Licence Appeal Tribunal File Number: 20-004429/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:
Ying Kwan
Applicant
and
Unica Insurance Inc.
Respondent
DECISION
ADJUDICATOR:
Derek Grant
APPEARANCES:
For the Applicant:
Tanjoyt Deol, Counsel
For the Respondent:
Jonathan Heeney, Counsel
HEARD:
By way of written submissions
BACKGROUND
1Y.K. was involved in an automobile accident on November 4, 2016, and sought benefits from the respondent, Unica, pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 20101 (the "Schedule"). Unica denied the benefits on the basis that it determined the treatment was not reasonable and necessary. Y.K. disagreed and applied to the Tribunal for resolution of the dispute.
ISSUES
2The issues in dispute are as follows:
a. Is the medical benefit in the amount of $2,990.39 for chiropractic services, recommended by Prime + Care Health Centre in a treatment plan (OCF-18) submitted on November 15, 2019, denied on November 18, 2019, reasonable and necessary?
b. Is the medical benefit in the amount of $3,253.04 for psychological services, recommended by Perfect Choice Psychological Services in an OCF-18 submitted on September 17, 2018, denied October 2, 2018, reasonable and necessary?
c. Is the medical benefit in the amount of $2,627.88 for chiropractic services, recommended by Perfect Physio and Rehab Centre in an OCF-18 submitted on March 11, 2018, denied on March 9, 2018, reasonable and necessary?
d. Is the medical benefit in the amount of $3,04.70 for medical services, recommended by Prime + Care Health Centre in an OCF-18 submitted on June 1, 2018, denied on June 14, 2018, reasonable and necessary?
e. Is Y.K. entitled to interest on any overdue payment of benefits?
FINDING
3Y.K. is not entitled to the OCF-18s or interest as she has not demonstrated that the benefits are reasonable and necessary.
BACKGROUND
4Y.K. has been involved in several accidents prior to the subject accident, and a subsequent accident since. On September 24, 2015, Y.K. was involved in a rear-end collision in which she sustained soft tissue injuries. Previous accident benefits claims arose out of motor vehicle collisions on July 10, 1999, February 7, 2010, April 3, 2001, June 22, 2002, May 27, 2005 and October 9, 2007.
5Y.K. was subsequently involved in a rollover accident on May 30, 2018. As a result of the 2018 accident, Y.K. sustained injuries and impairments identified as: neck, back, shoulder, head pain, concussion, depression, anxiety and dizziness.
6Following the 2018 accident, Y.K. applied for accident benefits from Allstate. Y.K. submitted various treatment plans including claims for chiropractic treatment from Prime + Care Health Centre and psychological counselling from Perfect Choice Psychological Services. The treatment plans included, but were not limited to:
a. An OCF-18 dated May 31, 2018 from Prime + Care for chiropractic treatment;
b. An OCF-18 dated September 14, 2018 from Prime + Care for chiropractic treatment;
c. An OCF-18 dated February 16, 2019 from Prime + Care for chiropractic treatment;
d. An OCF-18 dated July 5, 2019 from Prime + Care for chiropractic treatment;
e. An OCF-18 dated March 28, 2019 from Perfect Choice Psychological Services for a psychological assessment; and
f. An OCF-18 dated May 2, 2019 from Perfect Choice Psychological Services for psychological services.
7Y.K. settled her accident benefits claim with Allstate in October 2019. A summary of benefits from Allstate revealed that the majority of benefits paid were for chiropractic treatment from Prime + Care and psychological counselling from Perfect Choice.
ANALYSIS
8To be entitled to payment for an OCF-18 under the Schedule, an applicant bears the onus of establishing on a balance of probabilities that the benefit is reasonable and necessary as a result of the accident. In order to do so, an applicant must establish that the treatment goals are reasonable, that the goals are being met to a reasonable degree and that the overall costs of achieving the goals is reasonable.
9Y.K. submits that she suffers from ongoing pain and impairments which requires further treatment. To this end, she relies on a November 25, 2016 Disability Certificate (OCF-3), the clinical notes and records (CNRs) of her family physicians, Dr. Yeung and Dr. Wong, a report from Dr. Kachooie, a physiatry report from Dr. Bentley, a neurological evaluation from Dr. Basile, and a lumbar spine diagnostic imaging report.
10In response, Unica submits that that Y.K. has failed to address the reasonableness and necessity of the disputed OCF-18s. It further submits that there is no medical evidence that supports that she requires further facility-based treatment as a result of the subject accident. Its position is that the treatment plans are likely for treatment she requires as a result of the May 2018 accident.
11I agree with Unica. While Y.K. still reports ongoing pain symptomatology, she has failed to show how the treatment plans are reasonable and necessary to address her pain complaints. Her submissions are silent on whether the treatment goals are reasonable, whether the goals are being met to a reasonable degree and whether the overall cost of achieving the goals is reasonable.
12Further, Y.K. has not shown compelling medical evidence, outside of the OCF-18s, that the treatment was recommended by any of her treatment providers. This is supported by the following medical evidence:
a. The CNRs of Dr. Cheng, Dr. Yeung, Dr. Wong, and Dr. Kachooie recommend further pharmacological interventions and confirm that her injuries are soft tissue in nature. There are no recommendations for the treatment proposed in the OCF-18s.
b. In a September 19, 2018 report, psychologist Dr. McDowall, did not recommend further treatment as a result of the subject accident, but for the 2018 accident, due to Y.K. having "suffered a setback" as a result of the 2018 accident.
c. During the time period of the OCF-18s, there is no corroborating medical evidence that supports or recommends any of the treatment proposed in the OCF-18s for the subject accident.
d. Although Y.K. was admitted to hospital and diagnosed with bipolar disorder, there is no clear and direct causal link established between her bipolar disorder and the subject accident.
e. The treatment plans are largely recommended after the 2018 accident, which calls into question whether the 2018 accident may have been a more significant event requiring the additional treatment recommended in the OCF-18s before me.
13For these reasons, I find that Y.K. has not demonstrated that the OCF-18s are reasonable and necessary. As no benefits are overdue, no interest is payable under s. 51 of the Schedule.
CONCLUSION
14Y.K. has failed to demonstrate that the disputed OCF-18s are reasonable and necessary or that interest is payable.
Released: December 13, 2021
_______________________
Derek Grant, Adjudicator
Footnotes
- O. Reg. 34/10, as amended.