Applicant's Treatment Plans Do Not Show Treatment Reasonable and Necessary - Applicant v Pembridge LAT 17-000162

February 16, 2018, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

17-000162 v Pembridge Insurance Company, 2017 CanLII 81586 (ON LAT)

Decision Date: November 19, 2017
Heard Before: Adjudicator Gemma Harmison

ENTITLEMENT TO BENEFITS: applicant's treatment plans fail to show treatments are reasonable and necessary

The applicant was involved in a car accident on February 15, 2015. He was the driving on a highway when he was hit by a car changing lanes. This resulted in a second collision from the driver’s side. The applicant was able to get out of the car himself and declined the offer to be taken to hospital by ambulance. He went to a walk-in clinic on the next day where he reportedly was prescribed anti-inflammatory medication and was recommended to attend physiotherapy. He applied for SABs from Pembridge but when benefits were denied he applied to the LAT.

Issues:

1. Is the applicant entitled to receive a medical benefit in the amount of $1,096.41 for assistive devices, denied by Pembridge on October 6, 2015?
2. Is the applicant entitled to receive a medical benefit in the amount of $1,842.81 for chiropractic services, denied by Pembridge on August 24, 2016?
3. Is the applicant entitled to payment for the cost of examination in the amount of $2,000.00 for a social emotional assessment, denied by Pembridge on December 14, 2015?
4. Is the applicant entitled to payment for the cost of examination in the amount of $2,104.00 for an orthopaedic assessment, denied by Pembridge on June 27, 2016?
5. Is the applicant entitled to payment for the cost of examination in the amount of $2,152.00 for a functional ability assessment, denied by Pembridge on December 24, 2015?
6. Is the applicant entitled to payment for the cost of examination in the amount of $1,970.00 for a neurological assessment, denied by Pembridge on August 24, 2016?
7. Is the applicant entitled to payment for the cost of examination in the amount of $2,000.00 for a chronic pain assessment, denied by Pembridge on September 16, 2016?
8. Is the applicant entitled to receive interest on any overdue payment of benefits?
9. Is either party entitled to costs of the proceeding?

Result:

1. The applicant is not entitled to medical benefits for the OCF-18s relating to assistive devices and chiropractic services;
2. The applicant is not entitled to payment for any of the five OCF-18s relating to costs of examinations;
3. Since no benefits are ordered payable, the applicant is not entitled to interest;
4. Neither party is entitled to costs.

The onus rests with the applicant to prove, on a balance of probabilities, that each of the disputed OCF-18s is reasonable and necessary. The Arbitrator reviewed all of the treatment plans and the evidence and determined that the applicant failed to show that on the balance of probabilities the treatment plans were 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.