Released Date: 09/25/2020
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:
Y. C. C.
Applicant
and
Motor Vehicle Accident Claims Fund (MVACF)
Respondent
DECISION
ADJUDICATOR:
Derek Grant
APPEARANCES:
For the Applicant:
Yu Jiang, Paralegal
For the Respondent:
Daniel Fenwick, Counsel
HEARD:
By way of written submissions
OVERVIEW
1The applicant ("Y.C.C.") was injured in an automobile accident ("the accident") on March 25, 2017 and sought benefits pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 2010 ("Schedule"), some of which were denied by the respondent, Motor Vehicle Accident Claims Fund ("MVACF").
2Y.C.C. submits that, as a result of injuries he sustained in the accident, the treatment he seeks is reasonable and necessary.
3MVACF argues that Y.C.C. has not established that the treatment plans are reasonable and necessary.
ISSUES
4In their submissions, the parties have resolved or agreed that issues are withdrawn. As a result, I am asked to determine the following remaining issues:
a. Is the medical benefit in the amount of $2,764.00 for dental treatment recommended by Dr. Chien in a treatment plan ("OCF-18") which was denied on October 11, 2017, reasonable and necessary?
b. Is Y.C.C. entitled to interest on any overdue payment of benefits?
c. Is MVACF liable to pay an award under Regulation 664 because it unreasonably withheld or delayed payments to the applicant?
FINDING
5Based on a review of the evidence, I find the following:
a. The OCF-18 is not reasonable and necessary, therefore there is no interest on any outstanding balance of payment; and
b. Y.C.C. is not entitled to an award.
LAW
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
ANALYSIS
OCF-18 for dental treatment
7Y.C.C.'s claims that due to his accident-related injuries2, the treatment he seeks is reasonable and necessary; I find the medical evidence does not support his claim.
8This OCF-18 is dated August 3, 2017 and was completed by Dr. Daphne Chien, dentist. It sought funding for removal of four teeth in addition to dentures. The goals of this OCF-18 are to aid in pain reduction and improve chewing ability.
9MVACF responded to this OCF-18 on September 7, 2017 noting that an independent medical assessment was necessary in order to determine whether the OCF-18 was reasonable and necessary. A formal denial by MVACF was provided to Y.C.C. on October 11, 2017. Included with the denial was a copy of the s. 44 dental assessment report completed by Dr. Ouanounou. MVACF relied upon Dr. Ouanounou's October 3, 2017 report in which Dr. Ouanounou concluded that Y.C.C. had "poor oral hygiene, multiple missing teeth and periodontitis. The file lacks any evidence to support that [the applicant] suffered trauma to his oral and maxillofacial structures". Dr. Ouanounou went on to state that Y.C.C. makes no mention of any symptoms or injuries in relation to his teeth or jaw. Dr. Ouanounou also noted that none of the documents provided for review make any reference of symptoms related to the teeth.
10Y.C.C. put forth no evidence that the OCF-18 is reasonable and necessary. It's important to note that Dr. Chien had no previous dental records available to review. Dr. Chien was also unable to provide an opinion on whether or not the dental issues are minor in nature. She is also not able to comment on whether there are pre-existing issues and is unable to determine the exact damage caused by the accident.
11On its own, an OCF-18 may not suffice to establish that treatment is reasonable and necessary. Without other supporting medical evidence or objective findings, Y.C.C. has not established that the OCF-18 is reasonable and necessary. In this proceeding, the OCF-18 author, Dr. Chien, is limited in what she is able to determine as a cause of the dental complaints, and there is no evidence that connects the dental complaints to the accident. Y.C.C.'s claim for this OCF-18 fails for the above reasons.
AWARD
12Section 10 of Regulation 664 permits the Tribunal to award a lump sum of up to 50% of the amount to which the insured person (i.e. Y.C.C.) was entitled at the time of the award together with interest on all amounts then owing (including unpaid interest) if it finds that that an insurer (i.e. MVACF) has "unreasonably" withheld or delayed payments.
13Since Y.C.C. is not entitled to the disputed OCF-18, MVACF cannot be found to have unreasonably withheld payment of the benefit. As a result, Y.C.C. is not entitled to an award.
COSTS
14Rule 19.1 of the Safety, Licencing Appeals & Standards Tribunals Ontario Common Rules of Practice and Procedure, October 2, 2017 provides that a party may make a request to the Tribunal for its costs where a party believes that another party in a proceeding has acted in an unreasonable, frivolous, vexatious manner or in bad faith. Rule 19.6 sets a limit of $1000.00 on costs.
15MVACF's request regarding costs is based on its position that Y.C.C. has "unreasonably brought this application in that the denied benefits were correctly denied and, in most part, denied due to the inaction of the Claimant". MVACF further submits that Y.C.C. withheld information materially important to the determination of his medical impairments.
16The costs provisions of Rule 19.1 are not intended to compensate parties for suffering an inconvenience or for the costs of their involvement in filing an application with the Tribunal. Costs are awarded to ensure civility, respect and order during Tribunal proceedings, and to deter conduct that threatens the orderly and civil resolution of an application.
17I agree with MVACF that there is evidence that Y.C.C. may not have provided all the updated medical records requested and agreed to during the case conference. However, there was a significant amount of medical documentation provided, to the extent that several issues were resolved and/or withdrawn subsequent to the completion of the case conference.
18I do not find that MVACF suffered such a degree of prejudice that it was unable to make fully informed decisions regarding the resolved issues. In fact, I find that MVACF was able to determine whether any of the aforementioned resolved issues were initially properly denied. The evidence shows that as OCF-18s were submitted for approval, MVACF took the appropriate steps in determining whether the requests for treatment were reasonable. It initially agreed that treatment was partially reasonable, and subsequently approved several remaining balances.
19It is not unusual that an insured might argue that any remaining OCF-18s might also be reasonable and necessary given similar circumstances to this proceeding.
20The onus is on Y.C.C. to establish on a balance of probabilities that the treatment he seeks is reasonable and necessary. Although there was a substantial amount of medical evidence put forth, there was still additional evidence that was requested and not provided. Despite the circumstances described above, MVACF managed to perform its due diligence in adjusting the file. I find that Y.C.C. provided enough evidence for MVACF to have sufficiently adjusted the file, and that sufficiency does not amount to an order for costs.
21Consequently, I disagree with MVACF that Y.C.C.'s actions during this proceeding have been unreasonable, frivolous, vexatious or in bad faith. MVACF's claim for costs is denied.
CONCLUSION
22For all of the above reasons, I find the following:
a. Y.C.C. is not entitled to the OCF-18 for dental treatment, therefore no interest is payable;
b. Y.C.C. is not entitled to an award;
c. MVACF's request for costs is denied; and
d. Y.C.C.'s application is dismissed.
Released: September 25, 2020
Derek Grant
Adjudicator
Footnotes
- Scarlett v. Belair Insurance, 2015 ONSC 3635.
- Applicant Document Brief – Tab 2 – Records from Rejuven8 Health Care, pg. 11 - Diagnoses were provided as upper back sprain/strain; lower back sprain/strain; left knee contusion, bruising, swelling; left leg contusion, swelling; left ankle contusion, bruising, swelling; concussion; nausea; dizziness; and headache.