Tribunal File Number: 17-004001/AABS
Case Name: 17-004001 v Aviva Insurance 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
Applicant
and
Aviva Insurance Canada
Respondent
Decision
Adjudicator:
Amanda Fricot
Appearances:
For the Applicant:
Nader Fathi, Representative
For the Respondent:
Christine Pham, Counsel
Heard in Writing:
October 31, 2017
Overview
1[The applicant] was involved in a motor vehicle accident on January 16, 2016 and sought accident benefits from Aviva Insurance Canada (“the respondent”) pursuant to the Statutory Accident Benefit Schedule – Effective September 1, 2010 (the “Schedule”). The respondent denied the applicant’s claim for a medical benefit for chiropractic services.
2The applicant submitted an application for dispute resolution services to the Licence Appeal Tribunal – Automobile Accident Benefit Services (the “Tribunal”). The parties were unable to resolve their dispute at a case conference and the matter proceeded to this written hearing.
Issues in Dispute
3The following issues are in dispute before the Tribunal:
i. Is the applicant entitled to a medical benefit in the amount of $1,300.00 for chiropractic services from Dr. Aaron Pereira, submitted on August 8, 2016 and denied on August 15, 2016?
ii. Is the applicant entitled to interest on any overdue payment of benefits?
Result
4After reviewing the parties’ submissions and the documentary evidence and for the reasons that follow, I find:
The treatment plan is not reasonable and necessary and accordingly the applicant is not entitled to the medical benefit for chiropractic benefits in the amount of $1,300.00.
The applicant is not entitled to interest.
Background
5The applicant was injured in a motor vehicle accident on January 16, 2016. She attended at [a hospital] on the day of the accident with complaints of pain in her left shoulder and scapular area and numbness into her left arm. She was diagnosed with left back injury and was discharged with prescriptions for Tylenol #3 and anti-inflammatory medication and was advised to use ice and see her family doctor for physiotherapy and ongoing care.
6On January 19, 2016 the applicant went to [the hospital] with complaints of ongoing nausea; headaches; neck, back and abdominal pain; and left arm tingling. She was discharged, given a note to be off work for 1 week and advised to take Advil and Tylenol.
7The applicant returned to her job as a Registered Practical Nurse (RPN) one day after the accident, then stayed off work for three days, and subsequently returned to work on regular hours and regular duties.
8The applicant successfully completed a rehabilitation program at CBI Spine and Sport Physiotherapy that ran from January 29, 2016 to July 15, 2016.
9On August 2, 2016 the applicant was assessed by Dr. Aaron Pereira, chiropractor, who completed the OCF-18 submitted on August 8, 2016 (‘the treatment plan”), which is in issue in this Application.
Analysis
10Sections 14 and 15 of the Schedule provide that an insurer is liable to pay for medical benefits for all reasonable and necessary expenses incurred by or on behalf of the insured person as a result of an accident.
11Although the applicant is no longer subject to the Minor Injury Guidelines as a result of psychological impairment, the applicant bears the onus of proving, on a balance of probabilities, that the specific benefits claimed are reasonable and necessary.1 To satisfy that onus, the applicant must establish that the treatment plan for chiropractic benefits is reasonable and that there is adequate medical evidence supporting the need for the treatment proposed.
Is the applicant entitled to the medical benefit for chiropractic treatment?
12I find that the treatment plan is not reasonable and necessary and that the applicant is not entitled to the medical benefit sought for the following reasons.
Applicant’s Submissions and Evidence
13The applicant submits that the treatment plan is reasonable and necessary but does not refer to any evidence that establishes the necessity or reasonableness of the proposed treatment, other than the treatment plan itself.
14In the treatment plan, Dr. Pereira describes the applicant’s injuries as including rotator cuff syndrome; sprain and strain and injury of muscles and tendons of shoulder joint and rotator cuff capsule; dislocation, sprain and strain of joints and ligaments of neck level, thorax, lumbar spine, pelvis, shoulder girdle; injury of muscle and tendon at neck, thorax, abdomen, lower back and pelvis; nonorganic sleep disorders, dizziness and giddiness. The treatment plan recommends 6 weeks