Applicant Fails to Provide Evidence Supporting NEB Claim - Applicant and Allstate Insurance Company LAT 16-004309

April 06, 2018, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

Applicant and Allstate Insurance Company LAT 16-004309 CanLII 2303

Date of Decision: January 11, 2018
Heard Before: Adjudicator Blaine Baker

NEBs: applicant fails to provide evidence to support NEB claim; applicant is granted treatment plans as the treatments are reasonable and necessary

The applicant was injured in a car accident on November 15, 2014, and sought benefits under the SABs. After 6 months of paying NEBs Allstate concluded on the basis of a series of insurer’s examinations that the applicant did not meet the test for that benefit, and now asks that the Tribunal retroactively terminate those benefits as of May 15, 2015. Allstate also refused to pay for certain medical benefits.

The applicant disagreed with Allstate’s decisions and applied to the LAT for resolution of the dispute.

Issues:

1. Is the applicant entitled to NEBs of $185 per week from May 13, 2015 to date, and ongoing?
2. Is the applicant entitled to a medical benefit in the amount of $2,646.40 for physiotherapy in a treatment plan submitted to Allstate on October 20, 2015 and denied on October 26, 2015?
3. Is the applicant entitled to a medical benefit in the amount of $2,413.60 for physiotherapy that was recommended in a treatment plan submitted to Allstate on March 9, 2016 and denied on April 1, 2016?
4. Is the applicant entitled to interest on the overdue payment of benefits?

Result:

1. The applicant is not entitled to NEBs from November 13, 2015 to date and ongoing, but was entitled to that benefit during the May 14, 2015 to November 13, 2015 during which it was paid by Allstate.
2. The applicant is entitled to a medical benefit of $2,646.40 for physiotherapy in a treatment plan submitted to Allstate on October 20, 2015 and denied on October 26, 2015.
3. The applicant is also entitled to a medical benefit of $2,413.60 for physiotherapy in a treatment plan submitted to Allstate on March 9, 2016 and denied on April 1, 2016.
4. The applicant is entitled to interest on the overdue payment of benefits.

Reasons:

The test for entitlement to NEBs is set out in the Schedule. The applicant must prove she suffers from a complete inability to carry on a normal life as a result of the accident and sustains an impairment that continuously prevents her from engaging in substantially all of the activities in which she ordinarily engaged before the accident.

In support of her claim for NEBs, the applicant’s evidence was unconvincing. Limited information about the applicant’s pre-accident life was provided to the Adjudicator and much of what was available came from the insurer to indicate that little had changed in the applicant’s life since the accident.

The applicant submitted two physiotherapy treatment plans that were recommended for her by Midland Wellness Centre in October of 2015 and March of 2016. The test for entitlement to treatment is whether the treatment claimed is reasonable and necessary. The Adjudicator found the treatment plans to be 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.