Tribunal File Number: 18-004347/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:
C. J.
Applicant
And
Certas Home and Auto Insurance
Respondent
DECISION
PANEL:
Brian Norris, Adjudicator
APPEARANCES:
For the Applicant:
Nader Fathi, Representative
For the Respondent:
Andrea R. Lim, Counsel
HEARD:
In Writing on: February 28, 2019
OVERVIEW
1The applicant was injured in an automobile accident on September 5, 2017 and sought benefits from the respondent pursuant to Statutory Accident Benefits Schedule – Effective September 1, 2010, O. Reg. 34/10 (the “Schedule”). The applicant applied for certain medical benefits which the respondent refused to pay for. As a result, the applicant has applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of this dispute.
ISSUES
2The disputed issues in this hearing are:
- Is the applicant entitled to receive medical benefits recommended by Mackenzie Medical Rehabilitation Centre as follows;
a) $1,779.60 for a chiropractic treatment plan submitted April 9, 2018; and
b) $1,384.70 for a massage therapy treatment plan submitted June 5, 2018?
- Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant is not entitled to the disputed treatment plans. No interest is payable.
BACKGROUND
4The applicant was the driver of a vehicle which was struck from behind while stopped on the off-ramp of a highway. The applicant was able to drive home following the accident. Later that day, the applicant was taken by a friend to the hospital and was diagnosed with soft tissue injuries and referred to physiotherapy. The applicant commenced a claim for accident benefits and, despite being diagnosed with predominantly minor injuries, the applicant was not subject to the Minor Injury Guideline because of pre-existing medical conditions which affect the applicant’s recovery.
5The applicant engaged in treatment with Mackenzie Medical Rehabilitation Centre (“Mackenzie”) and sought funding from the respondent for the disputed treatment plans listed above. The respondent found the treatment plans were not reasonable and necessary and denied funding for them.
ARE THE DISPUTED TREATMENT PLANS REASONABLE AND NECESSARY?
6I have reviewed the evidence and submissions and find the applicant is not entitled to the disputed treatment plans because the treatment plans are not reasonable and necessary. My reasons are as follows.
7The applicant claims entitlement to the disputed treatment plans and submits they are reasonable and necessary because: 1) the applicant is not bound by the $3,500.00 funding limit provided by the MIG and 2) to ensure the applicant’s aggravated pre-existing injuries are not further exacerbated. The respondent submits the applicant has not provided enough evidence to support a finding the treatment plans are reasonable and necessary and the evidence before the Tribunal concludes the applicant does not have an ongoing impairment and the proposed passive treatment would not be beneficial.
8The applicant has not provided any evidence to show the disputed treatment plans are reasonable and necessary. The applicant has provided the following four medical documents;
A treatment and assessment plan from Mackenzie dated September 11, 2017;
A disability certificate completed by Dr. Y. Charko of Mackenzie dated September 11, 2017;
The clinical notes and records (“CNRs”) from Mackenzie Regional Health Centre; and
The CNRs of Dr. R. Leone, family physician.
9Although the applicant’s documents support a finding the applicant should not be treated within the MIG because of pre-existing injuries, I find the evidence does not support of a finding the disputed treatment plans are reasonable and necessary. Insured persons are not entitled to treatment simply because they are no longer subject to the funding limit provided by the MIG. It is essential to provide evidence the proposed treatment is reasonable and necessary, which the applicant has not done. The two documents from Mackenzie were created more than 6 months prior to the disputed treatment plans were and provide no information about the applicant’s condition at the time the treatment plans are proposed. The CNRs from Mackenzie Regional Health Centre only provide information about the applicant’s hospital visit of the day of the accident and no other information. The CNRs of Dr. Leone are only from the period ending September 20, 2017 and, like the Makenzie documents, provide no information about the applicant’s medical condition at the time the treatment plans were proposed.
10The respondent’s evidence on the other hand, namely the insurer’s examination by Dr. I. Manhas, family physician, is for the relevant period and expressly states the disputed treatment plans are not reasonable and necessary based on the in-person examination on May 9, 2018. Dr. Manhas examined the applicant and found no musculoskeletal impairment, no range of motion impairment in any of the applicant’s affected areas, and Dr. Manhas observed no pain behaviours during the assessment and concluded the therapy proposed is unlikely to benefit the applicant.
11When considering the relevance and content of the medical documents, I find the insurer’s examination report by Dr. Manhas dated May 24, 2017 outweighs the totality of the applicant’s evidence. As a result, I find the disputed treatment plans not reasonable and necessary.
COSTS & EXPENSES
12The applicant requested an order that the respondent pay costs and disbursements of no set amount. The applicant did not provide any reasons for the requests. The respondent submits the applicant is not entitled to costs and expenses because the respondent has maintained civility during the proceeding and has not interfered in the Tribunal’s ability to conduct a fair, efficient, and effective process. I agree with the respondent.
13Costs are addressed in rule 19.1 of the Common Rules of Practice and Procedure. Rule 19.1 provides that costs may be awarded in the event that a party in a proceeding has acted unreasonably, frivolously, vexatiously or in bad faith.
14I reject the applicant’s request for the costs and expenses because there is no evidence or submissions before me to substantiate the claim. I see no evidence the respondent acted unreasonably, frivolously, vexatiously, or in bad faith during the proceeding.
CONCLUSION
15The applicant is not entitled to the treatment plans in dispute because they are not reasonable and necessary.
16There is no interest payable and no payments went overdue.
Released: July 16, 2019
Brian Norris
Adjudicator