Applicant Fails to Establish Entitlement to ACBs - NN v Certas LAT 17-001002

January 26, 2018, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

NN v Certas LAT 17-001002

Decision Date: December 19, 2017
Heard Before: Adjudicator Billeh Hamud

ATTENDANT CARE BENEFITS: applicant fails to establish entitlement to ACBs; applicant fails to show that treatment plans are reasonable and necessary.  

NN was injured in a car accident on November 15, 2015 and sought benefits pursuant the SABs. Certas denied attendant care benefits and two treatment plans. NN applied to the LAT.

Issues:

1. Is NN entitled to attendant care benefits in the monthly amount of $1,143.79 as submitted on December 17, 2015?
2. Is NN entitled to a medical benefit in the amount of $2,460.00 for an orthopaedic assessment as recommended in a Treatment and Assessment Plan (OCF-18) on May 28, 2016?
3. Is NN entitled to a medical benefit in the amount of $2,220.85 for assistive devices and occupational therapist services as recommended in an OCF-18 submitted on January 25, 2016?
4. Is NN entitled to interest for the overdue payment of benefits?

RESULT:

1. NN is not entitled to attendant care benefits.
2. NN is not entitled to a medical benefit in the amount of $2,460.00 for an orthopedic assessment recommended by All Health Medical Centre.
3. NN is not entitled to a medical benefit in the amount of $2,220.85 for assistive devices and OT services.
4. NN is not entitled to interest.

The Adjudicator reviewed the law and the evidence.

Is NN is entitled to Attendant Care Benefits?

NN is not entitled to attendant care benefits since the Adjudicator found that he was independent with his activities of daily living or that he was functionally capable of doing them and that he has failed to establish any economic loss by the person providing attendant care services. The ACB services are not reasonable and necessary.

Is NN entitled to a medical benefit for an orthopaedic assessment?

The Adjudicator reviewed the evidence and found that NN is not entitled to the cost of an orthopaedic assessment because the medical evidence does not establish that it is reasonable and necessary. NN failed to prove on the balance of probabilities that the claimed medical expenses are reasonable and necessary.

Is NN entitled to a medical benefit for assistive devices and OT services?

NN is not entitled to assistive devices and OT services because there is insufficient medical evidence to convince me that the assistive devices and OT services are reasonable and necessary. NN failed to provide the Tribunal with the OCF-18 in dispute, thus the Adjudicator relied on Certas’ submissions and assessment report dated March 16, 2016 to determine the list of assistive devices claimed by NN. On this basis the Adjudicator found that NN has failed to provide sufficient medical evidence to establish that the OT services and assistive devices sought are reasonable and necessary for the reasons discussed below.

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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.