16-004660 v Dominion of Canada General Insurance Company (Travelers Canada)
Tribunal File Number: 16-004660/AABS
Case Name: 16-004660 v Dominion of Canada General Insurance Company (Travelers Canada)
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
and
Dominion of Canada General Insurance Company (Travelers Canada)
Respondent
DECISION
ADJUDICATOR: Robert Watt
APPEARANCES:
For the Applicant: Jono Schneider, Counsel
For the Respondent: Erin Morgan, Counsel
HEARD IN WRITING ON: May 24, 2017
OVERVIEW
1The applicant’s Mother was injured in a motor vehicle accident on May 15, 2015. The applicant was not involved in the accident but applied for accident benefits. The applicant applied for accident benefits from Travelers Canada, (taken over by Dominion of Canada General Insurance Company) (“the respondent”) under the Statutory Accident Benefit Schedule-Effective September 1, 2010 (the “Schedule”).
2The respondent denied claims for medical benefits on the basis that the applicant was not an insured person under section 3(1) of the SABS.
3The applicant submitted an application for dispute resolution services to the License Appeal Tribunal-Automobile Accident Benefit Services (‘the “Tribunal”). The parties were unable to resolve their dispute at a case conference held on March 29, 2017, and the matter proceeded to a written hearing.
ISSUES AS NOTED IN THE CASE CONFERENCE ORDER
4The case conference order dated May 1, 2017, indicated that the following issues were in dispute:
a. Is the applicant an insured person as defined by the schedule?
b. Is the applicant entitled to payments for the cost of examinations in the amount of $2,200.00 for a psychological assessment recommended by the Psychological Recovery Clinic, in a treatment plan dated November 28, 2016, and denied by the respondent on December 2, 2016?
c. Is the applicant entitled to payments for the cost of examinations in the amount of $2,429.50 for an in home assessment recommended by Allied-Med Trauma Evaluations, in a treatment plan dated December 5, 2016?
d. Is the respondent liable to pay an award under regulation 664, because it unreasonably withheld or delayed payments to the applicant?
e. Is the applicant entitled to interest on any overdue payment of benefits?
EVENTS FOLLOWING THE CASE CONFERENCE
5Following the case conference, the respondent by letter dated May 8, 2017, confirmed that the applicant is an insured person, and also agreed to pay the costs associated with the psychological assessment. As such, issues (a) and (b) as noted in paragraph 4 above, are no longer in dispute.
THE LAW, EVIDENCE AND ANALYSIS
Is the applicant entitled to payments for the cost of examination in the amount of $2,429.50, for an in home assessment recommended by Allied-Med Trauma Evaluations, in a treatment plan dated December 5, 2016?
6I find that the applicant, on the applicant’s own admission, did not submit the treatment plan to the Health Claims for Auto Insurance (HCAI). The applicant asserts that this was not possible because the respondent refused to set up a claim number.
7I prefer the respondent’s evidence therefore over that of the applicant’s evidence because the respondent’s evidence was more reasonable. The applicant’s treatment plan dated November 28, 2016, was submitted to HCAI and subsequently approved by the respondent with a claim number. Since the treatment plan was not submitted by the applicant to HCAI, I find that it was not received nor denied by the respondent.
8The Financial Services Commission of Ontario / Superintendent’s Guideline No. 01/15 requires all treatment & Assessment Plans (OCF-18) to be delivered first to the CPA, regardless of whether or not the Participating Facility is a Service Provider (licensed under the Insurance Act). Section 49 of the SABS requires an invoice for the expense to be submitted before payment. This guideline was not followed by the applicant, and therefore the applicant’s application does not require consideration by the respondent.
Is the respondent liable to pay an award under regulation 664, because it unreasonably withheld or delayed payments to the applicant?
9I find that the respondent is not liable to pay to the applicant an award under regulation 664. I do not find that the respondent unreasonably withheld or delayed the payment for the psychological treatment plan because:
a. The accident occurred on May 15, 2015;
b. The treatment plan for a medical benefit in the amount of $2,200.00 for psychological services was submitted to the respondent on November 28, 2016, 18 months post-accident;
c. The respondent by letter dated December 2, 2016, requested further medical documentation before it could make any decision on the treatment plan. Again on February 15, 2017, the respondent requested the medical documents as set out in its letter dated December 2, 2016. These medical documents were never provided by the applicant.
d. A case conference was held on March 29, 2017.
e. Discussions between counsel for resolution of the issues took place between April 29, and May 3, 2017, with written correspondence sent by the respondent on May 8, 2017, settling the issue of the treatment plan submitted on November 28, 2016.
Is the applicant entitled to interest on any overdue payment of benefits?
10I find that interest is payable by the respondent to the applicant from December 28, 2016, to May 8, 2017, on the amount of $2,200.00, as set out in the treatment plan dated November 28, 2016, pursuant to section 51(2) (4) of the SABS.
COSTS
11I do not find costs to either party are warranted in this case because there is no evidence before the Tribunal that any party during the proceedings has acted “unreasonably, frivolously, vexatious, or in bad faith”, as required under Rule 19 of the LAT Rules of Practice.
ORDER
12I order that interest be paid by the respondent to the applicant from December 28, 2016, to May 8, 2017 on the amount of $2,200.00.
Released: November 28, 2017
Robert Watt Adjudicator