Licence Appeal Tribunal File Number: 22-007470/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:
Sarojinidevi Gnanalingam
Applicant
and
Certas Direct Insurance Company
Respondent
DECISION
ADJUDICATOR: Robert Rock
APPEARANCES:
For the Applicant: Saloumeh Baghbani, Counsel
For the Respondent: Yann Grand-Clement, Counsel
HEARD: In Writing
Heard by way of written submissions
OVERVIEW
1Ms. Sarojinidevi Gnanalingam (the applicant), was involved in an automobile accident on November 20, 2019, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (the “Schedule”). The applicant was denied benefits by the respondent, Certas Direct Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issues in dispute are:
a) Is the applicant entitled to $3,157.78 for chiropractic and physiotherapy treatments and documentary fee proposed by Anker Gonsalves, submitted March 15, 2021 and denied July 4, 2021?
b) Is the applicant entitled to $3,331.96 for chiropractic, physiotherapy, rehabilitation devices and documentary fees proposed by Phuraka Somanath, submitted June 14, 2021 and June 29, 2021?
c) Is the applicant entitled to $4,251.55 for aquatherapy treatments and related devices proposed Alireza Mirzaesmaeeli, submitted November 22, 2021 and denied November 26, 2021?
d) Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant has not established that any of the disputed treatment plans are reasonable and necessary. As there are no benefits owing, no interest is payable. The application is dismissed.
ANALYSIS
Applicant’s onus to establish a treatment plan is reasonable and necessary
4To receive payment for a treatment and assessment plan under s. 15 and 16 of 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.
5There must be objective medical evidence demonstrating a causal connection between the accident and injuries giving rise to a claim for benefits. A treatment plan on its own does not prove that the benefits sought are reasonable and necessary.
6In demonstrating the reasonableness and necessity of a benefit sought, 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 the goals are reasonable.
Chiropractic services and aqua therapy treatment plans are not reasonable and necessary.
7The applicant has not established that these three treatment plans, the first for chiropractic and physiotherapy, and the second for chiropractic and physiotherapy, rehabilitation devices and documentary fees and a third for aqua therapy are reasonable and necessary.
8The goals of the treatment plans in question are pain reduction, increase in strength and increased range of motion. The aqua therapy goal is to increase muscle strength. All of these goals are to allow the applicant to return to her activities of normal living.
9The applicant argues that her pre-existing neck, back, and bilateral knee problems have been worsened by the motor vehicle accident. To support her claim, the applicant relies on records from the Clinical Notes and Records of Dr. Issar, and records from Healthmax Physiotherapy.
10The respondent argues that the HealthMax records, from the same facility recommending all treatment plans, provide little objective evidence that the applicant’s accident-related injuries are ongoing.
11In review of the CNRs of Dr. Issar, the applicant’s family doctor I find very few references to the motor vehicle accident. I also find a lack of causal linking of ongoing reports of pain to the motor vehicle accident. The pain complaints by the applicant in her neck, back, and knee are very similar pre and post accident, with no diagnosis by the doctor that any of this reports by the applicant have been made worse by the motor vehicle accident.
12The Initial Assessment Report completed by Dr. Somanath, was completed on November 27, 2019. The doctor diagnosed the applicant with sprain and strain injuries. Another initial assessment report was completed by Dr. Somanath on August 10, 2020. This report seemed to be nearly identical to the first assessment and diagnosed similar sprain and strain injuries, but added radiculopathy, cervical spine, and internal derangement of knee to his diagnosis. A third initial assessment report was completed by Dr. Somanath on October 5, 2020. This report was very similar to the second report.
13An Orthopedic Surgery Assessment Report was completed by Dr. Auguste on March 11, 2021. The doctor noted that the applicant displayed suboptimal effort and poor effort in the testing performed with no clinical findings to explain this presentation. All physical testing was unremarkable, and the doctor found no clinical signs of any accident-related impairments. The doctor specifically addressed the issue of pre-existing right knee issues and noted in review of medical imaging pre and post accident, there is no objective clinical signs of any accident-related impairments.
14An Orthopedic Surgery Assessment Paper Review Report was completed by Dr. Auguste on May 14, 2021. In this paper review, the doctor was asked to review additional documentation to determine if it would alter her original opinions. After review of the documentation, the doctor did not change her opinion that there are no clinical signs of any accident-related impairments, and no causal link to the motor vehicle accident.
15In a review of all the submitted evidence, I agree with the respondent that the applicant has failed to provide medical evidence establishing a causal link between the accident and the applicant’s injuries. As such, the treatment plans at issue are not reasonable and necessary.
16I deemed the medical evidence provided lacking, because I was not presented detailed or objective clinical testing of the applicant that showed a link between the injuries and the accident in the Healthmax records. In addition, I did not find any reporting in the Healthmax records that showed the applicant had any improvements in her pain related complaints over all the treatments that she had received.
17The respondent submitted objective testing of the applicant that did not show the link between the applicant’s injuries and the accident. All the medical imaging evidence pre and post accident does not show any changes in the applicant’s knees. Added to this was the CNRs of Dr. Issar which also did not make any link between the applicant’s reporting of ongoing pain to the motor vehicle accident.
18Therefore, I find that the three treatment plans for chiropractic services, physiotherapy, aqua therapy, rehabilitation devices and documentary fees are not reasonable and necessary.
Interest
19As there are no benefits owing for treatment plans, no interest is payable.
ORDER
20I find that:
i. The applicant is not entitled to payment for any of the three treatment plans, or interest.
ii. The application is dismissed.
Released: August 15, 2024
Robert Rock
Adjudicator