Applicant shows treatment plans are reasonable and necessary - Applicant v travelers LAT 16-003313

January 24, 2018, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

Applicant v Travelers LAT 16-003313

Decision Date: December 8, 2017
Heard Before: Adjudicator Paul Gosio

ENTITLEMENT TO BENEFITS: treatments are reasonable and necessary

The applicant was injured in a CAR accident on June 30, 2016.  She was the front-seated passenger in a vehicle that rear-ended the car ahead of her while travelling on the highway. The windshield shattered and fragments of glass penetrated the left side of her face, wrist and arm.  She was transported to Sunnybrook Hospital.  She sustained the following injuries as a result of the motor vehicle accident: left wrist and thumb fracture; bilateral corneal abrasions; pain in her neck, back, abdomen, left shoulder, and right leg.

The applicant sought benefits pursuant to the SABs.  She submitted a Treatment and Assessment Plan dated August 5, 2016, in the amount of $3,811.27 for occupational therapy and assistive devices and a Treatment and Assessment Plan dated September 7, 2016, in the amount of $3,296.02 for assistive devices, which included an orthopaedic memory foam mattress.  Both treatment plans were recommended by an occupational therapist. 

On November 8, 2016, Travelers conducted an in-home occupational therapy assessment in order to determine if the treatment plans were reasonable and necessary.  The respondent partially approved the August 5, 2016 Treatment Plan in the amount of $1,856.19.  The partial denial was based on the lack of evidence relating the proposed goods and services to the subject accident.  The September 7, 2016 Treatment Plan was denied in its entirety for the same reason.

The applicant applied to the LAT.

Issue

1. The applicant seeks a determination from the LAT that the treatment plans in dispute are reasonable and necessary pursuant to s. 14 and s. 15 of the Schedule.

Result

1. The applicant has met her onus of establishing on a balance of probabilities that she is entitled to the unapproved portion of the Treatment and Assessment Plan dated August 5, 2017, and the Treatment and Assessment Plan dated September 7, 2016, are reasonable and necessary.

Section 14 and 15 of the Schedule provides that an insurer is only liable to pay for medical expenses that are reasonable and necessary.  The applicant bears the onus of proving on a balance of probabilities that the treatment plan is reasonable and necessary.

The Arbitrator reviewed the evidence and the law. Based on the medical evidence of the injuries and the results of the assessments the Arbitrator determined that the benefits applied for 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.