Released Date: 02/01/2021
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:
Romel Corpuz
Applicant
and
Aviva General Insurance
Respondent
DECISION AND ORDER
VICE CHAIR:
Theresa McGee
APPEARANCES:
For the Applicant:
Lisa Bishop, Counsel
For the Respondent:
Matthew Owen, Counsel
HEARD:
By way of written submissions
REASONS FOR DECISION AND ORDER
OVERVIEW
1The applicant, R.C., was involved in an automobile accident on December 23, 2015, when the vehicle he was driving was rear-ended. He sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 20101 (the “Schedule”).
2The respondent, Aviva General Insurance, denied the applicant certain benefits and he applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (“Tribunal”) for a resolution of the dispute.
ISSUES IN DISPUTE
3I am to decide the following issues:
i. Is the applicant entitled to a medical benefit in the amount of $2,456.00 for chiropractic services recommended by Health-Pro Wellness in a Treatment and Assessment Plan (OCF-18) submitted March 7, 2019 and denied March 10, 2019?
ii. Is the applicant entitled to $1,997.29 for the cost of a Psychological Assessment recommended by Health-Pro Wellness in a Treatment and Assessment Plan (OCF-18) submitted April 18, 2016 and denied February 5, 2018?
iii. Is the applicant entitled to interest on any overdue payment of benefits?
iv. Is the applicant entitled to an award for unreasonably withheld or delayed payments under section 10 of Ontario Regulation 664?
RESULT
4The applicant has failed to demonstrate entitlement to the benefits he seeks. On a balance of probabilities, I find both the treatment and assessment in dispute not reasonable and necessary as a result of the accident. Since no benefits are owing, no interest is payable. There is no basis for an award.
5Conversely, the respondent is entitled to receive costs in the amount of $100.00.
ANALYSIS
Accident-related injuries
6Six days after the accident, on December 29, 2015, the applicant was assessed at Health-Pro Wellness by Dr. Aliya Salayeva, Chiropractor. Dr. Salayeva completed a Disability Certificate (OCF-3) on the applicant’s behalf, listing his injuries as whiplash associated disorder with neck pain and musculoskeletal signs, other sprain and strain of the cervical spine, strain and sprain of the thoracic spine, strain and sprain of other unspecified parts of the lumbar spine and pelvis, tension-type headaches, other sleep disorders, subluxation complex (vertebral), radiculopathy, and sprain and strain of the shoulder joint. In Part 7 of the Disability Certificate, (“Further Investigations or Consultations”), Dr. Salayeva indicated that a Psychological Assessment and Attendant Care Assessment were contemplated or required.
7One month later, on January 27, 2016, the applicant reported the accident to his family doctor, Dr. R. Atwal. Dr. Atwal’s clinical notes from the visit are handwritten and appear to indicate, in one type of handwriting, (which I take to be that of clinical staff), “+ history of whiplash injury to the neck, + frequent episodes of dizziness, headache, neck pain and lower back pain”. The remaining notes, which appear to be handwritten by Dr. Atwal (because they include a recommendation for motor vehicle accident rehabilitation and an order for an x-ray of the lumbar and thoracic spine), are otherwise illegible and have not been transcribed. It is unclear from the record whether x-rays were ever conducted, as the applicant has not tendered any diagnostic imaging reports.
The disputed Psychological Assessment
8On April 18, 2016, Health-Pro Wellness submitted a Treatment and Assessment Plan (OCF-18) completed by Dr. Fahimeh Aghamohseni on the applicant’s behalf. The plan recommended a Psychological Assessment at a cost of $1,997.29. In the “Additional Comments” section of the plan, Dr. Aghamohseni appended the results of a “Pre-Screening Assessment” conducted the day the plan was prepared.
The sufficiency of the denial
9The parties’ positions on what happened next diverge significantly. The applicant submits that the respondent first replied to the OCF-18 by requesting a Section 44 Insurer’s Examination (“IE”) on May