Applicant's Injuries Outside MIG but fails to show additional treatments are reasonable and necessary - Applicant v Wawanesa LAT 17-001083

January 22, 2018, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

Applicant v Wawanesa LAT 17-001083

Decision Date: December 15, 2017
Heard Before: Adjudicator Eleanor White

ENTITLEMENT TO BENEFITS: applicant fails to show that further treatment plans are reasonable and necessary

The applicant was involved in a car accident on December 11, 2014, and sought benefits pursuant to the SABs for medical benefits for assistive devices, and for both treatment and assessment of his injuries.  The applicant’s injuries arising from the accident were considered predominantly minor, as defined in the Schedule, and he received treatment outside the MIG because of his pre-accident medical history. Wawnesa determined that the various benefits included in the applican’s appeal to the Tribunal were not reasonable and necessary. 

Wawanesa found the information provided by the applicant was inconsistent and lacked credibility and the applicant’s claims for medical benefits were investigated and subsequently not approved.  

Issues:

1. Is the applicant entitled to a medical benefit in the amount of $1,819.32 for other assistive devices in a treatment plan dated January 5, 2016?
2. Is the applicant entitled to a medical benefit in the amount of $1,914.51 for other assistive devices in a treatment plan dated June 15, 2015?
3. Is the applicant entitled to a medical benefit in the amount of $5,450.00 for other assistive devices in a treatment plan dated October 29, 2015?
4. Is the applicant entitled to receive a medical benefit in the amount of $3,067.20 for chiropractic services in a treatment plan dated October 15, 2015?
5. Is the applicant entitled to a medical benefit in the amount of $2,486.49 for psychological services in a treatment plan dated May 16, 2016?
6. Is the applicant entitled to receive medical benefits in the amount of $5,450.00 for in-home physiotherapy services?
7. Is the applicant entitled to receive medical benefits in the amount of $3,427.53 for in-home physiotherapy services in a treatment plan dated August 25, 2016?
8. Is the applicant entitled to payments for the cost of examinations in the amount of $3,658.50 for an orthopedic assessment dated on June 30, 2015?
9. Is the applicant entitled to interest on the overdue amounts?

Results:

1. None of the Treatment Plans are reasonable and necessary.

On December 11, 2014, the applicant was involved in a rear-end motor vehicle accident while stopped at a stop sign.  His wife was also in the car.  No police or emergency personnel were summoned.   He drove his wife to work, then drove to the collision centre and finally had the car towed to a body shop.  He did not seek immediate medical attention.  He returned to his job at a pizza store on the following day and continued to work on a regular basis.

The applicant sought medical benefits from Wawnesa and was approved for $11,018.48 in physical and psychological services. The IE psychological assessor assessed the applicant, who denied any pre-existing psychological issues, and found the applicant’s symptoms significant and compelling enough to recommend exclusion from the confines of the MIG policy limit.  Wawnesa did so.

After the applicant incurred multiple treatment plans for physical and psychological services, Wawnesa denied further treatment plans.  The applicant attended various IEs and Wawnesa maintained its denial of these benefits.  As a result, the applicant appealed the denial to the Tribunal.

The Adjudicator reviewed the law. Under section 14 of the Schedule, an insurer is liable to pay the medical and rehabilitation to or on behalf of an insured person who sustains an impairment as a result of an accident.  The same section specifies that the medical benefits must be reasonable and necessary expenses incurred as a result of the accident.

Wawnesa raises the applicant’s credibility as an issue. The Adjudicator did not find credibility to be an impediment in determining the issues in dispute. The evidence was clear and consistent in that largely, the injuries arising from the accident were predominantly soft tissue in nature and quite likely related to older injuries in the lumbar spine. Before reviewing the Treatment Plans in dispute, the Adjudicator examined the accident and its effect on the applicant. 

Wawnesa decided to investigate the mechanism of the accident.  Some of the reported damage of the vehicle was not related to the accident. In this sort of accident, one would expect the nature of the injury to be commensurate with a low-speed, low-impact collision.

The Adjudicator reviewed the medical evidence and the injuries arising from the accident.  The applicant was diagnosed with primarily WAD I injuries.  In their diagnoses of the applicant’s injuries, the doctors assert that they are unaware of any pre-existing conditions. Additionally, the applicant denied any pre-accident psychological medications, treatments or issues during his IE psychological assessment.

The Arbitrator then reviewed the various treatment plans and determined that the applicant did not show that the treatment plans were reasonable and necessary. On that basis the claims are denied.

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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.