Citation: MAA vs. RBC Insurance, 2019 ONLAT 18-004989/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:
MAA
Applicant
and
RBC Insurance
Respondent
DECISION
APPEARANCES:
For the Applicant: Jeton Memeti, Paralegal
For the Respondent: Mark Vella, Counsel
HEARD: In Writing Hearing: March 11, 2019
REASONS FOR DECISION
OVERVIEW
The applicant, MAA, was involved in an automobile accident on February 14, 2017, and sought benefits pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 20101 (the ''Schedule'').
She applied for dispute resolution services to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”) when the respondent, RBC, denied the disputed claims.
DISPUTED BENEFITS
- The issues before the Tribunal are:
i. Is MAA entitled to a medical benefit in the amount of $1,384.70 for chiropractic treatment recommended by Mackenzie Medical in a treatment plan (“OCF-18”) submitted on April 23, 2017 and denied on May 1, 2018?
ii. Is MAA entitled to a cost of examination in the amount of $2,055.33 for a psychological assessment recommended by All Health Medical in an OCF-18 submitted on April 26, 2018 and denied on May 1, 2017?
iii. Is RBC liable to pay an award under Regulation 664, Automobile Insurance2 (“Regulation 664”) because it unreasonably withheld or delayed payments to the applicant?
FINDINGS
- I find that MAA has not proven her entitlement to medical benefits. Her application is denied. There is no basis for an award. No benefits are overdue and therefore no interest is payable.
ANALYSIS
Sections 14 and 15 of the Schedule provide that an insurer is only liable to pay for medical expenses that are reasonable and necessary as a result of the accident. The onus is on the applicant, in this case MAA, to show that the proposed medical benefits are reasonable and necessary.
To support her claims, MAA relies on the OCF-18s she submitted and on various clinical notes and records (CNRs) appended to her submission.
a) Chiropractic Treatment Plan
MAA acknowledges a pre-existing condition of rheumatoid arthritis severe enough to prevent her from working outside the home and to force her to perform domestic activities slowly.
In response, RBC relies on the following:
i. CNRs and correspondence from MAA’s own physician, Dr. Malik, an insurer’s examination (IE) failed to recommend physiotherapy (a modality included in the disputed plan) and instead recommend trying acupuncture, which is not included in the disputed OCF-18.3 The same documents indicate that MMA stated that her cervical pain had never resolved and that nothing helps.
ii. A report by Dr. Raymond Zabieliauskas, physiatrist, dated December 28, 2017, in which the doctor reports:
a. MAA’s ongoing complaints arise primarily from her severe deforming rheumatoid arthritis and not from the accident.
b. MAA sustained uncomplicated soft-tissue injuries – sprains and strains – from the accident.4
c. MAA has reached maximum medical recovery (MMR)5 from her accident-related injuries. Future OCF-18s would not be reasonable