Adjudicator Determines What is Reasonable and Necessary - GR v Aviva Insurance Canada, LAT 17-001146

December 14, 2017, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

GR v Aviva Insurance Canada, LAT 17-001146 2017 CanLII 69449 (ON LAT)

Decision Date: October 19, 2017
Heard Before: Adjudicator Chris Sewrattan

ENTITLEMENT OF BENEFITS: what treatment is reasonable and necessary; applicant presents evidence but fails to address key question; adjudicator left to draw conclusions  from medical evidence, testimony, and insurer’s evidence.

GR was injured in a car accident on November 9, 2015. He applied for accident to Aviva but when they were denied and mediation failed, GR applied for arbitration to the LAT.

Issues:

1. Is GR entitled to receive a $1,197.50 medical benefit for physiotherapy in a Treatment Plan dated May 19, 2016?
2. Is GR entitled to receive a $12,408.54 medical benefit for multidisciplinary chronic pain treatment in a Treatment Plan dated October 4, 2016?
3. Is GR entitled to receive a $2,170.83 ($4,265.37 less $2,094.54 approved) medical benefit for psychological services in a Treatment Plan dated June 1, 2016?
4. Is GR entitled to recover the cost of a $2,520.00 orthopaedic assessment in a Treatment Plan dated August 24, 2016?
5. Is GR entitled to interest on any overdue payment of benefits?
6. Is Aviva entitled to costs under Rule 19.1?

Result:

1. GR is entitled to $1,197.50 for physiotherapy services and $12,408.54 for multidisciplinary chronic pain treatment. He is entitled to interest on these outstanding payments in accordance with s. 51 of the Schedule. Due to the interplay between GR’s psychological condition and his physical impairment and injuries, GR is entitled to choose the modality of reducing his pain and increasing his strength. Pain reduction and increasing strength are reasonable and necessary goals in the circumstances of this case.
2. GR is not entitled to $2,170.83 for psychological services. He has not proven why amount of the Treatment Plan not approved by Aviva is a reasonable expense.
3. GR is not entitled to the cost of a $2,520.00 orthopaedic assessment. He has not proven that the assessment is a reasonable and necessary expense for the injuries he sustained as a result of the accident.
4. Aviva is not entitled to costs under Rule 19.1.

Analysis

GR was 68 when the car accident happened. The clinical notes and records following the accident reveal complaints of “low back pain radiating on the left groin, pain in the neck, worse at night and early mornings.” With regard to psychological injuries a report dated June 1, 2016 diagnosed GR with Adjustment disorder with mixed anxiety and depressed moods. The only real issue in this hearing is whether each of the four Treatment Plans in dispute is reasonable and necessary.

GR’s submissions are essentially a chronology of events that transpired after his accident. He did not address the reasonableness of the treatments. By contrast, Aviva provided substantial submissions on the reasonableness and necessity of the Treatment Plans.

On the basis of the evidence provided the Adjudicator determined which benefits were reasonable and necessary.

About Deutschmann Law

Deutschmann Law serves South-Western Ontario with offices in Kitchener-Waterloo, Cambridge, Woodstock, Brantford, Stratford and Ayr. The law practice of Robert Deutschmann focuses almost exclusively in personal injury and disability insurance matters. For more information, please visit www.deutschmannlaw.com or call us at 1-519-742-7774.

It is important that you review your accident benefit file with one of our experienced personal injury / car accident lawyers to ensure that you obtain access to all your benefits which include, but are limited to, things like physiotherapy, income replacement benefits, vocational retraining and home modifications.