and necessary.
i) Documentation support activity $250
8Regarding the “Documentation, Support Activity” fee, the applicant submits that Dr. Mills states the reasonableness and necessity in his letter of February 9, 2017 (“Dr. Mills Letter”). The applicant submits that the $250 “Documentation, Support Activity” is the fee for drafting the Progress Evaluation. I do not agree.
9Rather, I agree with the respondent’s submission that “Documentation, Support Activity” fee has not been explained. Contrary to what is stated in the Affidavit of Mr. So, Dr. Mills Letter does not indicate that this fee is for drafting the Progress Evaluation report. If this fee was meant to be for the 4 Progress Evaluations, I would have expected a claim for 4 progress evaluation reports.
10Evidence was not provided explaining what “Documentation, Support Activity” is nor is it defined in Dr. Mills Letter.
11The applicant has not met his onus and therefor the outstanding amount of $250 of the OCF-18 is not payable.
ii) 3 Progress Evaluations
12The OCF-18 recommended twelve 1.5 hour therapy sessions and four 1 hour Progress Evaluations.
13The applicant submits that the 3 denied Progress Evaluations are reasonable and necessary because they allow a psychologist to see if the techniques being used are improving the patient’s recovery and relies on Dr. Mills Letter.
14Dr. Mills references the Ontario Psychological Association Guidelines for Assessment and Treatment in Auto Insurance Claims, July 29, 2010, OPA Auto Task Force (“OPA Guideline”) to support the necessity of progress reports.
15While I agree that this supports why progress reports are required, the referenced OPA Guideline in Dr. Mills Letter does not provide the evidence to support a finding that 3 additional Progress Evaluations are reasonable and necessary.
16The OPA Guideline provides as follows:
In the stages model, continuation of further treatment is determined by response to each stage of treatment. …while it may be anticipated that a patient with long standing and severe impairments might require a year long or longer treatment, it would be unusual to propose this in a single treatment plan. Rather, we anticipate that treatment would be proposed in blocks or stages…Reassessment and feedback to the client should occur every 6-10 sessions, or after a significant stage of the stepped care model…
17I agree with the respondent that the request for 4 progress evaluations over 12 sessions is in excess of the OPA Guideline. The respondent’s approval of one Progress Evaluation for 12 sessions is in line with the OPA Guideline.
18The applicant has failed to adduce sufficient evidence to substantiate the reasonableness and necessity of 3 additional Progress Evaluations.
19Based on the evidence before me, I find that the applicant has not proven on a balance of probabilities that the balance of the treatment plan is reasonable and necessary and therefore, it is not payable.
Order
20Pursuant to s.280(2) of the Act, and for the reasons outlined above, I order that this application be dismissed.
Released: August 25, 2017
Lori Marzinotto, Adjudicator
Footnotes
- The treatment and assessment plan (OCF-18) was in the amount of $3,741.48. The respondent partially approved the OCF-18 in the amount of $3,042.65. The respondent approved the 12 claimed treatment sessions, one “Documentation support activity for claim form” ($200) and one progress evaluation but denied the additional 3 progress evaluations (1 hour each at a cost of $149.61 = $448.83) and denied one “documentation support activity” at a cost of $250 for a total of $698.83, the total amount listed as the issue in dispute.