Released Date: 12/18/2020
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:
Maria Corveira Fernandez
Applicant
and
Aviva General Insurance
Respondent
DECISION AND ORDER
ADJUDICATOR:
Avril A. Farlam
APPEARANCES:
For the Applicant:
Lisa Bishop
Counsel
For the Respondent:
Mohamed Hashim
Counsel
HEARD
By Way of Submissions in Writing
REASONS FOR DECISION AND ORDER
OVERVIEW
1Maria Corveira Fernandez(“applicant”), was involved in a motor vehicle accident on May 4, 2018 (“accident”). The applicant submits that she sustained serious injuries from the accident. The applicant was removed from the MIG May 15, 2019 due to identified psychological issues.
2The applicant sought benefits from Aviva General Insurance (“respondent”) pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (the ''Schedule''). 1 The applicant was denied certain benefits by the respondent and submitted an application to the Licence Appeal Tribunal - Automobile Accident Benefits Service (“Tribunal”) for dispute resolution.
3The respondent submits that the medical and rehabilitation benefits sought are not reasonable and necessary.
ISSUES
4The issues to be decided in this hearing are:
i. Is the applicant entitled to $1,340.20 for a functional impairment evaluation, recommended by Dr. Marcia Richards in a treatment plan submitted on September 27, 2018, and denied on November 19, 2018?
ii. Is the applicant entitled to $2,000.00 for a neurological assessment, recommended by Dr. Vincenzo Basile in a treatment plan (OCF-18) submitted on June 14, 2019, and denied on October 21, 2019?
iii. Is the applicant entitled to $1,521.26 for an attendant care assessment and Form 1, recommended by Dr. Oleksandr Pivtoran in a treatment plan (OCF-18) submitted on June 27, 2018, and denied on July 3, 2018?2
iv. Is the applicant entitled to an award under Ontario Regulation 664 because the respondent unreasonably withheld or delayed the payment of benefits?
v. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
5The applicant is not entitled to the costs of the three disputed treatment plans. No interest is payable. No award is made.
LAW
6Sections 14, 15 and 16 of the Schedule provide that an insurer is only liable to pay for medical and rehabilitation expenses that are reasonable and necessary as a result of the accident. The applicant bears the onus of proving on a balance of probabilities that the treatment plan he or she seeks is reasonable and necessary.3
ANALYSIS
Are the Disputed Treatment Plans Reasonable