Family Holiday Does Not Meet Criteria for Rehab Expenses

March 30, 2017, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

F.V. v Wawanesa: Entitlement to Benefits; expenses fall outside of SABs; Family trip does not meet criteria for professional services rendered; SABs;

Date of Decision: January 30, 2017
Heard Before: Arbitrator Chloe Lester

F.V., was hurt in a car accident on October 25, 2010. When disputes arose between F.V. and Wawanesa about SABs benefits F.V. applied for dispute resolution services to the LAT.

Issues:

1. Is F.V. entitled to receive payment for a rehabilitation benefit in the amount of $2,019.59 a treatment plan dated September 3, 2015; denied by Wawanesa on December 17, 2015?
2. Is F.V. entitled to receive payment for a rehabilitation benefit in the amount of $1,779.58 for a treatment plan dated September 9, 2015; denied by Wawanesa on December 17, 2015?
3. Is F.V. entitled to receive payment for a medical benefit in the amount of $890.64 for a treatment plan dated November 3, 2015; denied by Wawanesa on December 17, 2015?
4. Is F.V. entitled to interest on any overdue payment of benefits?

Result:

1. F.V. is not entitled to receive payment for the rehabilitation benefits.
2.  F.V. is not entitled to interest.

F.V. was deemed catastrophically impaired following his accident. F.V. applied for rehabilitation benefits relating to expenses incurred during a trip to Florida and Disney Land with his daughter’s family and grandchildren.  These expenses included, but are not limited to, flights, accommodations, meals for the attendant and medical supplies. F.V.  claims he is entitled to the rehabilitation benefit as the trip was to “facilitate the person’s reintegration into his or her family”, as stated in section 16 of the Schedule and were reasonable and necessary to spend quality time with them.

Wawanesa denied the rehabilitation benefits on the basis that the expenses claimed did not fall within the scope of rehabilitation benefits and they were not reasonable and necessary.

Prior to the accident, F.V. and his daughter had talked about taking a trip to Florida. F.V. submitted that this trip was identified as one of his rehabilitative long term goals as it was only possible to achieve 5 years after the accident. The costs were incurred to ensure the safety and well-being of F.V, and he argued that this was possibly the only opportunity for him to enjoy a family vacation and to create these memories due to his declining health conditions.

The Arbitrator reviewed the law and determined that in order for a rehabilitation benefit to be payable under section 16 of the Schedule, the expenses must first fit within the definition of a rehabilitation benefit and secondly, be reasonable and necessary.  Many of the describe activities and measures in the Schedule refer to counselling, training, home, work or vehicle modifications or devices to assist the injured person to reduce or eliminate the effects of the disability or to facilitate the person’s reintegration into his or her family, the rest of society and the labour market.  It is not a “catch all” for any and all additional expenses that the insured person desires to be reimbursed for, but the expenses must relate to or fit within the scope of the activities and measures described in subsection 3.   They must be provided for by a professional and require a treatment goal or be a modification or device that accommodates the needs of the insured person.

Based on the evidence and facts, the Arbitrator did not find that these expenses are a payable benefit under section 16 of the Schedule.

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.