Released Date: 04/02/2020
`File Number: 19-000319/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:
Q.Y.F.
Applicant
and
Aviva General Insurance
Respondent
DECISION
ADJUDICATOR:
Derek Grant
APPEARANCES:
For the Applicant:
Ivan Yau, Paralegal
For the Respondent:
Danielle Wilkinson, Counsel
HEARD: In Writing
December 2, 2019
OVERVIEW
1The applicant, Q.Y.F., was involved in an automobile accident on November 15, 2016, (the “accident”) and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (the ''Schedule''). This dispute focuses the respondent’s, Aviva General Insurance (“Aviva”), denial of Q.Y.F.’s entitlement to medical benefits.
2Q.Y.F. submits that, as a result of injuries she sustained in the accident, the treatment she seeks is reasonable and necessary.
3Aviva argues that Q.Y.F. has not established that the treatment plans are reasonable and necessary.
ISSUES
4The issues I must determine are as follows:
a. Is the medical benefit in the amount of $1,964.62 for chiropractic treatment recommended by Allied Physio and Rehab in a treatment plan submitted April 26, 2018 and denied on May 3, 2018, reasonable and necessary?
b. Is the medical benefit in the amount of $448.83 for psychological services recommended by Lingyu International Psychology Centre in a treatment plan submitted April 3, 2018 and denied on April 10, 2018, reasonable and necessary?
c. Is the medical benefit in the amount of $299.22 for psychological services recommended by Lingyu International Psychology Centre in a treatment plan submitted March 13, 2018 and denied on April 6, 2018, reasonable and necessary?
d. Is the medical benefit in the amount of $200.00 for goods and services of a medical nature recommended by Allied Physio and Rehab in a treatment plan submitted November 7, 2016 and denied on December 22, 2017, reasonable and necessary?
e. Is the medical benefit in the amount of $1,206.06 for other goods and services of a medical nature recommended by Lingyu International Psychology Centre in a treatment plan submitted November 7, 2016 and denied on December 22, 2017, reasonable and necessary?
f. Is the medical benefit in the amount of $1,280.62 for chiropractic and massage treatment recommended by Allied Physio and Rehab in a treatment plan submitted April 6, 2017 and denied on August 2, 2017, reasonable and necessary?
g. Is the medical benefit in the amount of $229.19 for chiropractic treatment recommended by Allied Physio and Rehab in a treatment plan submitted February 9, 2017 and denied on February 27, 2017, reasonable and necessary?
h. Is the medical benefit in the amount of $1,960.62 for chiropractic treatment recommended by Allied Physio and Rehab in a treatment plan submitted April 26, 2018 and denied on May 3, 2018, reasonable and necessary?
i. Is Q.Y.F. entitled to interest on any overdue payment of benefits?
FINDING
5Based on a review of the evidence, I find the following:
i. Q.Y.F. is entitled to the payment of the amount indicated in issue d., plus interest; and
ii. Q.Y.F. is not entitled to the remaining treatment plans in dispute, therefore no interest is payable.
ANALYSIS
6Sections 14 and 15 of the Schedule provide that an insurer is only liable to pay for reasonable and necessary medical expenses incurred as a result of an accident. The applicant bears the onus of proving on a balance of probabilities that any proposed treatment or assessment plan is reasonable and necessary.1
The chiropractic treatment plans are not reasonable and necessary
7Q.Y.F.’s submissions on medical benefits are confused and at some points almost incomprehensible. They lack any analysis of how the claimed treatment plans were reasonable and necessary to address her alleged injuries. They do not direct me to specific medical evidence which support any of her claims. I found nothing in her appended documentation to assist me in finding otherwise.
8I find that Q.Y.F. has failed prima facie to meet the burden of proof with respect to her chiropractic treatment claims. Accordingly, I do not find it necessary to set out Aviva’s rebuttal evidence or arguments. I note that Aviva provided evidence that all of its denials were based on medical evidence and reports from its own assessor and from Q.Y.F.’s claims documents.
Deduction of collateral benefits – psychological treatment plans
9Aviva submits that the OCF-18s (issues b. and c.) were approved subject to Q.Y.F. submitting the treatment plan to her collateral benefits provider. Aviva may consider payment of the remaining balance upon receipt of proof that Q.Y.F. has submitted her claims through her collateral benefits provider.
10Section 47 (2) of the Schedule allows an insurer to deduct payment that is reasonably available under any insurance plan or law.
11Aviva submits that, to date, Q.Y.F. has not provided evidence that the OCF-18s was submitted to the collateral benefits provider. Aviva contends that, as a result, it is not able to determine whether the balances are payable.
12Q.Y.F. has not directed me to any evidence that the OCF-18 was submitted to her collateral benefits provider. Although Q.Y.F. submits that there is no collateral benefits provider, an invoice2 appears to show that Seneca College provides Q.Y.F. with collateral benefits. As such, I find that Aviva is not required to pay any amount of the treatment plan until Q.Y.F. has provided Aviva with proof of submission to the collateral benefits provider.
The Auto Insurance Standard Invoice (OCF-21) for OCF-3 Form completion is payable
13Aviva submits that it did not receive a Disability Certificate (“OCF-3”) dated December 8, 2016. Q.Y.F. contends that the adjuster’s log notes establish that Aviva did receive an OCF-3. According to Q.Y.F., in the adjuster’s log notes there is an entry regarding an OCF-3 which states:
OCF-3 on file does not support SB entitlement – med only claim
14Although I am not provided a copy of the OCF-3, it appears that the adjuster’s log note entry clearly indicates an OCF-3 on file. Further, there is no mention of any other OCF-3 on file, therefore I find that the OCF-3 indicated in the adjuster’s log notes is the December 8, 2016 OCF-3. As such, I find the fee for the completion of the OCF-3 to be payable.
CONCLUSIONS
15Q.Y.F. is entitled to payment in the amount of $200.00 for OCF-3 form completion, submitted by Allied Physio and Rehab in an OCF-21 dated November 7, 2016, including interest pursuant to s. 51 of the Schedule;
16Q.Y.F. has not proven her entitlement to any of the chiropractic benefits she claims;
17Q.Y.F. is not entitled to payment for the balances of the psychological treatment plans until proof of submission to her collateral benefits provider is given to Aviva; and
18The application is dismissed.
Released: April 2, 2020
Derek Grant
Adjudicator
Footnotes
- Scarlett v. Belair, 2015 ONSC 3635.
- EHC Statement dated May 13, 2017 – Respondent Submissions at Tab 9