Licence Appeal Tribunal File Number: 22-011240/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:
Raymond Seaton
Applicant
and
Economical Insurance Company
Respondent
DECISION
VICE-CHAIR: Monica Ciriello
APPEARANCES:
For the Applicant: Christina Trotta, Counsel
For the Respondent: Branson Wong, Counsel
HEARD: In Writing
OVERVIEW
1Raymond Seaton, the applicant, was involved in an automobile accident on January 24, 2022, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”). The applicant was denied benefits by the respondent, Economical Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The following issues are to be decided:
i. Is the applicant entitled to $1,813.83 for physiotherapy services, proposed by Scarborough South Physio and Rehab Centre in a treatment plan dated February 10, 2023?
ii. Is the applicant entitled to a special award?
iii. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3I find that the applicant is not entitled to:
i. The treatment plan in the amount of $1,813.83;
ii. Interest; and
iii. A special award.
ANALYSIS
4The MIG is not an issue before the Tribunal in the proceeding, and the applicant makes no submissions on the issue of his removal from the MIG. I interpret from the submissions that the applicant is not arguing that he should be removed from the MIG but rather, that the respondent made a procedural error under section 38(8) of the Schedule resulting in the finding that the remaining balance of $112.81 (total balance $1,813.83) is not payable and as a result the applicant’s position is that because of this error, the respondent is unable to rely on MIG prohibition argument. The respondent submits that it is not prohibited from taking the position that the applicant’s injuries are confined to the MIG as the treatment plan was addressed in a timely manner which complied with section 38(8) of the Schedule. The MIG limit has been exhausted.
Section 38 of the Schedule
5Section 38(8) of the Schedule provides that an insurer shall respond to a treatment and assessment plan within 10 business days of receiving it by identifying the goods, services, assessments and examinations described in the plan that the insurer does and does not agree to pay for. The insurer must also provide medical and all other reasons why it has determined that the treatment and assessment plan is not reasonable and necessary.
6Section 44(5) of the Schedule provides that an insurer shall give notice of an examination with the medical and other reasons for the examination.
7The Tribunal has recognized medical reasons for denial as specific details about the insured’s condition forming the basis for the insurer’s decision or identifying information about the insured’s condition that the insurer still requires. In addition, the insurer should refer to the specific benefit or determination at issue with the relevant section of the Schedule.
8I find that section 38(8) of the Schedule is not at issue, as the respondent complied with the 10-business day requirement and is therefore able to rely on the MIG prohibition.
Sufficiency of the respondent’s denial of treatment plan dated February 10, 2023
9The applicant submits that the respondent did not respond to the treatment plan prepared by Mr. Justin Pascual of Scarborough South Physio and Rehab Centre Inc., dated February 10, 2023, until February 28, 2023, 13 days after the receipt of the treatment plan, in contravention of the Schedule.
10It is the applicant’s position that due to the respondent’s failure to provide the applicant with proper notice in accordance with section 38(8) of the Schedule, the respondent is prohibited from taking the position that the applicant’s impairments are confined to the MIG. Furthermore, the applicant submits that when the respondent did respond, the denial letter did not provide the applicant with sufficient medical reasons to deny the disputed treatment plan in accordance with section 38(8).
11The respondent agrees that the Schedule requires an insurer to respond to a treatment plan within 10 business days after it is received and submits that it complied with that timeline. Furthermore, the respondent takes the position that the denial letter provides that the applicant’s injuries are confined to the MIG, and lists specific reference to the injury sequelae, and makes a request for medical documentation.
12In reviewing the evidence, I find that although the treatment plan was signed and dated February 10, 2023, by Mr. Justin Pasqual, the treatment plan form indicates a HCAI submission date to the respondent of February 15, 2023, at 2:45 PM. I find the HCAI date to be more persuasive, then the date it was signed, as to when the disputed treatment plan was transmitted to the respondent.
13Therefore, I find that the respondent did reply within a timely manner on February 18, 2023 and in compliance section 38(8) of the Schedule as it was within 10 days. Furthermore, in reviewing the respondent’s denial letter, I find it to be valid. It indicates that the respondent has not received any compelling medical evidence to substantiate the injury and concluded that the injuries were predominately minor in nature. In review of the documents on file, the applicant’s injuries appear to be minor as defined in the Schedule and it was unable to determine if the recommendations on the plan are reasonable and necessary. Furthermore, the denial letter indicates that absent additional medical evidence, it can only approve treatment up to the limit under the MIG, which has already been exhausted.
14As I have found the respondent complied with section 38(8) of the Schedule, I am satisfied that the respondent can rely on the MIG prohibition. I find that it is not required to review the treatment plan in dispute to determine if it is reasonable and necessary.
Interest
15As there are no overdue payment of benefits, the applicant is not entitled to interest pursuant to s. 51 of the Schedule.
Award
16The applicant seeks an award under section 10 of Regulation 664. I find that no benefits have been unreasonably withheld or delayed, and therefore no award is payable.
ORDER
17For the reasons outlined above, I find that:
i. The respondent complied with section 38 of the Schedule;
ii. The applicant is not entitled to the treatment plan in dispute;
iii. The applicant is not entitled to interest;
iv. The applicant is not entitled to a special award;
v. The application is dismissed.
Released: November 20, 2024
Monica Ciriello
Vice-Chair