Applicant Provides No Supporting Medical Evidence - AM and State Farm Mutual Automobile Insurance LAT 16-003519 2018 CanLII 2307

April 04, 2018, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

AM and State Farm Mutual Automobile Insurance LAT 16-003519 2018 CanLII 2307

Date of Decision: January 9, 2018
Heard Before: Adjudicator Paul Gosio

ENTITLEMENT TO TREATMENT: applicant fails to show that treatment is reasonable and necessary; treatment denied; applicant provides no supporting medical evidence

AM was injured in a car accident on April 9, 2011 and as a result complained of temporomandibular joint pain.  AM sought benefits under the SABs for a Treatment and Assessment Plan dated April 9, 2013, in the amount of $1,750.00 for an adjustment to an existing myofascial appliance and a Treatment and Assessment Plan dated April 9, 2013, in the amount of $1,625.00 for an adjustment to natural dentition. Both treatment plans were recommended by a dentist.

On October 1, 2014, State Farm conducted a dental assessment in order to determine whether the April 9, 2013 treatment and assessment plans were reasonable and necessary. Based on the report generated from this assessment, State Farm concluded that the treatment plans were not reasonable and necessary.

On that basis AM applied to the LAT for Arbitration.

Issue

1. Is the April 9, 2013 treatment and assessment plans were reasonable and necessary pursuant to ss. 14 and 15 of the Schedule.

Result

1. AM has not met her onus of establishing on a balance of probabilities that she is entitled to the treatment and assessment plans dated April 9, 2013. They are not reasonable and necessary.

AM suggests that the treatment and assessment plans in dispute are reasonable and necessary as the dentist diagnosed AM with temporomandibular joint disorder. The adjustments to AM’s bite guard and bite plate would help alleviate this pain which has been ongoing since the date of the motor vehicle accident.

AM’s case is based entirely on counsel’s submissions, as no supporting medical evidence, such as clinical notes and records, medical reports, or even the treatment plans in dispute, was provided to the Tribunal. Submissions are not evidence.

Based on the lack of evidence from AM, and the IE from State Farm the Adjudicator found that the treatment and assessment plans dated April 9, 2013, are not reasonable and necessary as they are unlikely to improve AM’s TMJ pain which originated from a 2007 motor vehicle accident. Without any medical evidence from AM to the contrary. AM has not met her onus in establishing on a balance of probabilities that the treatment plans dated August 9, 2013, are reasonable and necessary.

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