Licence Appeal Tribunal File Number: 22-008976/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:
Sarah Presley
Applicant
and
The Personal Insurance Co.
Respondent
DECISION
VICE-CHAIR: Monica Ciriello
APPEARANCES:
For the Applicant: Gavin Cosgrove, Counsel
For the Respondent: Yann Grand-Clement, Counsel
HEARD: In Writing
OVERVIEW
1Sarah Presley, the applicant, was involved in an automobile accident on November 27, 2018, 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, The Personal Insurance Co., 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 a catastrophic assessment in the amount of $3,612.00 ($14,012.00 less $10,400.00 approved) recommended by Capital Vocational Specialists, in a treatment plan dated August 6, 2020?
ii. Is the applicant entitled to a case management assessment in the amount of $1,834.19 recommended by Rehabilitation Management Inc., in a treatment plan dated October 13, 2022?
iii. Is the applicant entitled to a psychological assessment in the amount of $2,200.00 recommended by Mind By Design, in a treatment plan dated February 27, 2023?
iv. Is the applicant entitled to a dietetic assessment in the amount of $2,228.25 recommended by Critical Trauma Therapy, in a treatment plan dated March 22, 2023?
v. Is the applicant entitled to an attendant care assessment in the amount of $918.37 recommended by Modern OT, in a treatment plan dated April 6, 2023?
vi. Is the applicant entitled to a special award?
vii. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3I find that the applicant is not entitled to:
i. catastrophic assessment in the balance amount of $3,612.00;
ii. case management assessment in the amount of $1,834.19;
iii. psychological assessment in the amount of $2,200.00;
iv. dietetic assessment in the amount of $2,228.25;
v. attendant care assessment in the amount of $918.37;
vi. interest; or
vii. an award.
ANALYSIS
Are the treatment plans reasonable and necessary?
4Sections 14 and 15 of the Schedule provide that the insurer shall pay medical benefits to, or on behalf of, an applicant so long as the applicant sustains an impairment as a result of an accident and the medical benefit is a reasonable and necessary expense incurred by the applicant as a result of the accident.
5The applicant bears the onus of proving entitlement to the proposed treatment by proving that the treatment plans are reasonable and necessary on a balance of probabilities.
Catastrophic assessment in the balance amount of $3,612.00 in a treatment plan dated August 6, 2020
6The treatment plan was submitted in the amount of $14,012.00. The respondent partially approved the plan on November 29, 2022 in the amount of $10,400.00, leaving a balance amount of $3,612.00.
7The applicant submits the remaining balance of the treatment plan is reasonable and necessary. The applicant relies on a determination for catastrophic impairment (“OCF-19”) on May 18, 2022, that found the applicant met the criteria pursuant to criterion 7 and 8. The applicant also submits that despite the partial amount approved, the respondent still at a minimum owes applicable taxes. The applicant makes no further submissions as to why the treatment plan is reasonable and necessary but rather provides the reasons for the respondent’s denial.
8The respondent submits that it did approve the catastrophic assessment at a rate of $2,000.00 per assessment as set out in the Professional Services Guideline. The respondent submits that the additional costs outstanding are not reasonable.
9I agree with the respondent. The applicant’s submissions do not address why the balance amount of $3,612.00 is reasonable and necessary. Pursuant to s. 25 of the Schedule, the respondent is not required to pay more than $2,000.00 in respect of any one assessment and preparing the associated report.
10I find that the applicant is not entitled to the balance of the treatment plan for the catastrophic impairment assessment.
Case management assessment in the amount of $1,834.19 dated October 13, 2022
11The applicant submits the treatment plan is reasonable and necessary. The applicant relies on the treatment plan, and the Rehabilitation Needs Assessment Report dated, February 16, 2023, prepared by Ms. Laurie Heizer, case manager. Ms. Heizer makes several treatment recommendations including a case management assessment. The applicant makes no further submissions as to why the treatment plan is reasonable and necessary.
12The respondent submits that little weight should be given to the recommendation of Ms. Heizer, as the Schedule states that case management services are available to individuals who have been found to be catastrophically impaired.
13I agree with the respondent. I find that a catastrophic impairment benefit is not in dispute before the Tribunal, entitlement to catastrophic benefits is not an issue in dispute before the Tribunal, and case management assessments are available to individuals who have been found to be catastrophically impaired. The applicant did not provide a catastrophic designation therefore the treatment plan is not reasonable and necessary.
14I find that the applicant is not entitled to the treatment plan for the case management assessment.
Psychological assessment in the amount of $2,200.00 dated February 27, 2023
15The applicant submits the treatment plan is reasonable and necessary. The applicant relies on the pre-screening assessment report dated February 9, 2023, prepared by Dr. Bita Sharifzadeh, clinical psychologist. Dr. Sharifzadeh recommended a full psychological assessment of the applicant to obtain a thorough understanding of her difficulties and plan reasonable and necessary treatment going forward.
16The respondent submits that the applicant has undergone two psychological assessments. First by Dr. Tonya Bauermann, clinical psychologist, dated May 4, 2020, and second, a section 25 Psychiatric Evaluation, by Dr. Bobbie Ross, psychiatrist, dated April 25, 2022. The respondent submits that the conclusion of Dr. Sharifzadeh is not persuasive evidence to demonstrate why a third psychological assessment from a new treatment provider is reasonable and necessary.
17I agree with the respondent. I do not find that the applicant has provided persuasive evidence to demonstrate that another psychological assessment is reasonable and necessary. I also find that the evidence relied on by applicant is not the pre-screening assessment findings but rather the comments made my Dr. Sharifzadeh in the comments section of the treatment plan. I find that a treatment itself is not objective evidence, and other than the treatment plan, the applicant points to no other evidence to demonstrate that another psychological assessment is reasonable and necessary.
18I find that the applicant is not entitled to the treatment plan for a psychological assessment.
Dietetic assessment in the amount of $2,228.25 dated March 22, 2023
19The applicant submits the treatment plan is reasonable and necessary. The applicant relies on a dietetic assessment submission letter of Ms. Jennifer Accursi, social worker. Ms. Accursi recommends treatment plan as a means to address the impact of the applicant’s physical, psychological-emotional and cognitive impairments.
20The respondent submits that the applicant has not provided evidence to demonstrate that five years post accident she suffers from nutrition issues as a result of the accident. The respondent submits that little weight should be given to the recommendation of Ms. Accursi, as it is not medical evidence but rather an assessment by a treatment provider that stands to gain financially.
21I agree with the respondent. I do not find that the applicant has provided persuasive evidence to demonstrate that a dietetic assessment is reasonable and necessary. The applicant was not referred to Ms. Accursi by a medical professional, there is no indication in any medical records that the applicant suffers from nutritional issues and the conclusions of Ms. Accursi are based solely on the applicant’s self-reporting. I am not persuaded that the treatment is reasonable and necessary.
22I find that the applicant is not entitled to the treatment plan for a dietetic assessment.
Attendant care assessment in the amount of $918.37 dated April 6, 2023
23The applicant submits the treatment plan is reasonable and necessary. The applicant relies on Rehabilitation Needs Assessment Report dated, February 16, 2023, prepared by Ms. Heizer. Ms. Heizer makes several treatment recommendations including an attendant care assessment. The applicant makes no further submissions as to why the treatment plan is reasonable and necessary.
24The respondent submits that the applicant has not demonstrated that the treatment plan is reasonable and necessary, as there is no evidence from any medical physician recommending an attendant care assessment.
25I agree with the respondent. The applicant does not direct me to any medical evidence nor make persuasive submissions with respect to why the attendant care assessment is reasonable and necessary.
26I find that the applicant is not entitled to the treatment plan for an attendant care assessment.
INTEREST
27Section 51 of the Schedule sets out the criteria for assessing and awarding interest on overdue payments. There being no overdue benefits payments, no interest is payable.
AWARD
28The 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
29The application is dismissed, and I find that the applicant is not entitled to:
i. catastrophic assessment in the balance amount of $3,612.00;
ii. case management assessment in the amount of $1,834.19;
iii. psychological assessment in the amount of $2,200.00;
iv. dietetic assessment in the amount of $2,228.25;
v. attendant care assessment in the amount of $918.37;
vi. interest; or
vii. award.
Released: August 21, 2024
Monica Ciriello
Vice-Chair