Licence Appeal Tribunal File Number: 23-001030/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:
Allan Godden
Applicant
and
Aviva General Insurance Company
Respondent
DECISION
VICE-CHAIR:
Monica Ciriello
APPEARANCES:
For the Applicant:
John Chui, Paralegal
For the Respondent:
Ashley Panzarella, Paralegal
HEARD:
In Writing
OVERVIEW
1Allan Godden, the applicant, was involved in an automobile accident on July 26, 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, Aviva General Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The following are to be decided:
i. Is the applicant entitled to $1,528.11 for chiropractic services, proposed by Complete Rehab Centre in a treatment plan dated September 19, 2022?
ii. Is the applicant entitled to $2,460.00 for a psychological assessment, proposed by Elite Specialist Group Inc. in a treatment plan dated February 24, 2022?
iii. Is the respondent liable to pay an award under section 10 of Regulation 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
3I find that the applicant is not entitled to:
i. $1,528.11 for chiropractic services;
ii. $2,460.00 for a psychological assessment;
iii. An award;
iv. Interest.
ANALYSIS
Is the treatment plan 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.
Chiropractic treatment in the amount of $1,528.11 dated September 19, 2022
6I find that the chiropractic treatment plan completed by Mr. Rahim Jessa, chiropractor, in the amount of $1,528.11 is not reasonable and necessary.
7The goals of the proposed treatment plan are to reduce pain and help the applicant increase his strength.
8Absent medical evidence support, the applicant submits that he has not yet reached maximum medical recovery and therefore the treatment plan is reasonable and necessary. The applicant relies on the clinical notes and records (“CNRs”) of Mr. Jessa dated August 3, 2018, a few weeks after the accident report that the applicant’s injuries are sprain and strain of the cervical and thoracic spine, sprain, and strain of the lumbar spin with radiculopathy, sprain and strain of the shoulder joint – bilateral, headache, insomnia, and reaction to severe stress.
9The CNRs of Dr. Loana Tita, family physician, reveal that the applicant’s first medical appointment was six months post-accident on January 21, 2019. In reviewing the CNRs the applicant had various appointments between January and September with complaints of knee, back, hand and left rib pain as a result of gym or workplace injuries. The CNRs make no reference to the accident nor specialist referrals as a result of the accident.
10In response, the respondent submits that the treatment plan is not reasonable or necessary. The respondent relies on section 44 physiatry assessment of Dr. Seyed Hosseini, physiatrist, dated October 6, 2020. During the assessment the applicant self-reported exacerbation of neck and back pain following the accident and denied any workplace injuries. Dr. Hosseini diagnosed the applicant with soft tissue sprain and strain injuries and opined that the applicant had reached maximum medical improvement as it relates to facility-based physical therapy. Dr. Hosseini concluded that further facility-based chiropractic and massage therapy was not reasonable or necessary, considering the applicant had received facility-based treatment since 2017 it was unlikely to provide any future benefit. The applicant was encouraged to continue to participate in home-based exercise programs.
11I find CNRs of Dr. Hosseini, as well as Mr. Jessa indicate that the applicant suffered soft tissue injuries as a result of the accident. These injuries are supported by the delay in a medical appointment with Dr. Tita, and no reference in the CNRs of the accident. I am persuaded by the uncontested medical opinion of Dr. Hosseini, the only medical evidence submitted, that concludes the applicant has reached maximum medical improvement and that the treatment plan is not reasonable or necessary.
Psychological assessment in the amount of $2,460.00 dated February 24, 2022
12I find that the psychological assessment proposed by Elite Specialist Group, in the amount of $2,460.00 is not reasonable and necessary.
13The goals of the proposed treatment plan are to decrease psychological problems and allow the applicant to return to activities of normal living.
14The applicant submits that the treatment plan is reasonable and necessary because he continues to suffer psychological impairments as a result of the accident. The applicant references that he has already undergone a section 25 psychological assessment dated August 16, 2019, by Dr. Helen Ilios, psychotherapist, which was funded by the respondent. Dr. Ilios diagnosed the applicant with adjustment disorder with mixed anxiety and depressed mood and specific phobia. Dr. Ilios recommended 14 counselling sessions. The applicant subsequently submitted a treatment plan, and these sessions were approved by the respondent on September 26, 2019.
15In response, the respondent submits that the treatment plan is not reasonable or necessary. The treatment plan is submitted three and half years post-accident, and is duplicative, because the respondent already funded the section 25 psychological assessment. The respondent also highlights that as of the date of the explanation of benefits, the applicant had not attended any of the 14 previously approved psychological sessions, nor provided explanations for not attending.
16The respondent also submits that the post-accident CNRs of Dr. Tita do not include any psychological concerns raised by the applicant nor referrals to a psychologist, psychiatrist, psychotherapist, social worker, or mental health counselling.
17I find that the applicant has failed to establish that the treatment plan is reasonable or necessary. In reviewing the evidence, I am satisfied that the applicant received a psychological assessment in 2019 at the cost of the respondent, and that as a result of that assessment psychological sessions were approved. The applicant does not provide compelling evidence to suggest why a new psychological assessment three years post- accident at the cost of the respondent is reasonable or necessary. The medical evidence reveals that post-accident the applicant did not raise any psychological concerns during any appointment with his family physician Dr. Tita from 2019-2021. I find that the treatment plan is duplicative and is therefore not reasonable or necessary.
AWARD
18The applicant seeks an award under section 10 of Regulation 664. I find that no benefits have bene unreasonably withheld or delayed, and therefore no award is payable.
INTEREST
19Section 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.
ORDER
20For the reasons outlined above, I find that the applicant is not entitled to:
i. $1,528.11 for chiropractic services;
ii. $2,460.00 for a psychological assessment;
iii. An award;
iv. Interest.
Released: January 28, 2025
Monica Ciriello
Vice-Chair