Treatments Are Not Shown Proven Reasonable or Necessary - K. K. v Aviva Insurance LAT 16-000863

August 23, 2017, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

K. K. v Aviva Insurance         LAT 16-000863

Date of Decision: June 28, 2017
Heard Before: Adjudicator Catherine Bickley

Entitlement to Treatment: Applicant fails to prove treatments is reasonable or necessary

KK was injured in a car accident on October 20, 2015.   She sought benefits pursuant to the provisions of the SABS, however when Aviva denied of three treatment plans KK applied to the LAT.

Issues:

1. Is KK entitled to a medical benefit in the amount of $1,494.50 for physiotherapy denied on May 10, 2016?
2. Is KK entitled to a medical benefit in the amount of $3,652.00 for chiropractic treatment and massage denied on January 26, 2016?
3. Is KK entitled to a medical benefit in the amount of $200.00 for physiotherapy recommended denied on February 3, 2016?
4. Is KK entitled to the cost of an orthopedic assessment in the amount of $2,570.00 denied on July 28, 2016?

RESULT

1. KK is not entitled to a medical benefit in the amount of $1,494.50
2. KK is not entitled to a medical benefit in the amount of $3,652.00
3. KK is entitled to a medical benefit in the amount of $200.00 plus interest for physiotherapy recommended.
4. KK is not entitled to the cost of an orthopedic assessment.

The focus of KK’s submissions is on establishing that she should not be in the Minor Injury Guideline (“MIG”).  Aviva concedes that KK has been removed from the MIG but takes the position that all KK’s physical injuries are minor in nature, i.e., soft tissue sprains and strains.  It submits that there is no objective orthopedic evidence to support ongoing passive therapy such as physiotherapy, chiropractic and massage therapy. Based on the medical imaging evidence submitted by the parties the Arbitrator agreed. 

KK also relies on the diagnoses of chronic pain syndrome and pain disorder which she submits is  pain and discomfort in her right shoulder, right arm and wrist, her neck, her upper and lower back.  She also has headaches. KK’s family doctor’s clinical notes and records demonstrate continued complaints of pain, variously in KK’s right shoulder, back, flank, lumbar region and legs.

The parties agree that KK has psychological issues, although they disagree about the severity of those issues.  In any event, the treatment plans in dispute in this application are for the treatment and assessment of her physical issues. Based on the evidence the Arbitrator concluded that KK has not established a connection between her possible chronic pain and the treatment plans in dispute in this application.  Her focus on chronic pain have been, as noted above, directed at arguing that she should be removed from the MIG.

The Arbitrator found the treatment plans are not reasonable nor necessary because KK provided very little evidence to establish her entitlement to the treatment. Significantly, KK did not provide a copy of the treatment plans in issue. 

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.