Licence Appeal Tribunal File Number: 24-014699/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:
Eva Bohusova
Applicant
and
Certas Home and Auto Insurance Company
Respondent
DECISION
ADJUDICATOR:
Nadia Mauro
APPEARANCES:
For the Applicant:
David Gardiner, Counsel
For the Respondent:
Lori Marzinotto, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Eva Bohusova, the applicant, was involved in an automobile accident on June 9, 2022, 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, Certas Home and Auto 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 $1,153.17 for assistive devices, proposed by Function Ability Rehabilitation Services in a treatment plan (“OCF-18”) submitted on October 23, 2024, and denied on November 29, 2024?
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 proposed treatment plan for assistive devices, interest, or an award.
ANALYSIS
The applicant is not entitled to the proposed treatment plan for assistive devices
4The applicant has not demonstrated, on a balance of probabilities, that the proposed treatment plan for assistive devices is reasonable and necessary.
5To receive payment for a treatment and assessment plan under sections 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.
6The OCF-18 completed by occupational therapist, Brianna Whitteker, dated October 23, 2024, sought funding for the following assistive devices:
Line
Description
Quantity
Amount
Completing claim form
1
$200.00
Other supplies (cost adjustment)
1
$50.00
Prescription, support activity
1.5
$87.29
Other supplies (Non-slip bath mat and aids for daily living)
1
$80.00
Other supplies (Assista-Rail (bed rail), round raised toilet seat, transfer bath bench with curtain control, stainless steel grab bar, grab bar service visit)
1
$598.00
Other supplies (Suction holder for handheld shower head)
1
$14.53
Other supplies (long handled loofah)
1
$13.69
7The goals of the treatment plan are to increase safety, return to activities of daily living, improve safety with activities of daily living, functional mobility, and transfers using the recommended equipment.
8The applicant submits that the treatment plan is reasonable and necessary, and the assistive devices are required for her safety to help protect her in her recovery. The applicant relies on the s. 25 occupational therapy (OT) report of Brianna Whitteker, dated October 18, 2024, and s. 25 orthopedic assessment report of Dr. Michael Kliman, dated January 16, 2025.
9The OCF-18 indicates that Line 2: other supplies (cost adjustment) is with respect to the fact that online pricing frequently changes after the OCF-18 is submitted and approved for items at a specific price, and to avoid time required to request small price adjustments later, this OCF-18 includes the additional line item as a buffer in the event of the adjustment. The OCF-18 also indicates that Line 3: prescription, support activity is time required to order, ship, and arrange the correct purchase of the items. The applicant does not make specific submissions with respect to these line items. Given the further explanation of these proposed goods and services within the OCF-18, I agree with the respondent’s position with respect to Line 2 and 3 and find that neither of these items are payable under the Schedule, nor has the applicant established that they are reasonable and necessary.
10With respect to Line 5 through 7, Ms. Whitteker reports these proposed goods and services are to facilitate the applicant’s independence with bed, toilet, and shower mobility and transfers. Nonetheless, Ms. Whitteker in her OT report, dated October 18, 202