Licence Appeal Tribunal File Number: 22-011824/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:
Michele Cherubino
Applicant
and
Aviva Insurance Canada
Respondent
DECISION
ADJUDICATOR:
Brian Norris
APPEARANCES:
For the Applicant:
Alim Ramji, Counsel
For the Respondent:
Kathleen Mertes, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Michele Cherubino (“the Applicant”), was involved in an automobile accident on November 9, 2020, and sought benefits from Aviva Insurance company of Canada (“the Respondent”) pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”).
2The Applicant was denied benefits by the Respondent and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
3The issues to be decided in the hearing are:
Is the Applicant entitled to non-earner benefits (“NEBs”) in the amount of $185.00 per week for the period from December 9, 2020 to November 9, 2022?
Is the Applicant entitled to an attendant care benefit in the amount of $3,545.28 per month from December 29, 2020 to-date and ongoing?
Is the Applicant entitled to a medical benefit in the amount of $2,862.66 for physiotherapy, proposed by Complete Rehab Centre (“Complete”) in a treatment plan/OCF-18 (“plan”) dated August 4, 2021?
Is the Applicant entitled to a medical benefit in the amount of $4,239.07 for assistive devices, proposed by Complete in a plan dated December 16, 2020?
Is the Applicant entitled to a medical benefit in the amount of $9,425.00 ($23,310.25, less $13,885.25 approved by the Respondent) relating to a catastrophic impairment assessment, proposed by Complete in a plan dated February 8, 2022?
Is the Applicant entitled to a medical benefit in the amount of $2,530.60 for physiotherapy, proposed by Complete in a plan dated February 24, 2023?
Is the Applicant entitled to a medical benefit in the amount of $2,069.94 ($4,215.13 less $2,145.19 approved) for psychotherapy, proposed by Complete in a plan dated May 8, 2023?
Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
4The Applicant has not demonstrated that he suffers a complete inability to carry on a normal life as a result of the accident. Thus, he is not entitled to NEBs.
5The Applicant has not demonstrated that he is entitled to the remaining benefits claimed.
6No interest is payable.
BACKGROUND
7The Applicant was the driver of a vehicle which struck the side of another vehicle while traversing a suburban intersection. He sought no medical attention at the scene of the accident and was able to drive his vehicle home thereafter. He went to the hospital later that day with complaints of left elbow and arm pain, as well as neck and back pain. X-rays taken at the hospital showed no fractures and the Applicant was released and advised to follow up with his family physician, Dr. A. Lee.
8Dr. Lee assessed the Applicant and referred him to Dr. M. Bhargava, orthopaedic surgeon, for further consultation regarding his left arm. Dr. Bhargava met with the Applicant on November 11, 2020 and noted that his elbow moves well but produces a lot of pain. He ordered additional x-rays, which the Applicant had taken later that day, and advised the Applicant to follow up in two weeks. X-rays taken that day show no fracture, but degenerative changes were noted. The Applicant started treatment at Complete on November 16, 2020.
9The Applicant has a significant health history involving a triple-bypass heart surgery, chronic bilateral leg swelling and edema, sleep apnea with CPAP non-compliance, and other issues commonly related to obesity. The Applicant also has an olecranon spur on his left elbow, which appears to pre-date the accident.
10The Applicant claims that his accident-related injuries cause him to suffer a complete inability to carry on a normal life, cause him to require the services of an aide or attendant, and render the plans in dispute to be reasonable and necessary as a result of the accident. He bears the onus in demonstrating entitlement to the benefits claimed.
Preliminary issue
11The Respondent raised a preliminary issue in response to the Applicant’s submissions. It requests that the report of Dr. O. Benmoftah, dated August 10, 2023, the CNRs from Bolton Walk-in clinic, dated January 19, 2024, and the CNRs from Dr. A. Kozina, psychologist, and L. Imran, psychotherapist, dated September 5., 2023 be excluded from evidence. The Respondent submits that the reports were never disclosed to the Respondent prior to the hearing. The deadline for production of these documents was November 7, 2023.
12The Applicant agrees that the documents were disclosed late but submits that it is due to inadvertence. He submits that the Common Rules of Practice & Procedure (the “Rules”) ought to be liberally interpreted as the facts necessitate and, here, the evidence should be admitted because it is material to the central issue among the parties.
13I find the documents to be materially relevant to the dispute but place limited weight on them to mitigate prejudice to the Respondent, as it has not had an opportunity to review them with a qualified healthcare practitioner prior to the hearing.
ANALYSIS
Non-Earner Benefits (“NEBs”) for the period from Dec 9, 2020 to Nov 9, 2022
14I find that the Applicant is not entitled to NEBs because he does not suffer a complete inability to carry on a normal life as a result of the accident.
15Pursuant to section 12 of the Schedule, the Applicant must suffer a complete inability to carry on a normal life as a result of and within 104 weeks of the accident in order to qualify for NEBs. The test for NEBs involves a consideration of the Applicant’s activities and life circumstances pre-accident and compares them to his activities and life circumstances post-accident. Sustaining serious injuries or minor life changes does not automatically entitle the Applicant to NEBs. Rather, according to the test in Heath v. Economical Mutual Insurance Company, 2009 ONCA 391, (“Heath”), he must demonstrate that his life circumstances have changed and that the change must be significant enough to continuously prevent him from substantially engaging in all the activities that he engaged in before the accident.
16I find that the Applicant is a poor historian, who reports events in a manner inconsistent with contemporaneous records, causing his self-reporting to assessors to be uncompelling, and making it difficult to determine what, if any, life changes he has experienced since the accident because his reports tend to exaggerate. Some examples include:
i. He reported to an assessor that he was transported from the accident to the hospital by ambulance, even though he drove himself to the hospital;
ii. He reported to an assessor that he hit his head on the inside of the vehicle during the accident, and temporarily lost consciousness thereafter, yet the hospital records indicate no head injury or loss of consciousness;
iii. He reported to an assessor that he was in the hospital for over 14 hours, when the records indicate he was there fore a little over 5 hours;
iv. He reported to an assessor that he fractured his arm in the accident despite x-rays taken at the hospital and in the days thereafter showing no fracture.
17I am unable to find the Applicant’s self-reported limitations to be persuasive given his inconsistent reporting that leans towards over-reporting injuries to heath care providers.
18I give no weight to the disability certificate completed by Dr. R. Jessa, dated November 16, 2020. The document states that the Applicant suffers from issues such as feeling upset and anxious, but these issues are not reflected in the CNRs from Complete. Similarly, Dr. Jessa wrongly diagnosed the Applicant with a fractured forearm. More concerning is that the initial assessment records from Complete do not include a fracture as an accident-related injury, yet the disability certificate does. To me, the information in the disability certificate is either misleading or greatly contrasts with the other medical evidence, causing me to afford it less weight when assessing the evidence.
19I give no weight to the report of OT J. Dhirayain, dated November 23, 2020. This report states that the Applicant reported he was diagnosed with a left arm fracture, though rightfully clarifies that the diagnosis is self-reported. The report states that the Applicant also reported to OT Dhirayain that he was taken by ambulance to the hospital, despite all reports indicating that he drove himself there. There is nothing in the report by OT Dhirayain addressing the Applicant’s poor historical account of the accident and his injuries from it. Further the assessment by OT Dhirayain included no evaluation of any pre-accident medical records, and was conducted the assessment virtually, making it difficult for the assessor to measure any impairments and observe effort.
20On objective testing, the Applicant’s range of motion (“ROM) throughout his body is within normal limits. Occupational therapist (“OT”) R. Campos assessed the Applicant’s ROM for reports, dated February 2 & 11, 2021. In those reports, OT Campos observed that the Applicant’s ROM was mostly normal throughout his body, but for some mild restrictions to the elbow, neck, and low back. I find these mild restrictions to be in keeping with the Applicant’s pre-accident presentation and not of a magnitude to impair the Applicant from engaging in his pre-accident activities. The report notes that the Applicant demonstrated sufficient mobility, ROM, strength, as well as cognitive and psychosocial functioning to resume his normal activities of daily living while incorporating strategies such as energy conservation techniques, task modification, proper body mechanics and right one-handed techniques as needed.
21The Applicant was also assessed by Dr. J. Auguste, orthopaedic surgeon, resulting in a report, dated February 11, 2021. In that report Dr. Auguste found no accident-related substantive impairments of a musculoligamentous, osseous, or neurological nature. The Applicant was found to be self-limiting and pain-focused, demonstrating several indicators of non-organic behaviour. Dr. Auguste found that the Applicant’s current complaints are more likely related to the natural history and progression of pre-existing degenerative changes and his medical conditions, than to the accident. It was noted that the Applicant continues to drive, shop, attend to his affairs, and demonstrated sufficient ROM and strength to perform his usual activities of personal care, home maintenance and housekeeping that he was normally performing prior to the accident.
22I find Dr. Auguste’s opinion persuasive because it is consistent with the contemporaneous medical records. For example, a consultation report with Dr. J. Koifman, dated May 28, 2021, states that the Applicant has difficulty with ambulation as well as dressing because of his weight and edema. The report notes ongoing sleep issues due to sleep apnea and finds that the Applicant’s pedal edema is significant because of his likely severe uncontrolled sleep apnea. The accident is not mentioned at all in Dr. Koifman’s report.
23I give little weight to the August 24, 2021 report by Dr. M. West, orthopaedic surgeon. Dr. West reported that medical records were reviewed as part of the assessment, but never included a list of documents in the report. From this, it is difficult to determine why or how Dr. West concluded that the Applicant was asymptomatic at the time of the accident. In the report, when addressing the Applicant’s restrictions, the reader is referred to the Applicant’s self-reported restrictions and not to any objective testing or evaluation. Thus, the objective testing of OT Campos is preferred over the information provided by Dr. West. Dr. West provides a blanket approval for all treatment the Applicant has engaged in post-accident, stating that it is reasonable and necessary, but does not list the totality of treatment or post-accident care provided. Overall, Dr. West’s report and opinion is too broad to hold more weight than the reports of Dr. Auguste and OT Campos.
24The CNRs of Dr. L. Kember, orthopaedic surgeon, do not indicate a complete inability to carry on a normal life. The Applicant met with Dr. Kember on November 1 and December 14, 2021 for an orthopaedic consultations. During the first consultation, the Applicant reported that his elbow pain had improved considerably since the accident. Dr. Kember assessed the Applicant and found his left elbow issues related to an olecranon spur and his wrist pain is related to osteoarthritis. Dr. Kember opined at the first meeting that radiographs of the olecranon spur were suggestive of a previous fracture, which Dr. Kember states “was likely fractured during the accident”. I give little weight to this speculative opinion because Dr. Kember is the only orthopaedic surgeon to state that a fracture likely occurred in the accident. Whereas the x-rays, CT scans, and consultations with Dr. Bhargava, which are contemporaneous with the timing of the accident, concluded that no fracture occurred. Regardless, Dr. Kember advised that the Applicant could monitor and limit his activity with his left elbow but made no treatment recommendations. During the second meeting, the Applicant advised Dr. Kember that his left elbow pain was intermittent, every three to four, due to certain activities, and that he is able to do all his activities of daily living. Dr. Kember recommended against surgical intervention in light of the Applicant being a high-risk surgical patient based on his mediations and medical history. Regarding the Applicant’s wrist, Dr. Kember clearly concluded that it was osteoarthritis and not related to the accident.
25I give the ACB assessment report by OT Dhirayain, dated February 27, 2023, no weight when evaluating the Applicant’s eligibility for NEBs. This report post-dates the period of claim and includes no retroactive evaluation. The assessment was also conducted virtually, despite the lifting of all Covid-19 pandemic restrictions by March 2022.
26In a similar vein, I give no weight to the psychological assessment report by L. Imran, psychotherapist, supervise by Dr. A. Kozina, dated April; 24, 2023. This report was delivered late and was not subject to any scrutiny from the Respondent’s assessors. The report post-dates the Applicant’s period of claim and includes no indication that any of the Applicant’s medical documents were reviewed as part of the assessment. The latter is particularly impactful given the Applicant’s inability to accurately recount the accident and his care thereafter. This report notes that the Applicant’s left arm was fractured, and he lost consciousness in the accident, despite there being no evidence of such a fracture, and hospital records deny he sustained any loss of consciousness.
27Overall, the Applicant has not demonstrated a change in his circumstances for which I could find that his injuries continuously prevent him from substantially engaging in his pre-accident activities. Consider that the Applicant has not worked since 2002 and remains unemployed post-accident. His accident-related impairments, such as sprain and strain injuries to the neck, elbow, and wrist, as well as his psychological complaints, are not of the magnitude to preclude the Applicant from significantly engaging in his pre-accident activities of daily living. Accordingly, I find that he has not met his onus to demonstrate entitlement to NEBs.
ACBs
28I find that the Applicant has not incurred any ACBs. Accordingly, he is not entitled to payment for ACBs.
29Pursuant to section 19 of the Schedule, the Respondent is liable to pay for the reasonable and necessary expenses that are incurred by the Applicant for services provided by an aide or attendant. The onus is on the Applicant to demonstrate that he required the care of an aide or attendant and that he incurred the expense of hiring one.
30Pursuant to section 3(7)(e) of the Schedule, an expense in respect of goods and services is not incurred unless the person has received the goods or services to which the expense relates, the insured person has paid the expense or promised to pay the expense or is otherwise legally obligated to pay the expense, and the person who provided the goods or services did so in the course of their employment, occupation or profession in which they would ordinarily have been engaged, but for the accident, or sustained an economic loss as a result of providing the goods and services. The Applicant may still be entitled to ACBs despite not hiring an aide or attendant if she can show that the expense was not incurred because the Respondent unreasonably withheld or delayed payment of the benefit.
31In this case, the Applicant has not met his onus to demonstrate entitlement to the benefit claimed. I note that he made no submissions and led no evidence indicating that he incurred the services of an aide or attendant. The evidence he tendered, the reports of OT Dhirayain, hold almost no weight because they were obtained virtually and never included any review of the Applicant’s medical records to assess his pre-accident baseline functioning. The reports of OT Dhirayin are outweighed by the reports of OT Campos, as discussed. OT Campos noted possible factors to consider when assessing the cause of the Applicant’s impairments and found overall that the Applicant required the services of an aide or attendant, at the rate of $476.84 per month.
32The Applicant has given me no reason to deem the expense to be incurred, pursuant to section 3(7)(e) of the Schedule. The Applicant has not provided a reason why he never incurred ACBs, nor has he provided any submissions or directed me to any evidence to suggest that the expense was not incurred due to the Respondent unreasonably withholding or delaying payment of the benefit. Accordingly, his claim for ACBs is dismissed.
$2,862.66 for a physiotherapy plan, dated August 4, 2021, and
$2,530.60 for a physiotherapy treatment plan, dated February 24, 2023
33The Applicant submits that these physiotherapy plans are reasonable and necessary because they were recommended by Dr. West in the August 24, 2021 report, and by Dr. D. Nguyen, orthopaedic surgeon, in the May 30, 2022 catastrophic impairment report.
34The Respondent submits that the 2021 physiotherapy plan was denied based on the report of Dr. Auguste, dated August 24, 2021. Dr. August found no findings of any accident-related substantive impairments, as noted previously. It submits that the 2023 plan is not reasonable and necessary, based on Dr. Auguste’s May 24, 2023 report. In that report, Dr. August reiterated that the Applicant reached maximal medical improvement with respect to his accident-related injuries, and that there was no compelling evidence of an exacerbation of pre-existing conditions.
35As previously discussed, I give little weight to the August 24, 2021 report by Dr. M. West, orthopaedic surgeon, due to the deficiencies in it. I am particularly unpersuaded by Dr. West’s opinion that all the goods and services consumed by the Applicant following the accident are reasonable and necessary. This broad statement holds no weight because it was made without providing any information about the goods and services consumed. Without this information, there is no indication that Dr. West understood the scope of the goods and services consumed since the accident, and it is improper to opine on certain goods and services without understanding what they are.
36Dr. Nguyen’s report is unpersuasive. Dr. Nguyen’s report is not contemporaneous with the plans. It was issued nine months after the first physiotherapy plan, and nine months before the second plan. Dr. Nguyen stated that the Applicant went to the hospital right away after his vehicle was struck in a T-bone style accident however, the Applicant was the driver of the vehicle that struck another vehicle – not the other way around – and he did not go to the hospital from the scene of the accident. Moreover, Dr. Nguyen’s report includes virtually no mention of, or discussion, regarding the Applicant’s extensive pre-existing health condition at the time of the accident.
37Given the deficiencies in Dr. West’s report, and the timing and unpersuasive nature of Dr. Nguyen’s recommendation, I prefer the reports and opinion of Dr. Auguste. As noted, Dr. Auguste concluded that the Applicant demonstrated no accident-related substantive impairments and concluded that the physiotherapy plans are not reasonable and necessary.
$4,239.07 for an assistive devices plan, dated December 16, 2020
38I find that the Applicant has not met his onus to demonstrate that the assistive devices are reasonable and necessary as a result of the accident.
39The Applicant submits that he reported limitations in completing his housekeeping tasks, sleeping difficulties, and difficulties showering as a result of accident-related pain. He submits that these devices were recommended by OT Dhirayain in the report, dated November 23, 2020. The Respondent submits the devices are not reasonable and necessary because, according to the report of OT Campos, the Applicant is capable of performing most of his self care tasks independently, while pacing and using proper body mechanics, task simplification, and right one-handed techniques. It also submits that, if the devices are found to be reasonable and necessary, they are priced at an above-market rate.
40I find that the Applicant has not demonstrated that the assistive devices are reasonable and necessary as a result of the accident. I prefer the opinion of OT Campos over OT Dhirayain. OT Dhirayain’s report recommends the proposed devices to optimize the Applicant’s functional independence. As noted, OT Dhirayian’s assessment was conducted virtually and does not appear to include any review of the Applicant’s medical records. Thus, the recommendations for devices are related to the Applicant’s overall presentation, and do not factor in his pre-existing impairments. This significantly diminishes the weight the report holds. While OT Campos conducted an in-person examination and accounted for the Applicant’s pre-existing impairments. OT Campos found that the Applicant did not require assistive devices to perform his self-care activities.
41Accordingly, I find that the Applicant has not demonstrated that the assistive devices are reasonable and necessary as a result of the accident.
$23,310.25, less $13,885.25 approved by the Respondent, for catastrophic impairment assessment plan, dated February 8, 2022
42I find that the Applicant has not demonstrated entitlement to the unapproved balance of the catastrophic impairment assessment plans.
43The amounts claimed and approved as the relate to the catastrophic impairment assessments are as follows:
| Service | Cost Proposed | Cost Approved | Difference |
|---|---|---|---|
| Form fee | $200.00 | $200.00 | $0.00 |
| Orthopaedic assessment | $2,800.00 | $2,000.00 | $800.00 |
| Documentation by orthopaedic surgeon | $3,200.00 | $0.00 | $3,200.00 |
| WPI rating and CAT determination | $3,200.00 | $2,000.00 | $1,200.00 |
| Neuropsychological intake, interview, and screening | $2,000.00 | $0.00 | $2,000.00 |
| Neuropsychological assessment psychometric examination report | $2,000.00 | $2,000.00 | $0.00 |
| Neuropsychological diagnostic and interpretation report | $2,000.00 | $2,000.00 | $0.00 |
| Third party documentation | $200 | $200 | $0.00 |
| In-home assessment (1) | $2,000.00 | $2,000.00 | $0.00 |
| In-home assessment (2) | $2,000.00 | $2,000.00 | $0.00 |
| Transportation | Flat fee $1,100.00 | .40/km | Unknown |
| Interpretation | $1,125.00 | $0.00 | $1,125.00 |
| Tax | $1,485.25 | $1,485.25 | $0.00 |
| Total | $23,310.25 | $13,885.25 | $9,425.00 |
44Pursuant to section 25(5) of the Schedule, the Applicant is entitled to funding for reasonable and necessary assessments performed in connection with a determination of whether he suffered a catastrophic impairment. Section 25(5)(a) of the Schedule caps the cost of an assessment at $2,000.00.
45The Applicant has not demonstrated how or why he would be entitled to an enhanced rate for the orthopaedic assessment. Assessments are capped at $2,000.00 and the cost of a report associated with the assessment is included in that fee. The Applicant has not addressed why he would be entitled to more than the funding limits outlined in section 25(5)(a) of the Schedule, other to say that the components of the assessment are reasonable and necessary. I find that this reason is insufficient, and the Applicant is required to provide a rationale for the enhanced rate. Accordingly, I find that the unapproved funding for the orthopaedic assessment is not reasonable and necessary.
46The Applicant has not demonstrated why a neuropsychological intake and other services should not be included in the assessment fees. As noted, the Respondent approved two neuropsychological assessment fees - $2,000.00 for the psychometric examination report and $2,000.00 for the diagnostic and interpretation examination report. He has not addressed how or why the intake and other services are not goods and services provided as part of the two approved neuropsychological assessments. Accordingly, I find that he is not entitled to an additional fee of $2,000.00 for intake and associated services.
47The Applicant has not demonstrated that he is entitled to transportation fees claimed. The Applicant clarified his claim in his submissions, adjusting the amount claimed, and submits that transportation fees in the amount of $745.80 are reasonable and necessary. He has not directed me to any authority or evidence for his claim. The Respondent submits that it is not liable to pay for transportation because the Applicant lives within the 50 km deductible for transportation, as outlined in section 3(1) of the Schedule. It submits that a round trip to the assessment centre is 39 km, and thus no transportation expenses are payable.
48I am unable to find that the Applicant is entitled to transportation fees because he has not provided any information on the distance travelled for the assessments. The explanation of benefits is clear in that the Respondent approved transportation fees at a rate of $.40 per kilometer, and never referenced the 50-kilometer deductible. Accordingly, the Applicant ought to be entitled to transportation at that rate and should not be subject to the deductible. However, the Applicant has not provided any information regarding the distance travelled for the assessments. Without this information, I am unable to determine his entitlement and conclude that he has not met his onus to demonstrate entitlement to the transportation expenses claimed.
49The Applicant has not demonstrated that he is entitled to interpretation services. The Applicant never addressed this component in his submissions. The Respondent holds that the Applicant is not entitled to interpretation services because he speaks English and does not require interpretation. I find that the Applicant is not entitled to interpretation services because the evidence demonstrates that he speaks English and does not require interpretation. This is exemplified in that none of the reports before me included interpretation services.
50Accordingly, I find that the Applicant has not demonstrated that he is entitled to the unapproved balance of the catastrophic impairment assessment plan.
$4,215.13, less $2,145.19 approved by the Respondent, for a psychotherapy treatment plan, dated May 8, 2023
51I find that the Applicant has not demonstrated that he is entitled to the unapproved balance of the psychotherapy treatment plan.
52This dispute primarily relates to the hourly rate of the service provider. The Applicant received services from a psychotherapist – a profession that is not included in the The Professional Services Guideline – Superintendent’s Guideline no.03/14 (“the PSG”). He submits that Tribunal should follow the reasoning in J.V. v. Intact Insurance Company, 2019 CanLII 76995 (ON LAT) (“JV”), which found that a psychotherapist providing cognitive behavioral therapy (“CBT”) was entitled to the rate of a psychologist, who effectively provides the same service.
53The Respondent partially approved this treatment plan. The unapproved balance relates to fees related to preparation, the cost of a progress report, educational material, and the difference in hourly rate for the service provider – The Applicant sought funding for $149.63 per hour, and the Respondent approved the plan at the hourly rate of $99.75.
54The Applicant submits that the psychotherapist is entitled to the higher hourly rate because they provide CBT, and that this is the same service that a psychologist provides. He provided no submissions on the other costs, such as educational materials and preparation. The Respondent contends that there is no rate specified for psychotherapists and that it agreed to the rate of $99.75 for psychotherapy in good faith. It also submits that the credentials of the psychotherapist were never provided and, thus, it cannot assess whether they have the education and experience to warrant the hourly rate of a psychologist.
55I agree with the Respondent and find that the Applicant is not entitled to the unapproved balance of this treatment plan. The Applicant has not provided the psychotherapists credentials to justify the enhanced rate, as was the case in JV. In this case, there is no evidence before me to demonstrate that the psychotherapist is experienced in, and qualified to provide, CBT. The issue here is not whether the psychotherapist provided CBT, it is whether the psychotherapist is entitled to an enhanced rate due to their education, training, and experience in the field. I find they are not.
56Additionally, the Applicant is not entitled to the unapproved goods and services because he has provided no submissions or evidence justifying the ancillary costs associated with this treatment plan. He has not addressed what the proposed education materials are. Further, he has provided no information as to why preparation fees and a progress report are reasonable and necessary components of the treatment. The PSG provides that insurers are not liable for any administration or other costs that have the result of increasing the effective hourly rates, or the maximum fees payable for completing forms, beyond what is permitted under the PSG.
Interest
57Interest applies on the payment of any overdue benefits pursuant to section 51 of the Schedule. Having found no benefits payable, it follows that no interest is payable.
CONCLUSION AND ORDER
58The Applicant has not met his onus to demonstrate he suffers a complete inability to carry on a normal life as a result of the accident. He is not entitled to NEBs as a result.
59The Applicant has not incurred the expense of an aide or attendant, nor has an expense been deemed incurred, as a result of the accident. Accordingly, he is not entitled to ACBs.
60The Applicant is not entitled to the medical and rehabilitation benefits claimed because he has not demonstrated that they are reasonable and necessary as a result of the accident.
61No interest is payable.
62The application is dismissed.
Released: January 21, 2024
Brian Norris
Adjudicator