Licence Appeal Tribunal File Number: 23-002717/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:
Angela Scandlan
Applicant
and
Primmum Insurance Company
Respondent
DECISION
ADJUDICATOR:
Robert Rock
APPEARANCES:
For the Applicant:
Alicia D Stuart, Counsel
For the Respondent:
Annie Padhani, Counsel
HEARD:
By way of written submission
OVERVIEW
1Angela Scandlan, the applicant’s husband and son, were involved in an automobile accident on March 23, 2014, and sought benefits pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 2010 (the “Schedule”). The applicant was denied benefits by the respondent, Primmum 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:
i. Is the applicant entitled to $3,791.06 for occupational therapy services, proposed by Joanne Nunn in a treatment plan submitted October 25, 2022?
ii. Is the applicant entitled to $4,171.42 for rehabilitation therapy services, proposed by Erin McReady in a treatment plan submitted October 25, 2022?
iii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant has not proven on a balance of probabilities that the treatment plans at issue are reasonable and necessary.
4As there are no overdue benefit payments, no interest is owing.
5As no benefit payments were unreasonably withheld or delayed, the respondent is not liable to pay an award.
ANALYSIS
6To 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. To do so, 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 them are reasonable.
Occupational Therapy treatment plan
7I find that the applicant has not proven on a balance of probabilities that the treatment plan for occupational therapy is reasonable and necessary.
8The goal of the occupational therapy treatment plan is occupational therapy intervention.
9The treatment plan includes documentation, preparation services, travel time, and six training/cognition and learning session.
10The applicant argues that the occupational therapy treatment plan is reasonable and necessary, based on the medical evidence provided. The applicant relies on an occupational therapy in-home assessment completed by Ms. Nunn, OT, on July 7, 2022.
11I find that the occupational therapy in-home assessment by Ms. Nunn supports the applicant’s claim that the treatment plan in question is reasonable and necessary. The assessment recommended multiple treatment modalities in the recommendations. However, I note that the respondent argues that the treatment plan is a duplication of an occupational therapy treatment plan that it approved on August 1, 2023.
12I have reviewed the occupational therapy treatment plan submitted on October 25, 2022, and the treatment plan submitted on July 25, 2023, and approved by the respondent on August 1, 2023. The goals, objectives, and treatment modalities are the exact same. There is also a payment record in evidence showing that the applicant has been paying for occupational therapy services as they have occurred, and there is a balance outstanding in their approval of the treatment plan.
13I find that the occupation therapy treatment plan from October 25, 2022, is not reasonable and necessary because it is duplicative of the July 25, 2023 treatment plan approved by the respondent. The applicant has not submitted any compelling evidence as to why a duplication of a submitted treatment plan is reasonable and necessary, particularly when the existing treatment plan has yet to be exhausted.
14I find on a balance of probabilities that the applicant is not entitled to the occupational therapy treatment plan.
Rehabilitation Therapy Services Treatment Plan
15I find that the applicant has not proven on a balance of probabilities that the rehabilitation therapy services treatment plan is reasonable and necessary.
16The goal of the treatment plan is to coordinate the applicant’s medical and rehabilitation needs.
17The rehabilitation therapy services treatment plan includes twelve client sessions, documentation, travel time, and planning/communication.
18The applicant argues that the medical evidence shows that the treatment plan is reasonable and necessary. However, the applicant does not direct me to any specific medical evidence that would support that the rehabilitation therapy service treatment plan is reasonable and necessary.
19The respondent argues that the applicant has failed to point to specific medical evidence to show that the treatment plan in question is reasonable and necessary.
20I find that the rehabilitation therapy service treatment plan is not reasonable and necessary. I was not directed to any compelling medical evidence that substantiates that the treatment plan is reasonable and necessary.
21I find on a balance of probabilities that the applicant is not entitled to the rehabilitation therapy service treatment plan.
Non-Compliance with Section 38(8)
22I find that the respondent has complied with s.38(8) of the Schedule.
23Section 38(8) states,
i. Within 10 business days after it receives the treatment and assessment plan, the insurer shall:
(i) give the insured person a notice that identifies the goods, services, assessments and examinations described in the treatment and assessment plan that the insurer agrees to pay for,
(ii) any the insurer does not agree to pay for and,
(iii) the medical reasons and all of the other reasons why the insurer considers any goods, services, assessments and examinations, or the proposed costs of them, not to be reasonable and necessary.
24The applicant argues that the respondent has not complied with s.38(8) of the Schedule in denying the two treatment plans in question. The applicant submits that the “medical and all of the other reasons” provided by the respondent are not sufficient to meet the standard of s.38(8) and failed to provide an unsophisticated person with enough information to make an informed decision on the denial.
25The respondent has not made submissions regarding s.38(8) of the Schedule.
26The explanation of benefits for the occupational therapy treatment plan from the respondent states the HCAI document outlining the treatment plan, the person who submitted the plan, when it was submitted and the amount of the treatment plan. The explanation of benefit states, “we are 8 years post the accident, and there is not medical evidence to support that the proposed goods and services are essential to your ongoing treatment/ rehabilitation. At this time, the insurer does not agree that the proposed goods and services as described above are essential to ongoing treatment and rehabilitation.” Additionally, the explanation of benefits, outlines that some of the costs in the submitted treatment plan are not eligible for payment as they constitute case management functions.
27I find that this denial notice is compliant with s. 38(8) because it was timely, identified the treatment plan, and outlined the respondent’s reasoning for not approving it.
28The explanation of benefits for the rehabilitation therapy service treatment plan from the respondent states the HCAI document outlining the treatment plan, the person who submitted the plan, when it was submitted and the amount of the treatment plan. The explanation of benefit states, “we are 8 years post the accident, and there is not medical evidence to support that the proposed goods and services are essential to your ongoing treatment/ rehabilitation.” Additionally, the explanation of benefits, outlines that some of the costs in the submitted treatment plan are not eligible for payment as they constitute case management functions.
29I find that this denial notice is compliant with s. 38(8) because it was timely, identified the treatment plan, and outlined the respondent’s reasoning for not approving it.
30In sum, I find that the respondent has complied with s.38(8) of the Schedule in their denials of the treatment plans in dispute.
Interest
31Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As there are no overdue benefit payments, no interest is owing.
Award
32The applicant sought an award under s. 10 of Reg. 664. Under s. 10, the Tribunal may grant an award of up to 50 per cent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits. As no benefit payments have been unreasonably withheld or delayed, no award is due.
ORDER
33I find that:
i. The applicant is not entitled to the two treatment plans in dispute.
ii. As there are no overdue benefit payments, no interest is owing.
iii. As no benefit payments have been unreasonably withheld or delayed, the respondent is not liable to pay an award.
Released: June 2, 2025
__________________________
Robert Rock
Adjudicator