Licence Appeal Tribunal File Number: 22-006559/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:
Carson Wodzinski
A minor by his litigation guardian Tammy Wodzinski
Applicant
and
Aviva Insurance Canada
Respondent
DECISION
ADJUDICATOR:
Lisa Holland
APPEARANCES:
For the Applicant:
Chris Beckett, Counsel
For the Respondent:
Rajesan Rajendran, Counsel
Geoffrey Keating, Counsel
HEARD:
By Way of Written Submissions
OVERVIEW
1Tammy Wodzinski, parent on behalf of a minor, the applicant, has a claim arising out of an automobile accident which occurred on April 22, 2016, and sought medical and rehabilitation benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (the “Schedule”).
2The respondent, Aviva Insurance Canada denied the treatment in dispute on the basis that the treatment plan is not reasonable and necessary. The applicant disagreed and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
3The issues in dispute are:
i. Is the applicant entitled to $2,556.61 for speech language pathology services, proposed by Rehab First in a treatment plan/OCF-18 (“plan”) dated March 4, 2021?
ii. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
4I find that the applicant has failed to demonstrate that the proposed treatment plan (OCF-18) is reasonable and necessary for his accident-related injuries. As a result, the OCF-18 in dispute is not payable. The applicant is not entitled to interest on any overdue payment of benefits pursuant to s. 51 of the Schedule.
5The application is dismissed.
ANALYSIS
6To receive payment for a treatment plan (OCF-18) under the Schedule, the applicant bears the burden of demonstrating on a balance of probabilities that the benefit is reasonable and necessary as a result of the accident. The applicant should identify the goals of treatment, how the goals would be met to a reasonable degree and that the overall costs of achieving same are reasonable.
Is the treatment plan for speech language pathology reasonable and necessary?
7I find there are no medical records in support of OCF-18 dated March 4, 2021 by occupational therapist Robyn McMackin in the amount of $2,556.61 for speech language pathology. The applicant relies on the OCF-18 dated March 4, 2021 by occupational therapist, Robyn McMackin indicating that the applicant has a pre-existing medical condition of cornea transplant surgery that will prevent his recovery under the Minor Injury Guideline (“MIG”) limits. However, the MIG is not an issue in dispute. Ms. McMackin indicates that the applicant has emotional difficulties and cognitive communication difficulties as a result of the accident. The goals of the OCF-18 are to improve cognitive communication skills, including memory, attention, information processing, social interaction and executive functioning and activities of daily living. The applicant mentions that an Individual Education Plan (“IEP”) is in place at school, but no school records or assessment reports have been provided to the respondent or the Tribunal. In addition, the applicant has not provided any clinical notes and records of his treating physicians and specialists in support of the OCF-18.
8In response, the respondent relies on letter dated June 16, 2021 from life care planner, Gareth Smit of Rehab First to the applicant’s pediatrician, Dr. Joshua Dooyum Ndur of Central Community Health and clinical note of Dr. Ndur dated January 17, 2023. Mr. Smit mentions the applicant’s congenital disorder of Peter’s Anamoly which includes impaired vision and developmental delay with lifelong dependency. Dr. Ndur indicates that the applicant’s cataract surgery is related to a congenital condition. Dr. Ndur does not mention the accident or whether the cornea transplant surgery has been aggravated by the accident. To the contrary, Dr. Ndur indicates the applicant has been doing remarkably well. He intends to refer the applicant to a child psychiatrist for further evaluation regarding his aggressive behaviour. There are no further medical records or reports to explain the applicant’s behaviour or cognitive communication difficulties.
9I find that the applicant has failed to provide any independent medical evidence in support of the OCF-18 of Ms. McMackin. Dr. Ndur recommended a psychiatric evaluation of the applicant’s behaviour. However, no medical reports have been provided. The applicant has failed to establish that the OCF-18 for speech language pathology services is reasonable and necessary as a result of the accident.
Interest
10Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since the applicant was not successful on the OCF-18 in dispute for speech language pathology services, no benefits are owing and interest does not apply.
ORDER
11The applicant is not entitled to the treatment plan in dispute, nor interest. The application is dismissed.
Released: June 27, 2024
__________________________
Lisa Holland
Adjudicator