Licence Appeal Tribunal File Number: 20-009974/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:
Farah Sharif
Applicant
and
BelairDirect
Respondent
DECISION [AND ORDER]
ADJUDICATOR:
Rakesh Sharma
APPEARANCES:
For the Applicant:
Victoria Tchilikova, Paralegal
For the Respondent:
Michael Courneyea, Counsel
HEARD:
By Way of Written Submissions
REASONS FOR DECISION [AND/OR ORDER]
BACKGROUND
1The applicant was involved in an automobile accident on January 6, 2018 and sought benefits pursuant to the O.Reg.34/10 Statutory Accident Benefits Schedule (the “Schedule”) – Effective September 1, 2010 (including amendments effective June 1, 2016). The applicant was denied certain benefits by the respondent and submitted an application to the Licence Appeal Tribunal - Automobile Accident Benefits Service (“Tribunal”).
2The applicant sustained injuries as passenger in a vehicle that was rear ended on a highway.
3Belair Insurance Company (the “respondent”) denied certain benefits claimed by the applicant. The applicant submitted an application to the Licence Appeal Tribunal - Automobile Accident Benefits Service (“Tribunal”) to dispute the denial of the benefits.
ISSUES IN DISPUTE
4The issues to be decided in the hearing are:
i. Are the applicant’s injuries predominantly minor as defined in s. 3 of the “Schedule” and the $3,500.00 limit and in the Minor Injury Guideline?
ii. Is the applicant entitled to $1,300.00 for chiropractic services, proposed by Liruma Rehabilitation Centre in a treatment plan/OCF-18 (“plan”) dated April 9, 2018?
iii. Is the applicant entitled to $1,215.29 for chiropractic services, proposed by Liruma Rehabilitation Centre in a plan dated July 19, 2018?
iv. Is the applicant entitled to $1,761.34 for chiropractic services, proposed by Liruma Rehabilitation Centre in a plan dated November 19, 2018?
v. Is the applicant entitled to $1,310.00 ($2,200 less $889.42 approved) for chiropractic services, proposed by Liruma Rehabilitation Centre in a plan dated January 9, 2018?
vi. Is the applicant entitled to $87.19 ($200.00 less $112.81 approved) for completion of an OCF-3 dated January 22, 2018?
vii. Is the respondent liable to pay an award under s. 10 of O. Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
viii. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
5The applicant sustained predominantly minor injury as defined under the “Schedule” and does not have a pre-existing medical condition that would prevent the maximal recovery if subjected to Minor Injury Guideline (MIG) limits of $3,500. Therefore, the applicant remains in the MIG and subject to medical and rehabilitation benefits not exceeding $3,500.
6The applicant is not entitled to the treatment plans in dispute under Para [4] ii, iii. iv, v. as the applicant remains in the MIG. Since the applicant remains in the MIG, an analysis of whether the above-mentioned treatment plans in dispute seeking medical benefits outside of the MIG are reasonable and necessary for rehabilitation of the applicant is not required.
7The applicant is entitled to the amount of $87.19 for completion of an OCF-3 dated January 22, 2018. (Para [4] vi)
8The applicant is not entitled to an award as there are no unreasonably withheld or delayed payments.
9The applicant is entitled to interest on $87.19 under section 51 of the “Schedule” in respect of the issue in dispute under Para [4] vi above.
Minor Injury Guideline (MIG) Legal Framework:
10The MIG establishes a treatment framework to an injured person who sustains predominantly, a minor injury as a result of the accident. Section 3(1) of the Schedule states that “minor injury” means one or more of a sprain, strain, whiplash associated disorder, contusion, abrasion, laceration, or subluxation and included any clinically associated sequelae to such an injury.
11Section 18. (1) of the Schedule states the monetary limits regarding medical and rehabilitation benefits in respect of an impairment that is predominantly a minor injury shall not exceed $3,500.
12Section 38 of the Schedule applies to the claims for medical and rehabilitation benefits and approval of assessments other than benefits payable under the MIG. A treatment and assessment plan is required to be submitted for claiming medical and rehabilitation benefits beyond the MIG limits stating that:
(A) The applicant’s impairment is not predominantly a minor injury, OR
(B) The applicant’s impairment is predominantly a minor injury but, based on compelling evidence provided by the health practitioner, the insured person does not come within the Minor Injury Guideline because the insured person has a pre-existing medical condition that was documented by a health practitioner before the accident and that will prevent the insured person from achieving maximal recovery from the minor injury if the insured person is subject to the limit or is limited to the goods and services authorized under the Minor Injury Guideline “MIG”.
13The Divisional court interpreted “Compelling evidence” in Scarlett v Belair, 2015 ONSC 3635, 2015 ONSC3635 as the word “compelling” is directed at the sufficiency of the evidence required to satisfy the “balance of probabilities” standard and that whether the evidence in a particular case is sufficient to meet the test of “compelling” must be determined on the facts of each case having regard to what is reasonable in all the circumstances.
14The onus is on the applicant to prove on the balance of probabilities, entitlement to the benefits in dispute.
15Section 4 of the MIG states that compelling evidence should be provided using the Treatment and Assessment Plan (OCF-18) with attached medical documentation, if any, prepared by a health practitioner.
16“Impairment” is defined in s.3(1) of the Schedule as a loss or abnormality of psychological, physiological or anatomical structure or function.
Are the applicant’s injuries predominantly minor injury as defined in section 3 of the Schedule and therefore under the Minor Injury Guideline “MIG”?
Analysis
17The applicant disputes to be out of MIG based on the treatment plan/OCF-18 dated July 19, 2018 for $1,215.19 submitted by Liruma Rehab and identified as an issue in dispute under Para [4] iii above. In particular, the applicant asserts that she should be removed from the MIG because of a pre-existing medical condition. Part 4 of the treatment plan states that the impairment was predominantly a minor injury, but the applicant has a pre-existing medical condition that will prevent maximal recovery of the minor injury if subjected to $3,500 MIG limit. Under Part 6, the injuries mentioned are injury of muscle and tendon at neck level, sprain/strain of shoulder joint, injury of muscle and tendon at abdomen, lower back and pelvis. Under Part 7, a prior condition refers to a “previous mva in 2009/2010”.
18In response, the respondent relies on an in-person insurer examination report dated September 24, 2018 of Dr. Ahmad Mian, Physician, to hold the applicant within the MIG. Dr. Mian reviewed the treatment plan/OCF-18 dated July 19, 2018, CNR’s of Dr. Sayed dated June 15, 2018. OCF-1 dated January 11, 2018 and OCF-3 dated January 9, 2018. Dr. Mian concluded that the applicant sustained lumbar symptomatology, which has completely resolved, as well as a right shoulder sprain/strain, that these injuries are considered minor injuries, that the applicant does not have a pre-existing medical condition that would hinder the claimant’s recovery, therefore, the applicant’s accident-related injuries can be treated within the confines of the MIG. Dr. Mian also concluded that the treatment plan/OCF-18 dated July 19, 2018 for $1,215.19 as not reasonable and necessary. The said treatment plan is listed as an issue in dispute under para [4] iii above.
19The applicant in the written submissions does not dispute the conclusions of the insurer examination report dated September 24, 2018 of Dr. Ahmad Mian that hold the applicant within the MIG.
20Instead, the applicant in the written submissions under para 36 submits that the physical impairments fall outside of MIG and the applicant continues to experience functional limitations and pain symptoms in the neck, back and shoulder. The applicant does not draw attention to any compelling evidence of a pre-existing condition that was documented before the accident and that will prevent maximal recovery if treatment is subjected to the MIG limit of $3,500. The applicant does not draw attention to any inconsistency in the insurer examination report of Dr. Ahmad Mian to be removed from the MIG.
21Based on the evidence on record, I find, the applicant has failed to disprove on the balance of the probabilities the conclusions of the insurer examination report dated September 24, 2018 holding the applicant within the MIG. Therefore, the applicant sustained minor injuries from the accident and does not have a pre-existing medical condition that would prevent her from achieving maximal recovery if subjected to the limits under the MIG. Accordingly, the applicant remains in the MIG.
Is the applicant entitled to the treatment plans in dispute listed under Para [4] ii, iii, iv, v.?
22As the applicant remains in the MIG, she is not entitled to any of these treatment plans as the treatment plans seek treatment outside of the MIG. Thus, an analysis of whether any of the treatment plans is reasonable and necessary is not required.
Applicants’ additional grounds for entitlement to the treatment plans in dispute under para [4] ii to v above.
23The applicant states that the respondent was not compliant in section 38(8)(9) of the Schedule in responding to the treatment plans/OCF-18 in dispute under para [4] ii to v above, and therefore, seeks relief under section 38(11) of the Schedule.
Legal Framework:
24Section38(8) states, within 10 business days after it receives the treatment and assessment plan (OCF-18) the insurer shall give the insured person a notice that identifies the goods and services, assessments and examinations described in the treatment and assessment plan (OCF-18)
I. that the insurer agrees to pay for,
II. any the insurer does not agree to pay for and;
III. the medical reasons and all of the other reasons why the insurer considers any goods, services, assessments and examinations or the proposed costs of them, not to be reasonable and necessary.
25Section 38(9) states, if the insurer believes that MIG applies to the insured person’s impairment, the notice under subsection (8) must so advise the insured person.
26Section 38(11) of the Schedule states:
if the insurer fails to give notice in accordance with subsection 38 (8) in connection with a treatment and assessment plan (OCF-18) the following rules apply:
I. The insurer is prohibited from taking the position that the insured person has an impairment to which the MIG applies.
II. The insurer shall pay for all goods, services, assessments and examinations described in the treatment and assessment plan (OCF-18) that relate to the period starting the 11th business day after the insurer received the application and ending the day the insurer gives a notice described in subsection (8).
Notice and Delivery:
27Section 64. (1) states that a notice must be in writing except for a notice under Section 32(1) or (6).
28Section 64.(24) states that “A reference in this regulation to a number of days between two events shall be read as excluding the day on which the first event happens and including the day on which the second even happens” Thus, calculation of number days shall exclude the day on which the treatment plan was submitted and shall include the day on which the treatment plan was responded.
29Section 64.(25) states that the time period expressed in days or business days expires on the last day of the time period at 5 p.m. local time.
30Section 64.(26) states that if the last day of the time period expires on a day that is not a business day, the time period is deemed to expire on the next day that is a business day at 5 p.m. local time.
31Section 3.(1) states “business day means a day that is not,
(a) Saturday, or
(b) A holiday within the meaning of section 88 of the Legislation Act, 2006, other than Easter Monday and Remembrance Day.
(c) Section 88(2) of the Legislation Act, 2006 states following are holiday: Sunday, New Year’s Day, Family Day, Good Friday, Easter Monday, Victoria Day, Canada Day, Labour Day, Thanksgiving Day, Remembrance Day, Christmas Day, Boxing Day, and any day fixed as a holiday by proclamation of the Governor General or Lieutenant Governor.
32Section 64.(7) states that the rules that apply in the circumstances specified in a Guideline issued for the purposes of this section to a document that is listed in section 66, is specified in the Guideline and is required under this Regulation to be delivered to an insurer to whom the Guideline applies.
33Section 66.4 includes a treatment and assessment plan referred to in section 38.
34Since treatment and assessment plans under section 38 of the Schedule are in dispute and it is a document listed under section 66 of the Schedule. Therefore, in the instant case the notice and delivery rules mentioned under Section 64.(7) to (14) (22) and (23) apply.
35The Guideline referred to in section 64.(7) of the Schedule is “Health Claims for Auto Insurance(“HCAI”) September 2010 Guideline, Superintendent’s Guideline No. 07/10. The Guideline is issued for the purposes of section 49(1) and section 64(7) of the Schedule effective September 1, 2010 and applies to the documents that are delivered on or after September 1, 2010 regardless of the date of the accident.
36A document to which the Guideline applies is to be sent to a Central Processing Agency(“CPA”) established by the insurance industry to receive such documents on behalf of the insurers. HCAI is the CPA for the purposes of this Guideline and section 64(7) of the Schedule.
37Section 64(8) (9) states that a treatment and assessment plan is deemed to be received by the insurer to whom it is addressed on the later of, the date on which it is delivered in a manner specified in the HCAI to the CPA and the date on which the last of any attachments is received by the insurer.
38Section 64(13) states that an insurer that is deemed by section 64(8) (9) to have received a document shall in a manner and within the time required by the HCAI provide the CPA with the information about the particulars of the goods and services referred in the treatment and assessment plan (OCF-18) which the insurer agrees to pay and for which the insurer does not agree to pay.
39Section 64(22) states, subject to section (20), subsection 22(3) of the Electronics Commerce Act, 2000 applies to determine when a document is delivered in accordance with clause (2) e is deemed to be delivered to the recipient.
40Section 64.(23) states that if section 64(8) (9) applies, the recipient for the purpose of subsection 64.(22) is the CPA and HCAI is the CPA.
41HCAI under the heading “Requirements for Insurers” states that information to the CPA shall be provided in electronic form in a manner that results in it being capable of being retrieved and accessed by the CPA. HCAI requires the insurer to provide information referred to in section 64(13) of the Schedule to the CPA within 5 business days after the document has been processed by the insurer. HCAI clarifies that these deadlines are independent of the deadlines of the Schedule within which the insurer is to process and respond to a document.
42In a nutshell, the treatment and assessment plan/OCF-18 under section 38 of the Schedule finds mention in Section 66 of the Schedule, therefore, provisions of section 64(7) to (14) (22) and (23) of the Schedule apply to determine the method of receipt and response to the treatment plan/OCF-18.
I. Under section 64(8) the insurer is deemed to receive a document on the later of the date the CPA determines the document to be duly completed and to contain all information required by the regulation and the date on which the last of any attachments is received by the insurer.
II. Under section 64(13) an insurer that is deemed by section 64(8) (9) to have received a document shall in a manner and within the time required by the HCAI provide the CPA with the information about the particulars of the goods and services referred in the treatment and assessment plan (OCF-18) which the insurer agrees to pay and for which the insurer does not agree to pay.
III. Under section 64(23) for a document under section 64(8) or (9) the recipient is the CPA/HCAI and the document is deemed to be delivered to the recipient in accordance with the provisions of subsection 22(3) of the Electronics Commerce Act, 2000
IV. Thus,10 business days notice period under section 38(8) of the Schedule starts when the insurer is deemed to have received the treatment plan/OCF-18 by the CPA in HCAI under section 64(8) or (9) of the Schedule.
V. Under Section 64 (22) and (23) the insurer onus under section 38(8) of the Schedule is discharged by responding to the treatment plan (OCF-18) within 10 business days in HCAI to the CPA electronically by agreeing to pay or not agreeing to pay for the goods and services in the (OCF-18).
VI. There is no provision of an insurer response to be followed by a letter to the applicant and the letter also to be delivered within 10 business days to comply with the 10-day notice period provisions of section 38(8).
Is the respondent compliant the 10 business days notice period under section 38(8) of the Schedule to respond to a treatment and assessment plan (OCF-18) in dispute listed under Para [4] ii. to v. above?
43The parties incorrectly rely upon section 64(2) (d) and section 64(18) to calculate the notice period of 10 business days stipulated under section 38(8), which state that a person is deemed to receive anything delivered by ordinary mail under clause (2) (d) on the fifth business day after the day the document is mailed in accordance with clause (2) (d).
44In the instant case the provisions of section 64(7) to (14) (22) and (23) of the Schedule apply to determine the method of receipt and response to the document by the CPA in HCAI. Section 64(24(25)(26) and 3.1 and section 88 of the Legislation Act 2006 apply to calculate the number of business days.
45The applicant admits that the treatment plan (OCF-18) for $1,300 was submitted on HCAI on April 20, 2018 and it was partially approved for $1,074.38 on HCAI on May 2, 2018, which is the 8th business day from the date of receipt on HCAI. (Para [4] ii.)
46The applicant admits that the treatment plan (OCF-18) for $1,215 was submitted on HCAI on July 31, 2018 and it was denied on HCAI on August 10, 2018, which is 8th business day from the date of receipt on HCAI. (Para [4] iii.)
47The applicant admits that the treatment plan (OCF-18) for $1,761.34 was submitted on HCAI on January 10, 2019 and it was denied on HCAI on January 24, 2019, which is the 10th business day from the date of receipt on HCAI. (Para [4] iv.)
48The applicant admits that the treatment plan (OCF-18) for $1,310.10 was submitted on HCAI on July 8, 2019 and partially approved on HCAI on July 19, 2019 which is the 9th business day from the date of receipt on HCAI. (Para [4] v.)
49Therefore, I find the respondent is compliant 10 business days notice period as stipulated under section 38(8) of the “Schedule” to respond to the disputed treatment and assessment plans (OCF-18) listed under Para [4] ii. to v.
Is the respondent compliant section 38(8) (9) of the Schedule to provide the medical reasons and any other reasons for the denial of the treatment plans (OCF-18) in dispute listed under Para [4 ] ii. to v. above
Is the applicant entitled to $1,300.00 for chiropractic services, proposed by Liruma Rehabilitation Centre in a treatment plan/OCF-18 (“plan”) dated April 9, 2018? (Para [4] ii.)
50The applicant submits that the respondent’s notice of May 3, 2018 did not refer to the applicant’s medical condition with specific details, identity the goods and services assessments and examinations described in the OCF-18 that the respondent did not agree to pay. Further the notice was vague and confusing as it noted the maximum medical and rehab benefits payable is $3,500 yet the respondent only approved $1,074.38 out of $1,300 of the total proposed treatment without any further explanation.
51Review of the said treatment plan revealed that under Part 4, it affirmed that the impairment was predominantly a minor injury and additional treatment was required under the MIG, within the $3,500 limit.
52The respondent response letter dated May 3, 2018 provides the medical reason for partial approval of the treatment plan as minor injury, which the applicant also admits. The letter explains that the maximum payable for treatment under minor injury is $3,500 and the respondent partially approved the treatment for $1,074.38 explaining inability to approve over the maximum limit of $3,500. The letter also explained the criteria to qualify for medical and rehabilitation benefits over the MIG limit of $3,500.
53Therefore, I find the respondent has provided the medical and other reasons for partial approval of the treatment plan in dispute and has satisfied the criteria under section 38(8) (9) of the Schedule in respect of the treatment plan in dispute.
Is the applicant entitled to $1,215.29 for chiropractic services, proposed by Liruma Rehabilitation Centre in a plan dated July 19, 2018? (Para [4] iii.)
54The applicant further submits that the notice provided by the respondent is non-compliant with s. 38(8) as it fails to provide adequate medical and other reasons for denying the disputed OCF-18. The Applicant submits that the notice of August 14, 2018 did not: refer to the applicant’s medical conditions with specific detail; identify the goods, services, assessments and examinations described in the OCF-18 that the respondent did not agree to pay. Furthermore, the notice was vague and confusing as it said, “the medical reasons and all of the other reasons why includes: is treatment reasonable and necessary.” The notice was further vague and confusing as it said that “medical goods and services in the amount of $2,200.00 are pre-approved,” which was followed by a statement, that the payment beyond $2,200.00 for any goods or services recommended by the OCF-18 will not be considered until IE report is received. The applicant submits that the value of the OCF-18 was less then $2,200.00; however, to date the incurred amount remains outstanding. The applicant also points out that the respondent partially approved later OCF-18 of July 8, 2019 (discussed below) which also consisted of multidisciplinary rehab sessions.
55Review of the said treatment plan revealed that under Part 4, the impairment was predominantly a minor injury. The applicant has a pre-existing medical condition that will prevent maximal recovery of the minor injury if subjected to $3,500 minor injury limit. Under Part 7 Prior and Concurrent Conditions is stated “previous MVA in 2009/2010”.
56The respondent response letter dated August 14, 2018 explains minor injury. It also explains that under minor injury $2,200 for medical services is pre-approved. It further states that the treatment plan was reviewed and the based on the documents provided the injuries are predominantly minor injuries and there is insufficient evidence of pre-existing medical condition. The respondent took the position that MIG applies and made arrangements for the applicant to participate in the insurer examination under section 44 of the Schedule.
57I agree with the applicant that one sentence in the said letter “the medical reasons and all of the other reasons why includes: is treatment reasonable and necessary” is vague, but this one sentence does not render the whole content of the letter also vague. In spite of the one sentence being not clear, the letter meets with the criteria under section 38(8) (9) of the Schedule to provide medical and other reasons for the action of the respondent.
58Therefore, I find the respondent has provided the medical and other reasons for denial of the treatment plan in dispute and has satisfied the criteria under section 38(8) (9) of the Schedule in respect of the treatment plan in dispute.
Is the applicant entitled to $1,761.34 for chiropractic services, proposed by Liruma Rehabilitation Centre in a plan dated November 19, 2018? (Para [4] iv.)
59The applicant submits that the notice provided by the respondent is non-compliant with s. 38(8) as it failed to provide adequate medical and other reasons for denying the OCF-18. The applicant submits that the notice of January 25, 2019, did not refer to the applicant’s medical conditions with specific detail; identify the goods, services, assessments and examinations described in the OCF-18 that the respondent did not agree to pay. The applicant further submits that the notice was vague and confusing as it said that “medical goods and services in the amount of $2,200.00 are pre-approved”, yet even though the value of the OCF-18 is less then the $2,200.00, the incurred amount remains outstanding. The applicant also points out that the respondent partially approved treatment in a consequent OCF-18 of July 8, 2019 which also consisted of multidisciplinary rehab sessions.
60Review of the said treatment plan revealed that under Part 4, the impairment was predominantly not a minor injury as referred to in the MIG.
61The respondent response letter dated January 25, 2019 explains minor injury. It also explains that under minor injury $2,200 for medical services is pre-approved and the maximum payable for treatment under minor injury is $3,500. The respondent denied the treatment plan under section 38(5) (6) of the Schedule, because the treatment plan describes the goods or services are to be received in respect of period during which the entitlement is to receive goods or services under the MIG.
62The respondent denied the treatment plan under section 38(5) (6) of the Schedule.
63Therefore, I find the respondent has provided the medical and other reasons for denial of the treatment plan in dispute and has satisfied the criteria under section 38(8) (9) of the Schedule in respect of the treatment plan in dispute.
Is the applicant entitled to $325.37($1310.10 less approved $889.42) for chiropractic services, proposed by Liruma Rehabilitation Centre in a plan dated July 8, 2019? (Para [4]v.)
64The applicant submits that the notice provided by the respondent is non-compliant with s.38(8) as it failed to provide adequate medical and other reasons for denying the disputed OCF-18. The applicant submits that the notice of July 22, 2019 did not refer to the applicant’s medical conditions with specific detail; identify the goods, services, assessments and examinations described in the OCF-18 that the respondent did agree and did not agree to pay.
65Review of the said treatment plan revealed that under Part 4, the impairment was predominantly not a minor injury as referred to in the Minor Injury Guideline MIG.
66The respondent response letter dated July 22, 2019 explains that injuries sustained in the MVA qualify the applicant for treatment under MIG. The letter explains the minor injury as defined in the Schedule the maximum payable for treatment under minor injury is $3,500 and the partial approval of $889.42 under section 38(8) of the Schedule as unable to consider the expenses exceeding the maximum limit of $3,500.
67Therefore, I find the respondent has provided the medical and other reasons for denial of the treatment plan in dispute and has satisfied the criteria under section 38(8) (9) of the Schedule in respect of the treatment plan in dispute.
68Since the respondent is compliant section 38(8) (9) of the Schedule in respect of the treatment plans in dispute under Para [4] ii to v above. The applicant is not entitled to the relief available under section 38(11) of the Schedule.
Is the applicant entitled to $87.19 ($200.00 less $112.81 approved) for completion of an OCF-3 dated January 22, 2018? (Para [4] vi.)
69The applicant states the fee of $200 is reasonable for completion of OCF-3 and it is allowable under Superintendent’s Guideline No. 03/14 “FSCO Guideline”.
70The respondent states the OCF-3 was completed by a chiropractor and the maximum hourly rate for chiropractor under the FSCO Guideline, is $112.81 and one hour is sufficient time to complete the OCF-3.
71I disagree with the reasoning of the respondent that an hour is sufficient for completion of the OCF-3. The FSCO Professional Services Guideline – 03/14 “Guideline” does not state the reasonable time for completion of the forms and then to apply the hourly rates for the professionals who completed the forms to determine the amounts payable. Rather the Guideline states the maximum $200 is payable for completion of OCF-3.
72Therefore, I find the applicant is entitled $200 for completion of OCF-3 and the respondent shall pay to the applicant the balance amount of $87.19.
Is the respondent liable to pay an award under s. 10 of O. Reg. 664 because it unreasonably withheld or delayed payments to the applicant in respect of issue under Para [4} vi.?
73In the instant case, the respondent partially approved the amount of $112.81 instead of the incurred amount of $200 for completion of OCF-3. The respondent provided the reason for partial approval. As I differed with the respondent’s reason of partial approval the respondent’s action does not result into unreasonably withholding of the balance amount in dispute. An unreasonable denial has been interpreted by the courts to mean that is excessive, imprudent, stubborn, inflexible, unyielding or immoderate.
74Therefore I find, the applicant is not entitled to an award for partial denial of $87.19 for completion of an OCF-3 as the respondent did not unreasonably withheld or delayed the payment.
Is the applicant entitled to interest on any overdue payment of benefits of $87.19 in respect of the issue under Para [4] vi.?
75I find, the applicant is entitled to applicable interest under section 51 of the Schedule on overdue payment of $87.19 for completion of OCF-3.
ORDER
76The applicant sustained predominantly minor injuries as defined under the Schedule and therefore remains in MIG and subject to the limit on medical and rehabilitation benefits not exceeding $3,500.
77The applicant remains in the MIG therefore an analysis to decide whether the treatment plans in dispute listed under Para [4] ii to v are reasonable and necessary for the rehabilitation of the applicant is not required.
78The respondent is compliant the provisions of section 38(8) (9) of the Schedule in respect of the 10-day notice period and also in respect of providing the medical reasons and any other reasons in respect of the treatment plans in dispute listed under Para [4] ii to v. Therefore, the applicant is not entitled to relief under section 38.11 of the Schedule.
79The applicant is entitled to $87.19 being the balance amount in dispute for completion of an OCF-3.
80The applicant is not entitled to an award as there are no unreasonably withheld or delayed payments.
81The applicant is entitled to applicable interest under section 51 of the Schedule on overdue payment of $87.19 for completion of OCF-3.
Released: June 8, 2022
Rakesh Sharma
Adjudicator