Licence Appeal Tribunal File Number: 23-003949/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:
Joel Metcalf
Applicant
and
Intact Insurance Company
Respondent
DECISION
ADJUDICATOR: Melanie Malach
APPEARANCES:
For the Applicant: Christina Martin, Counsel
For the Respondent: Thomas Petrella, Counsel
HEARD: By way of written submissions
OVERVIEW
1Joel Metcalf, the applicant, was involved in an automobile accident on December 13, 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, Intact Insurance, and applied to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issues in dispute are:
i Is the applicant entitled to $10,000.76 ($28,306.76 less $18,306.00 approved) for a multi-disciplinary Catastrophic (“CAT”) Impairment Assessment, proposed by AssessNet Inc., in a treatment plan dated March 26, 2021?
ii Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
iii Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant is not entitled to the unapproved amount of the treatment plan, dated March 26, 2021, interest or an award.
ANALYSIS
The applicant is not entitled to the unapproved amount of the treatment plan dated March 26, 2021, for a multi-disciplinary CAT impairment assessment
4I find that the applicant has not proven on a balance of probabilities that he is entitled to the unapproved amount of the treatment plan dated March 26, 2021.
5The applicant claims entitlement to $10,000.76 ($28,306.76 less amounts approved of $18,306.00) for the cost of a multi-disciplinary CAT impairment assessment proposed by AssessNet Inc., in a treatment plan dated March 26, 2021.
6Section 25(1)5 of the Schedule provides that an insurer shall pay for reasonable fees for the determination of whether the insured person has sustained a catastrophic impairment, including any assessment or examination necessary for that purpose. This is to be read in conjunction with s. 25(5)(a) of the Schedule which limits the cost of any one assessment or examination to $2,000.00. The applicant bears the onus of proving on a balance of probabilities, that each of the disputed components of the treatment plan are reasonable and necessary.
7The respondent approved the following:
i $2,000.00 for an Orthopaedic Evaluation by Dr. D. Wismer, orthopaedic surgeon;
ii $2,000.00 for a Psychiatry Evaluation by Dr. D. Pallandi, psychiatrist;
iii $2,000.00 for a Neuropsychological Evaluation by Dr. C. Alyman, neuropsychologist;
iv $2,000.00 for Psychometric Testing by Dr. C. Alyman, neuropsychologist;
v $2,000.00 for a GOS-E Questionnaire by Dr. C. Alyman, neuropsychologist, and Cristyn Franic, occupational therapist;
vi $2,000.00 for an In-Home Evaluation by Cristyn Franic, occupational therapist;
vii $2,000.00 for a Situational Evaluation by Cristyn Franic, occupational therapist;
viii $2,000.00 for a Catastrophic Analysis by Dr. A. Persi, chiropractor;
ix $200.00 for completion of OCF-18, by Dr. A. Persi, chiropractor; and
x $2,106.00 for tax.
8The respondent denied the following:
i $2,000.00 for Collation of Information by Dr. C. Alyman, neuropsychologist;
ii $2,000.00 for a Functional Review Evaluation by Dr. A. Tartaglia, chiropractor;
iii $548.63 for travel time for Cristyn Franic, occupational therapist;
iv $301.60 for mileage for Cristyn Franic, occupational therapist;
v $2000.00 for an Abstract of Documentation by Dr. A. Persi, chiropractor;
vi $2,000.00 for a Consensus Opinion by Dr. A. Persi, chiropractor; and
vii $1,150.53 for tax.
Collation of information
9I find that the applicant has not met his burden of proving that a Collation of Information is reasonable and necessary.
10The applicant submits that the Collation of Information by Dr. Alyman, neuropsychologist, is reasonable and necessary because individual assessments often become voluminous and difficult to understand. The applicant submits that this Collation of Information is necessary to making a CAT determination.
11The respondent submits that a Collation of Information is not a stand-alone assessment and should form part of each individual assessment. It further submits that it does not constitute an independent billable task.
12I find that the applicant has not provided a reasonable explanation as to why a stand-alone Collation of Information was required or the specifics of what this task actually entailed. The applicant has not provided any evidence to support that it was necessary.
13In addition, while the applicant’s medical documentation may have been voluminous requiring the documentation to be organized and collated, I do not find the proposed cost at the maximum rate of $2,000.00 for this largely administrative exercise which is the same cost as a full day assessment and report from a medical professional, to be reasonable.
14I accordingly find, on a balance of probabilities, that the applicant has not established that a Collation of Information is reasonable and necessary.
Functional Review Evaluation
15I find that the applicant has not met his burden of proving that a Functional Review Evaluation is reasonable and necessary.
16The applicant submits that a Functional Review Evaluation is required in order to complete a thorough and fulsome CAT impairment assessment. The applicant submits that Dr. Tartaglia’s evaluation would provide the assessors with important information concerning the applicant’s functional impairments and their applicability to the determination of whether the applicant meets the CAT impairment threshold.
17The respondent submits that the applicant’s functional limitations were assessed in the context of the approved occupational therapy in-home and situational evaluation assessments. The respondent submits that these assessments were more than sufficient to identify “the capacity and limitations” of the applicant. The respondent further submits that there is no basis for the applicant to obtain an additional assessment, in the same discipline, with different assessors. Such an assessment would be redundant, unreasonable and unnecessary.
18I find that a Functional Review Evaluation is not reasonable and necessary. I agree with the respondent that the two occupational therapy assessments properly identified and assessed the applicant’s functional limitations. A third evaluation to address the applicant’s functional limitations with a different assessor is not reasonable and necessary. I find that the applicant has not provided any submissions to differentiate the functional assessments and has not provided me with any evidence to support that a third assessment is reasonable and necessary. I further find that the applicant has not provided any evidence to support that without this evaluation, the assessors would not have sufficient information to correctly assess the applicant’s impairment level.
19I accordingly find, on a balance of probabilities, that this portion of the treatment plan is not reasonable and necessary.
Travel Time and Mileage
20I find that the applicant has not met his burden of proving that travel time or mileage is reasonable and necessary.
21The applicant submits that the travel time and mileage for Cristyn Franic, occupational therapist, to assess the applicant, is reasonable and necessary. The applicant further submits that these expenses should be paid because he has the right to be assessed by the medical expert of his choosing.
22The respondent submits that the occupational therapist’s travel time is not an assessment and is therefore not payable over and above the cost of the Occupational Therapy Assessments which were both approved.
23I find that the applicant has not met his burden to establish, on a balance of probabilities, his entitlement to this expense. The respondent denied this expense as it had already approved the maximum amounts under s. 25(5) of the Schedule for the occupational therapy assessments. I find that the respondent is not required to pay transportation expenses for the provider because the transportation costs for the provider are included in the s. 25(5)(a) cap of $2,000.00 for fees and expenses relating to any one assessment. The applicant has not made any submissions regarding this line item except to say that he has the right to be assessed by the medical expert of his choosing.
24I accordingly find, on a balance of probabilities, that the applicant has not met his burden in proving that the travel time and mileage expenses should be paid outside of the s. 25(5) cap for each assessment.
Abstract of Documentation
25I find that the applicant has not met his burden in proving that an Abstract of Documentation is reasonable and necessary.
26The applicant submits that the Abstract of Documentation prepared by Dr. Persi, chiropractor, is necessary to provide a fulsome CAT assessment report that would be persuasive to the respondent.
27The respondent submits that a file review or an Abstract of Documentation should be completed within the approved assessments and is not a stand-alone assessment.
28I find that the applicant has not provided an explanation as to why an Abstract of Documentation is warranted when each assessor conducted their own file review. In addition, the applicant has not provided any evidence to support his submission that the Abstract of Documentation is necessary to provide a fulsome CAT assessment report. Further, the respondent relies on Wu v. Aviva General Insurance, 2022 CanLII 92741, where the Tribunal found that the plain language of s. 25(5) of the Schedule means that the cap of $2,000.00 applies to all parts of an assessment, and therefore a separate amount for a file review is not payable. Although I am not bound by this decision, I agree and adopt the Tribunal’s reasoning in that decision.
29I accordingly find, on a balance of probabilities, that the applicant is not entitled to the cost of this portion of the treatment plan.
Consensus Opinion
30I find that the applicant has not met his burden in proving that a consensus opinion is reasonable and necessary.
31The applicant submits that the Consensus Opinion by Dr. Persi, chiropractor, is necessary to provide a fulsome CAT assessment report that would be persuasive to the respondent.
32The respondent submits that only one assessment is payable for the purposes of summarizing and drawing a conclusion with respect to the applicant’s catastrophic designation and therefore the Consensus Opinion is not necessary.
33I find that the respondent approved a Catastrophic Analysis by Dr. Persi in the amount of $2,000.00. I agree with the respondent that only one assessment is payable for the purpose of summarizing and drawing a conclusion with respect to the CAT designation. I find that the applicant has not provided any evidence to support that a Consensus Opinion was required. I therefore find that the applicant is not entitled to a Consensus Opinion as it is a duplication of an already approved assessment and is therefore not reasonable and necessary.
34I further find that the applicant has not made any submissions in respect to this line item except to say that it is necessary to provide a fulsome CAT assessment report.
35I accordingly find, on a balance of probabilities, that the applicant is not entitled to the cost of this portion of the treatment plan.
Interest
36Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Having found that the applicant is not entitled to the disputed treatment plan, no payments are overdue, and thus no interest is payable.
Award
37The applicant sought an award under s. 10 of Reg. 664. Under s. 10, the Tribunal may grant an award of up to 50 percent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits. The applicant is not entitled to an award under s. 10 of Reg. 664, because there is no evidence that the respondent unreasonably withheld or delayed the payment of benefits.
ORDER
38For the reasons outlined above, I find that the applicant is not entitled to the unapproved amount of the treatment plan, dated March 26, 2021, interest or an award. The Application is dismissed.
Released: February 21, 2025
Melanie Malach
Adjudicator