Reid v. Aviva Insurance Company of Canada, 2019 CanLII 148099

Licence Appeal Tribunal

Citation: Reid v. Aviva Insurance Company of Canada, 2021 ONLAT 20-004370/AABS

Licence Appeal Tribunal File Number: 20-004370/AABS

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:

Ingrid Reid

Applicant

and

Aviva Insurance Company of Canada

Respondent

DECISION

ADJUDICATOR:

Chloe Lester, Vice-Chair

APPEARANCES:

For the Applicant:

Frank N. Del Giudice, Counsel

For the Respondent:

Jennifer Cosentino, Counsel

HEARD:

By way of written submissions

REASONS FOR DECISION

1The applicant, Ingrid Reid, was rear-ended by another vehicle on March 29, 2017, causing an accident. As a result, she alleges that she sustained physical and psychological injuries.

2The applicant applied to the respondent, Aviva Insurance Company of Canada, for a social worker assessment¹ in accordance with the Schedule.²

3Aviva denied the social worker assessment on the basis that it required more information to determine whether the recommended assessment is reasonable and necessary.³

4The applicant disagreed and filed an application for dispute resolution with the Tribunal.⁴

BACKGROUND

5After receiving the initially denied treatment plan, Novo Medical sent a letter to Aviva providing the information requested by them. Novo Medical had recommended the social worker assessment following the recommendations from Dr. Waisman’s report, psychiatrist.⁵

6After reviewing the information, Aviva denied the social worker assessment on the basis that Dr. Waisman did not recommend a social worker assessment. He recommended ongoing psychotherapy and referral to a multidisciplinary chronic pain management program. Aviva confirmed that they have approved ongoing psychotherapy and an assessment from a chronic pain assessment centre.⁶

ISSUES IN DISPUTE

7The issues to be determined are:

(a) is the applicant entitled to a social worker assessment in the amount of $2,090.00 proposed by Novo Medical Services?

(b) is the applicant entitled to interest?

RESULTS

8I find the applicant is not entitled to the social worker assessment or interest.

ANALYSIS

Is the applicant entitled to the social worker assessment?

9In this case, the applicant submits the assessment is reasonable and necessary because:

(a) of the applicant’s ongoing impairments;

(b) the applicant continues to struggle with social interactions, she is unable to complete her pre-accident housekeeping and employment duties; and

(c) the assessment is based on the biopsychosocial approach to managing chronic pain. This type of treatment was a preferred approach by Dr. Waisman for managing chronic pain and is part of his multidisciplinary treatment recommendation.

10The applicant relies on D.J. v. Aviva Insurance Company of Canada⁷ that a social worker can provide psychotherapy. The applicant submits that in Dr. Waisman’s report there is no specific distinction between psychotherapy and social worker counselling.

11The respondent submits that the recommendations by Dr. Waisman were already approved through other treatment plans, namely the recommendation for psychotherapy. They also claim that the applicant has had extensive treatments, and the records at Altima Physio shows that she was feeling better and improving. The respondent also submits there has been no medical documentation that supports a need for community resources like Ontario Works or Ontario Disability Support Program, a main goal of the assessment.

12Under s. 15 of the Schedule, the respondent is obligated to pay for all reasonable and necessary medical benefits incurred because of injuries sustained in the accident. The term “reasonable and necessary” is not defined in the Schedule. Nevertheless, some guiding principles to consider when determining if a benefit meets the test, are the necessity of the treatment in relation to the injuries sustained in the accident, the reasonableness of the treatment’s goal, the ability to achieve that goal, and the proposed treatment’s cost.

13Novo Medical recommended the social worker assessment based on the applicant suffering from adjustment disorders, mixed anxiety and depressive disorder, and problems related to social environment. The treatment goals sought to reduce pain, return the applicant to her activities of normal living, and help the applicant to identify skills and abilities to use her own resources and those of the community to resolve her problems. The aim of the assessment is to discover the barriers in leading a more socially active and dynamic lifestyle, determine whether the applicant can benefit from community resources, like Meals on Wheels or Ontario Works, and to provide counselling to develop skills and resources to increase social functioning. ⁸

14I do not find the social worker assessment reasonable or necessary as it is a duplication of services and there is no medical need for this assessment.

15At this time, I do not see a medical need for this type of assessment. The psychotherapy report and the report of Dr. Waisman do not recommend this type of assessment. The applicant’s psychotherapist recommended ongoing psychotherapy and physical therapy to manage her accident-related injuries. Dr. Waisman recommended psychotherapy and a pain management program. The applicant’s accident-related problems are already being explored through psychotherapy or with a recommendation for a pain management program. The social worker assessment will explore areas already being treated through the applicant’s psychotherapy treatment, and therefore, will not improve the applicant’s injuries.

16Based on the assessment of Dr. Waisman, the applicant suffers from major depressive disorder and her pain symptoms result in a high level of anxiety. In his report, Dr. Waisman comments that the biopsychosocial approach is the most commonly accepted view to understand chronic pain. Dr. Waisman recommended ongoing psychotherapy and a referral to a multidisciplinary pain management program.⁹ The respondent approved two treatment plans for psychotherapy and a driver reintegration program.¹⁰

17Unfortunately, the applicant is confusing the recommendations by the treating practitioners with the goals of the assessment. I agree with the applicant’s case law that a social worker may be able to provide psychotherapy. I also agree that Dr. Waisman recommends a biopsychosocial approach to managing the applicant’s chronic pain, but the assessment in dispute is neither. The social worker assessment is not evaluating a need for psychotherapy treatment, or for managing the applicant’s chronic pain. It is for identifying skills and abilities to use one’s own resources and those of the community to resolve the applicant’s problems. The goal of this assessment is not one that has been recommended by any of her treating practitioners. Therefore, there is no medical need for this assessment.

18I find the assessment to be a duplication of services. The applicant is already attending Novo Medical for psychotherapy. According to the progress report, the clinic is helping the applicant develop coping strategies to help manage her physical and psychological difficulties. The psychological difficulties include the applicant’s avoidance of big gatherings, public social settings and interacting with others.¹¹ The psychotherapy sessions are covering similar treatments that would be explored during the assessment.

19For the reasons listed, I find the applicant is not entitled to the social worker assessment or interest.

Footnotes

1. 1Treatment and Assessment Plan dated May 14, 2019 – Applicant’s Submissions Tab 2
2. 2Statutory Accident Benefits Schedule – Effective September 1, 2010, O. Reg. 34/10. (the “Schedule”)
3. 3Explanation of Benefits dated June 28, 2019 – Applicant’s Submissions Tab 4
4. 4Tribunals Ontario, Safety, Licensing Appeals and Standards Division, Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”)
5. 5Letter from Novo Medical to Aviva – Applicant’s Brief Tab 6
6. 6Letter from Aviva dated January 11, 2021 – Applicant’s Submissions Tab 7
7. 7D.J. vs. Aviva Insurance Company of Canada, 2020 ONLAT 18-012131/AABS – Applicant’s Submissions Tab 14
8. 8Treatment and Assessment Plan dated May 14, 2019 – Applicant’s Submissions Tab 2
9. 9Report of Dr. Waisman – Applicant’s Submissions Tab 6
10. 10Letter from Aviva to Ingrid Reid dated December 3, 2018 and letter dated December 28, 2018
11. 11Psychotherapy progress report dated September 19, 2019 from Novo Medical Services