Released: July 6, 2020
Tribunal File Number: 18-011897/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:
D. F.
Applicant
And
Aviva General Insance
Respondent
DECISION
ADJUDICATOR: Brian Norris
APPEARANCES:
For the Applicant: Loreto Scarola
For the Respondent: Stanford Cummings
Heard by way of written submissions
OVERVIEW
1The applicant was injured in an automobile accident on March 10, 2017 and sought benefits from the respondent pursuant to Statutory Accident Benefits Schedule - Effective September 1, 2010, O. Reg. 34/10 (the “Schedule”). The respondent refused to pay for certain benefits and the applicant applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of this dispute.
ISSUES
2The disputed claims in this hearing are:
Is the applicant entitled to a medical benefit in the amount of $1,553.72 for a chiropractic treatment plan recommended by P & C Rehabilitation Services in a treatment and assessment plan dated April 30, 2018?
Is the applicant entitled to a medical benefit in the amount of $1,553.72 for a chiropractic treatment plan recommended by P & C Rehabilitation Services in a treatment and assessment plan dated December 10, 2018?
Is the applicant entitled to a medical benefit in the amount of $2,830.26 for a psychological treatment plan recommended by Pilowsky Psychology Professional Corporation in a treatment and assessment plan dated June 4, 2018?
Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant is entitled to the costs of the chiropractic treatment plan dated April 30, 2018, plus interest. She is not entitled to the December 10, 2018 chiropractic treatment plan or the psychological treatment plan.
BACKGROUND
4The applicant was the driver of a vehicle which was struck on the front end on the driver’s side by another vehicle that proceeded through a red light. The impact of the collision pushed the applicant’s vehicle, causing it to strike another vehicle on the opposite side. She was taken from the scene of the accident to the hospital by ambulance where she reported headaches. She was assessed and imaging was conducted on her head, back and shoulder, which was negative for any fracture, misalignment or internal bleeding. Though it is unclear as to what part of her body required it, various reports note the applicant was given an injection to reduce pain before being released. The hospital records were not submitted for the purpose of this hearing.
5The applicant visited her family physician, Dr. O. Ajisafe a few days following the accident and complained of shoulder pain and headaches. Dr. Ajisafe diagnosed the applicant with soft tissue injuries. The applicant was prescribed Celebrex and referred to physiotherapy. She visited Dr. Ajisafe again about a month later and was diagnosed with post traumatic stress disorder (“PTSD”) and was advised to increase her use of Ativan. The applicant was also prescribed Cymbalta during a visit a few weeks after that.
6The applicant started treatment, primarily chiropractic, at P & C Rehabilitation Services about ten days following the accident. She regularly attended at a rate of about once per week. The treatment was funded by the respondent until the submission of the April 30, 2018 treatment plan, issue (1), which was denied after an insurer’s examination (“IE”) where the assessor found that the treatment was not reasonable and necessary. The applicant continued treatment, despite the lack of funding from the respondent, and submitted another treatment plan, dated December 10, 2018, issue (2), which the respondent also denied.
7Around July 17, 2017, the date of Dr. S. MacKay’s psychological IE report, the respondent no longer considered the applicant’s injuries to be within the definition of a minor injury and she was removed from the Minor Injury Guideline and no longer subject to the $3,500.00 funding limit on treatment. Dr. MacKay diagnosed the applicant with adjustment disorder with mixed anxiety and depressed mood. Following the IE, the applicant engaged in counselling to treat her psychological injuries, which the respondent funded. At the conclusion of the psychological treatment plan, the applicant sought further psychological treatment and submitted a plan dated June 4, 2018, listed as issue (3). The respondent denied this after an IE by Dr. A. Syed, neuropsychologist, found the treatment was not reasonable and necessary for her accident-related injuries.
8The onus is on the applicant to prove the disputed treatment and assessment plans are reasonable and necessary for her accident-related injuries.
THE CHIROPRACTIC TREATMENT PLAN DATED APRIL 30, 2018
9Considering the evidence before me, I find the chiropractic treatment plan dated April 30, 2018 to be reasonable and necessary for the applicant’s accident-related injuries.
10The medical evidence shows that the applicant continued to experience neck, back and shoulder pain which was relieved trough the therapy primarily provided by Dr. P. Agyemang, chiropractor. The treatment records from P & C Rehabilitation Services consistently note the applicant’s complaints of back, neck and shoulder pain and that she feels better following treatment. The records of Dr. O. Ajisafe, the applicant’s family physician, also document the applicant’s pain complaints - which I acknowledge were more frequent in the acute time following the accident. Nevertheless, the records note a visit due to right shoulder pain in March 2018 which prompted a bone scan, though that found only arthritic changes. The records from Pilowsky Psychology Professional Corporation consistently note that the applicant reports relief from her ongoing physical treatment. It is best evidenced in an entry dated April 23, 2018 where the applicant reported that she recently missed an appointment and was “feeling it”, which I interpret to mean that she felt worse from missing treatment.
11As submitted by the applicant, I find the content of the June 18, 2018 IE report by Dr. A. Oshidari, physiatrist, supports entitlement to the April 30, 2018 treatment plan, despite concluding the plan is not reasonable and necessary. Dr. Oshidari examined the applicant and found her cervical spine and right shoulder range of motion were mildly impaired and she complained of discomfort and pain during testing. Range of motion in her lumbar spine was at 60% of normal for flexion and rotation. Range of motion was at 20% of normal for extension and lateral bending, again, with reports of pain during the examination. Despite these findings, Dr. Oshidari concluded the applicant had functional range of motion of her upper extremities and spine. Dr. Oshidari further concluded that the applicant’s injuries fit the definition of a minor injury and can be treated within the MIG, despite having reviewed Dr. McKay’s psychological assessment report which prompted the applicant’s removal from the MIG in April 2017, more than a year prior to the assessment.
THE CHIROPRACTIC TREATMENT PLAN DATED DECEMBER 10, 2018
12While the April 30, 2018 treatment plan is reasonable and necessary, I find the plan dated December 10, 2018 is not because there is insufficient evidence to support ongoing treatment.
13There is insufficient evidence to support the December 10, 2018 treatment. Dr. Ajisafe’s records show fewer accident-related pain complaints as time passed since the accident and none around the time of this disputed treatment plan. The most relevant entry is an imaging report dated December 3, 2018 which showed mostly minor degenerative changes but also a concerning appearance at T1 and T2 which prompted a recommendation for a CT scan if the area is symptomatic. There is no record a CT scan occurred, suggesting the area was asymptomatic.
14The orthopaedic assessment report of Dr. V. Naumetz dated January 18, 2019 concludes that the December 10, 2018 treatment plan is not reasonable and necessary. Dr. Naumetz examined the applicant and found reasonable range of motion in the neck, back and shoulder with only slight tenderness in the cervical and posterior shoulder area. Dr. Naumets concluded there was no significant physical findings on examination, that the applicant had largely recovered from her accident-related injuries, and that the December 10, 2018 chiropractic treatment plan was not reasonable and necessary.
THE PSYCHOLOGICAL TREATMENT PLAN DATED JUNE 4, 2018
15I find the psychological treatment plan is not reasonable and necessary because the applicant has achieved the treatment plan goals and has reached maximal recovery of her psychological injuries.
16The treatment plan seeks to achieve goals the applicant has already achieved. The plan proposed counselling to decrease her psychological symptoms and return her to her activities of normal living. However, the applicant’s medical record shows virtually no symptoms of any residual psychological injury at the time the plan was submitted. Dr. Ajisafe’s records are devoid of any psychological complaints from the applicant in the time leading up to and immediately following the proposed psychological treatment. The psychological reassessment report by Dr. J. Pilowsky and Dr. S. Sagrati dated April 25, 2018 found the applicant had minimal depression and moderate anxiety but it made no recommendation for further treatment beyond the remaining treatment sessions that had already been approved. The applicant has returned to her activities of normal living. Her independence with her self-care activities is noted in several different reports and she has returned to her spiritual and social activities such as attending church, going for walks, and volunteering in the community.
INTEREST
17Pursuant to section 51 of the Schedule, interest is payable if the respondent fails to pay a benefit within the time period prescribed by the regulation. I find interest is only payable on the April 30, 2018 chiropractic treatment plan because it is reasonable and necessary and has been incurred by the applicant. The remaining treatment and assessment plans are not reasonable and necessary and, thus, no interest is payable on them.
CONCLUSION
18Considering the medical evidence before me, I find the April 30, 2018 chiropractic treatment plan is reasonable and necessary. The applicant is entitled to payment for the incurred goods and services plus interest pursuant to section 51 of the Schedule.
19There is insufficient evidence in favour of the December 10, 2018 chiropractic treatment plan and, consequently, I find it is not reasonable and necessary for the applicant’s accident-related injuries.
20The applicant has already reached the goals proposed in the psychological treatment plan. The plan is not reasonable and necessary as a result.
Released: July 6, 2020
___________________________
Brian Norris
Adjudicator