Applicant provides insufficient evidence to support claim for SABs and assessments - NC and Aviva Insurance Canada, 2018 CanLII 13187 ON LAT 17-004085

May 09, 2018, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

NC and Aviva Insurance Canada, 2018 CanLII 13187 ON LAT 17-004085

Date of Decision: February 26, 2018
Heard Before: Adjudicator Anita Goela

ENTITLEMENT TO MEDICAL ASSESSMENT: applicant fails to make case for SABs and medical assessment

NC was injured in a car accident on August 22, 2015 when she sustained physical injury to the left side of her body as a passenger on a motor cycle. She underwent arthroscopic knee surgery on April 19, 2016. She returned to work as a fitness and dance instructor in September 2016. NC sought SABs but when Aviva denied NC’s claim for a psychological assessment on the basis that the benefit was not reasonable and necessary she applied to the LAT.

Issue:

1. Is NC entitled to receive a medical benefit in the amount of $2,200.00 for a psychological assessment set out in the treatment plan dated March 2, 2017?

RESULT

1. NC is not entitled to the cost of the psychological assessment.

Section 15(1) of the Schedule provides that an insurer is required to pay for all reasonable and necessary expenses incurred by the insured person. The onus is on NC to prove that, on a balance of probabilities, it is reasonable and necessary to assess whether she suffers from a psychological impairment.

The Adjudicator did not find that NC provided sufficient evidence that the psychological assessment was reasonable and necessary on a balance of probabilities. While there was some evidence that NC may warrant a psychological assessment, NC did not meet her onus. The Adjudicator noted that NC’s written submissions were only 1.5 pages.

Aviva’s s. 44 psychological medical assessor found NC to demonstrate mild and below average symptoms of depression, anxiety and somatization concluding:

From a strictly psychological perspective, although [NC] continues to report mild symptomatology, she does not present with any identifiable impairment as a direct result of her psychological symptoms. She does not, in my opinion meet criteria for a psychological diagnosis.

The Adjudicator found the Aviva’s evidence to be more compelling than that provided by NC. 

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.