Treatment Plan Not Reasonable or Necessary - CL v Wawanesa - 16-002085

October 31, 2017, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

CL v Wawanesa - 16-002085 v Wawanesa Mutual Insurance, 2017 CanLII 56673 (ON LAT)

Date of Decision: August 14, 2017
Heard Before:  Adjudicator: Derek Grant

ENTITLEMENT TO BENEFITS: applicant fails to show that treatment plan is reasonable and necessary for her ailment

CL was injured in a car accident on June 28, 2014 and sought benefits from Wawanesa pursuant to the SABs. When a dispute arose with respect to the benefits and CL submitted an application to the LAT.

Issues:

1. Did CL sustain an impairment within the meaning of the Schedule as a result of the accident?

1. Is CL entitled to the following treatment plans:

•         $1,965.00 for physical therapy as detailed in a treatment plan dated November 17, 2014?

 •         $3,321.00 for chiropractic treatment as detailed in a treatment plan dated April 13, 2015?

•         $3,321.00 for chiropractic treatment by York Medical Centre, as detailed in a treatment plan dated August 13, 2015?

b.  Is C.L is entitled to the following cost of examination expenses:

• $2530.00 for a social work assessment as detailed in a treatment plan dated March 2, 2015?
• $265.00 for the preparation of a disability certificate submitted March 2, 2015?
• $265.00 for the preparation of a disability certificate by York Medical Centre dated July 9, 2014?
• $200.00 for the preparation of a disability certificate submitted September 21, 2015?

c.   Is CL entitled to interest on any overdue payment of benefits?

Result:

1. CL suffered an impairment within the meaning of the Schedule as a result of the accident.

b.   After reviewing the submissions and the evidence and for the reasons that follow, I none of the treatment plans for medical benefits or examination expenses to be reasonable or necessary.

c.   CL is not entitled to interest in accordance with s. 51 of the Schedule.

CL was in a car accident on June 28, 2014.  She went to the hospital and test results came back normal.  The physician at the emergency department recommended physical therapy.  On July 8, 2014, she started physical therapy.  On July 22, 2014, CL saw her family physician who sent her for x-rays and advised her to stay off work for one week.

CL claims she sustained impairment to her neck and back and her pre-existing sciatica was aggravated by the accident.  Consequently, CL argues that the treatment plans for chiropractic treatment and physical therapy are reasonable and necessary to treat her accident related injuries.  CL submits that the social work assessment is necessary for the purposes of determining whether or not a self-managed home treatment plan would be appropriate.  CL contends that the disability certificates are reasonable and necessary as nature of her injuries have changed over time, requiring new disability certificates.

Wawanesa argues that CL’s neck and back impairments were not as a result of the accident, and the treatment plans are not reasonable and necessary.  They argue she had reached maximum medical recovery from facility based treatment.  Wawanesa submits that the social work assessment is not reasonable and necessary on the basis that re-integration into CL’s life is not required, which is the purpose of the assessment.  Regarding the disability certificates, Wawanesa stated that no new disability certificates had been requested, therefore the expenses were not payable.

The Adjudicator reviewed the law and the evidence in the case in order to determine whether CL’s impairments resulted from the accident. If they do, then he must determine if the treatment plans and assessments in dispute and the cost of completion of the disability certificates are reasonable and necessary.

CL bears the onus to prove on a balance of probabilities that her impairments are as a result of the accident. She also bears the burden of proving that the benefits claimed are reasonable and necessary.

The evidence CL provided showed that CL’s neck and back injuries are a result of the accident. While her pre-accident clinical notes and records from 2011 to 2013 indicate that she suffered from headaches, neck pain and depression, the post-accident records of her family doctor confirm that she was prescribed stronger nerve pain medication after the accident.  In addition, the records show that CL suffered from right-sided sciatica, which had resolved prior to the accident. The medical practitioners and assessors agreed that CL suffered predominantly soft tissue injuries as a result of the accident and an exacerbation of her pre-existing psychological impairments.

The Adjudicator found that CL is not entitled to the medical benefit because she has not met her onus in proving entitlement to physical treatment.  Based on the evidence she would benefit from psychological treatment.  The medical records demonstrate that CL’s psychological issues act as the catalyst to CL’s recovery, which is not addressed through the recommended physical treatment plans in dispute.

CL argued that her psychological and pre-existing impairments are the main basis for why she is not able to successfully complete a home-based, self-directed exercise program.  However, there was no evidence submitted to support this.  CL relied on the treatment plans for physical therapy to support her ongoing need for treatment.

Wawanesa submits that the treatment plans in dispute are for physical treatment and not psychological treatment, and therefore are not 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.