Applicant's Complaints Consistently Show Need for Psychiatric Assessment - Applicant and Tradition Mutual LAT 17-002734

March 22, 2018, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

Applicant and Tradition Mutual LAT 17-002734  

Date of Decision: January 12, 2018
Heard Before: Adjudicator Brian Norris

PAYMENT FOR EXAMINATIONS: Applicant’s information more persuasive; applicant has consistently shown need for psychiatric treatment; treatment plan is reasonable and necessary

The applicant was injured in a car accident on March 13, 2014 and sought benefits from Tradition Mutual pursuant to the SABs, but when the insurer refused to pay some benefits the applicant applied to the SABs for arbitration.

Issues:

1. Is the applicant entitled to receive payment for the cost of examinations in the amount of $1,995.33 for a psychological assessment in a treatment plan submitted August 24, 2015?
2. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

1. The psychological assessment is reasonable and necessary as a result of the applicant’s accident on March 13, 2014. The applicant is entitled to interest.

On March 13, 2014, the applicant lost control of the SUV they were driving and hit a curb, causing the vehicle to roll over onto the roof. The applicant was transported via ambulance to St. Mary’s Hospital in Kitchener and was diagnosed with a minor head injury and soft tissue injuries and discharged the same day. The applicant returned to the hospital less than two days later with on-going complaints of headaches, sleep disturbance, anxiety, and difficulty concentrating.

The Adjudicator noted that entitlement to payment for the cost of examinations is governed by the Schedule which establishes that an insurer shall pay for reasonable fees charged by a health care practitioner for reviewing and approving a treatment and assessment plan.

The applicant submits that they are entitled to payment for a psychological assessment on the basis of fairness, because Tradition Mutual had an opportunity to perform a psychological assessment and the applicant should have the right to respond to Tradition Mutual’s position. The applicant relies on Certas Direct Insurance Company v. Gonsalves, 2011 ONSC 3986 (as precedent dictating that a party ought to have an opportunity to respond to the opposing party’s evidence.

The Adjudicator found that this matter is distinguishable from Gonsalves because this matter does not involve the timely production of documents or arguments. In Gonsalves, the applicant’s assessment reports were delivered to the insurer shortly before a hearing, leaving virtually no time for the insurer to obtain an independent opinion on the applicant’s fresh evidence.

In this matter, the applicant is requesting funding to obtain an opinion on the applicant’s injuries – not additional time to obtain the opinion. Regardless, on the merits of this application does not turn on the procedural fairness submissions.

Based on the totality of the evidence the Adjudicator found that the psychological assessment is necessary to determine the level of the applicant’s psychological impairment and what, if any, psychological treatment the applicant requires. The applicant’s evidence was more compelling with self-reported symptoms consistent throughout the applicant’s evidence. They are indicative of a psychological injury. The fact that the applicant had been prescribed antidepressants on more than one occasion by more than one health practitioner is also indicative of a psychological injury which would support further investigation and, possibly, treatment. The Adjudicator found that the applicant’s family physicians are qualified to render a diagnosis of a psychological injury

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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.