Release date: 09/29.2021
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:
Nadina Pereira
Applicant
and
Certas Direct Insurance Company
Respondent
DECISION
ADJUDICATOR:
Avril A. Farlam
APPEARANCES:
For the Applicant:
Ovidiu Klein, Paralegal
For the Respondent:
April Snow, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Nadina Pereira (“applicant”) was involved in an automobile accident on August 10, 2019 (“accident”) while operating her motorcycle and suffered injuries. The applicant sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (the ''Schedule''). 1The applicant was denied certain benefits by Certas Direct Insurance Company (“respondent”) and submitted an application to the Licence Appeal Tribunal - Automobile Accident Benefits Service (“Tribunal”).
2The respondent determined that the applicant’s injuries fit the definition of “minor injury” prescribed by s. 3(1) of the Schedule and, therefore, fall within the Minor Injury Guideline (“MIG”).2The respondent also submits that, even if the MIG is found not applicable, the applicant has not established that the disputed treatment plans are reasonable and necessary.
3The applicant’s position is that her fracture sustained in the accident takes her out of the MIG and that the proposed treatment plans are reasonable and necessary.
ISSUES
4The issues to be decided in this hearing are:
i. Are the applicant’s injuries predominantly minor as defined in s. 3 of the Schedule and therefore subject to treatment within the $3,500.00 limit and in the MIG?
ii. Is the applicant entitled to $2,174.50 for chiropractic treatment recommended by Mackenzie Medical Rehabilitation Centre in a treatment plan (OCF-18) submitted on December 3, 2019, and denied on December 19, 2019?
iii. Is the applicant entitled to $1,779.60 for chiropractic treatment recommended by Mackenzie Medical Rehabilitation Centre in a treatment plan (OCF-18) submitted on January 16, 2020, and denied on December 31, 2020?
iv. Is the applicant entitled to $2,569.40 for chiropractic treatment recommended by Mackenzie Medical Rehabilitation Centre in a treatment plan (OCF-18) submitted on February 11, 2020, and denied on February 18, 2020?
v. Is the applicant entitled to $2,514.40 ($2,569.40 less the partially approved amount of $55.00) for chiropractic treatment recommended by Mackenzie Medical Rehabilitation Centre in a treatment plan (OCF-18) submitted on October 25, 2019, and denied on November 6, 2019?
vi. Is the applicant entitled to $144.20 for a disability certificate (OCF-3) submitted on October 15, 2019, and denied on October 26, 2019?
vii. Is the applicant entitled to $2,254.72 for a psychological assessment, recommended by Q-Medical in a treatment plan (OCF-18) submitted on September 27, 2019, and denied on October 16, 2019?
viii. Is the applicant entitled to an award under Regulation 664 (“award”) because the respondent unreasonably withheld or delayed the payment of benefits?
ix. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
5The applicant’s injuries are not predominantly minor as defined in s. 3 of the Schedule and not therefore subject to the $3,500.00 funding limit in the Minor Injury Guideline. The applicant is entitled to the four chiropractic treatment plans for $2,51