17-001422 v ACE INA Insurance
Tribunal File Number: 17-001422/AABS
Case Name: 17-001422 v ACE INA Insurance
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:
Applicant
Applicant
and
ACE INA Insurance
Respondent
DECISION
Adjudicator: Nicole Treksler
APPEARANCES:
Applicant: [Applicant]
For the Applicant: Karine R. Hajje, Counsel
For the Respondent: Christopher McCormack, Counsel
Hearing in writing: July 19, 2017
I. Overview:
1The applicant was injured in an automobile accident on March 3, 2015, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (the ''Schedule'').
2The applicant applied for medical benefits, specifically chiropractic and physiotherapy services, which the respondent denied based on reports from orthopaedic surgeons Dr. Oleg Safir and Dr. Edwin Urovitz’s following insurer’s examinations. These reports indicated that the treatment plans were not reasonable and necessary.
3The applicant must show on a balance of probabilities that the medical benefits are reasonable and necessary.
4The applicant is also seeking payment of a psychological assessment in a treatment plan dated May 16, 2015, denied by the respondent July 24, 2015.
5The respondent is seeking repayment of income replacement benefits in the amount of $8,583.12 during the period of March 14, 2016 to January 11, 2017.
6Lastly, the applicant is seeking an award for the respondent’s delay in determining that the applicant’s injuries were not predominantly minor and subject to a limit of $3,500 for treatment in the minor injury guideline (MIG).
II. Issues:
7For this hearing, the issues in dispute are as follows:
a. Is the applicant entitled to receive medical benefits recommended by Toronto Health Care Clinic as follows:
i. $1,411.20 for a chiropractic treatment plan dated June 11, 2015, denied by the respondent June 15, 2015;
ii. $2,521 for a chiropractic treatment plan dated March 12, 2015, denied by the respondent July 24, 2015;
iii. $1,521.26 for chiropractic treatment plan dated April 16, 2015, denied by the respondent July 24, 2015;
iv. $1,611.21 for a chiropractic treatment plan dated July 20, 2015, denied by the respondent July 28, 2015; and
v. $733.33 for assistive devices recommended in a treatment plan dated July 9, 2015, denied by the respondent