Applicant falls outside of MIG but submitted treatment plans are not reasonable and necessary - TN and Aviva Insurance Canada, 2018 CanLII 13180 ON LAT 17-002971

May 21, 2018, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

TN and Aviva Insurance Canada, 2018 CanLII 13180 ON LAT 17-002971

Date of Decision: January 31, 2018
Heard Before: Adjudicator Derek Grant

MEDICAL BENEFITS: applicant is outside of MIG on psychological grounds; applicant eligible for reasonable and necessary treatment up to $50,000; submitted treatment plans are not shown by applicant to be reasonable and necessary

TN was injured in a car accident on January 22, 2015, and sought benefits pursuant to the SABs from Aviva. TN claimed medical benefits for chiropractic treatment which. Aviva initially denied on the basis of an IE which found that TN’s injuries were within the MIG.

Aviva has since acknowledged TN is no longer under the MIG designation based on a psychological IE, which determined that TN suffered from depression, anxiety and cognitive impairment as a result of the accident.

The onus is on TN to prove, on a balance of probabilities, that she is entitled to the benefits in dispute on the basis that the treatment is reasonable and necessary as a result of the accident.

Issues

1. Is TN entitled to receive a medical benefit in the amount of $1,458.92 for chiropractic services recommended in a treatment plan submitted July 17, 2015?
2. Is TN entitled to receive a medical benefit in the amount of 1,215.20 for chiropractic services recommended in a treatment plan submitted September 16, 2015?
3. Is TN entitled to receive a medical benefit in the amount of $1,763.66 for chiropractic services in a treatment plan submitted October 27, 2015?
4. Is TN entitled to interest on any overdue payment of benefits?
5. Is TN entitled to costs under Rule 19.1 of the LAT Rules?

Result

1. TN is not entitled to the treatment plans in dispute.
2. TN is not entitled to interest.
3. TN is not entitled to costs.

Analysis and Reasons

TN argues that the treatment plans are reasonable and necessary due to pre-existing lower back pain and chronic pain syndrome/disorder.  As a result of her pre-existing impairment, TN submits that recovery from her accident-related injuries has been slow, requiring continued chiropractic treatment, which has reduced her pain.

Aviva submits the treatment plans are not reasonable and necessary because, in the opinion of its medical assessors, TN has reached maximum medical recovery for her accident-related injuries and any further facility-based treatment for chiropractic treatment will not improve her condition.

Based on the evidence the Adjudicator could not find that further chiropractic treatment is reasonable and necessary when TN’s own treating health practitioners do not support or recommend chiropractic treatment. TN has not provided any other evidence in support of the chiropractic treatment.

The Adjudicator reviewed the evidence and concluded that TN’s injuries are not predominantly minor and she is eligible for treatment up to $50,000.00 in medical and rehab services for those treatment plans that are 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.