Treatment Plan not shown reasonable or necessary - RR and Aviva - 16-001627 v Aviva

October 25, 2017, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

RR and Aviva - 16-001627 v Aviva Insurance, 2017 CanLII 56668 (ON LAT)

Date of Decision: August 10, 2017
Heard Before:  Adjudicator Chris Sewrattan

ENTITLEMENT TO BENEFITS: assitive devices not shown to be beneficial; psychological treatment plan approved

RR was driving a 2008 Hyundai Accent when she was struck by another vehicle on June 4, 2014. At the time of the accident RR was employed full-time as a flight attendant. She took time off between June 21 and the end of July 2014 due to injuries. She sought beneftis under the SABs but Aviva denied payment for some claims. RR appealed to the LAT. RR’s injuries fall outside the MIG. RR must prove the treatment and assessments she applied for are reasonable and necessary.

Issue:

1. Is RR entitled to receive a medical benefit in the amount of $1,627.20 for assistive devices, recommended in a treatment plan dated November 9, 2015?
2. Is RR entitled to receive a medical benefit in the amount of $1,819.30 for assistive devices, recommended in a treatment plan dated January 18, 2016?
3. Is RR entitled to payments for the cost of an examination in the amount of $2,065.00 for a psychological assessment recommended in a treatment plan dated June 25, 2015?
4. Is RR entitled to interest on undue payments?

Result:

1. RR is not entitled to payment for any assistive devices because she has not sufficiently proven that they are reasonable and necessary expenses.
2. RR is entitled to payment for the psychological assessment. She is also entitled to interest on this payment in accordance with the Schedule.

 Assistive Devices:

The Adjudicator reviewed the treatment plans submitted to Aviva for assistive devices by RR, and also the IE report.

In both treatment plans RR’s assessor recommended devices were required “Due to the significance of RR’s injuries, she has extreme difficulty pushing, pulling, bending, sitting for a period of over 20 minutes, standing from the sitting position. Client finds it almost impossible to complete everyday tasks such as getting dressed and eating. Assistive devices are being recommended to help assist in the clients [sic] recovery.”.

Aviva’s IE paper review found that the Treatment Plan was not reasonable or necessary. Aviva denied payment based on the report.

RR’s claim for each set of assistive devices is denied. The devices are not reasonable and necessary expenses. Suring her IE she reported being able to perform her child care, household chores, and working full-time, and feeling about 80% improved by the time of the examination. In RR’s Reply submissions, she denied that she is about 80% improved but did not deny that she reported this fact. Further she did not provide any evidence or explanation as to what may have changed since reporting she was 80% improved. RR notes her “lack of improvement” in her submissions not her evidence.  Her submissions note that she continues to still experience pain to date. However, the Adjudicator did not see how the assistive devices will assist RR with completing everyday tasks when she has seemingly been able to complete them since November 2015.

Based on the Adjudicator’s analysis of the medical reports, RR is entitled to payment for the psychological examination. It is reasonable and necessary that RR is given an opportunity to manage and mitigate her depression and anxiety issues. a psychological examination is needed to afford this opportunity.  Given the decision, interest shall be paid in relation to the psychological examination in accordance with the Schedule.

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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.