Treatments Reasonable and Necessary - MZ and Royal - 16-002126 v Royal

October 20, 2017, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

MZ and Royal - 16-002126 v Royal 2017 CanLII 59509 (ON LAT)

Date:     2017-08-22
Heard Before: Adjudicator Khizer Anwar

ENTITLEMENT TO BENEFITS: Applicant shows that treatments are reasonable and necessary for full recovery

MZ was injured in a car accident on September 2, 2011 and sought benefits from her Royal pursuant to the SABs. MZ submitted three treatment and assessment plans (OCF-18) to Royal, requesting funding for physiotherapy/chiropractic services, psychological services and a vocational assessment. Royal denied funding for chiropractic services and vocational assessment, as it deemed the requests to be not reasonable and necessary. Royal provided partial funding to MZ to obtain psychological services. MZ disagreed submitted an application for dispute resolution services to the LAT.

Issues:

1. Is MZ entitled to a medical benefit in the amount of $1,647.00, for physiotherapy and chiropractic services, as outlined in the Treatment and Assessment plan (OCF-18) dated June 4, 2015,?
2. Is MZ entitled to a medical benefit in the amount of $1,046.34 ($3,571.88 less $2,525.54 – partially approved), for psychological services, as outlined in the Treatment and Assessment plan (OCF-18) dated August 18, 2015?
3. Is MZ entitled to a cost of examination incurred in the amount of $1,496.25, for a vocational assessment, as outlined in the Treatment and Assessment plan (OCF-18) dated October 29, 2015?
4. Is MZ entitled to interest on overdue payment of benefits?

RESULT

1. MZ is entitled to the medical benefit in the amount of $1,647.00.
2. MZ is entitled to the medical benefit in the amount of $1,046.34.
3. MZ is entitled to the cost of examination in the amount of $1,496.25.
4. MZ is entitled to interest on overdue payments on above-noted benefits.

The Adjudicator reviewed MZ’s accident related injuries and medical evidence.  MZ started visiting her family doctor in relation to the accident related injuries a few days after the accident, and as Dr.’s CNRs, continued to do so until 2016. During the first visit MZ’s injuries were noted to be: 1) mild tenderness at neck and neck pain; 2) back pain and mild tenderness at L5-S1; 3) dizziness; 4) headaches; and 5) mood changes. The Doctor made no further recommendations at that time.

MZ submits that her accident related injuries gradually deteriorated and she started visiting the Doctor in relation to sciatica pain from August 2012 onward. MZ underwent a CT scan in October 2012, which revealed that MZ suffered from degenerative disc disease in her lumbar spine, specifically at L3-L4, L4-L5 and L5-S1, and noticeable disc herniation at L5-S1 with possible S1 nerve root compression. Based on the results of the CT scan, MZ was referred to a neurologist, rheumatologist and an orthopaedic surgeon.

A neurologist, confirmed the findings of the CT scan and diagnosed MZ with “S1 left radiculopathy”. Dr. Wong’s recommendations included: 1) MRI of the lumbar spine; 2) specific neurophysiotherapy; and 3) neuropathic pain medicine, on an as needed basis.

Upon examination a rheumatologist found MZ to be suffering from: 1) decreased left ankle reflex compared to the right; 2) tenderness in L4-5 region; and 3) decreased lumbosacral range of motion with paraspinal muscle spasm. These findings were consistent with left-sided sciatica with possible herniated disc L5-S1 and S1 root compression. Recommendations included pelvic traction, intensive lumbar stretching exercises and paying attention to lumbar support.  The MRI results further corroborated the findings of the CT scan and reaffirmed these.

An orthopaedic surgeon, confirmed all the findings noted above. After examining MZ  potential treatment options for MZ included surgery, a left sided L5-S1 posterolateral decompression and discotomy, which after deliberation, MZ refused with an intention to focus on non-surgical rehabilitation.

Royal denied treatments to MZ based on the opinions of its assessors. Royal submits that MZ suffered uncomplicated soft tissue injuries; and a significant time lapse between MZ’s complaints and the accident served as evidence that MZ’s injuries were unrelated to the accident.

The Adjudicator considered the reasonableness and necessity of each disputed treatment and assessment plan based on the medical evidence The Adjudicator accepted MZ’s position that pain relief is a legitimate medical and rehabilitative goal. The results of the CT scan and MRI are objective, unequivocal and clear. Based on the objective evidence and the corroborating medical opinions of the three medical practitioners discussed in paragraphs 21, 22 and 24, the treatment plan in dispute in the amount of $1,647.00 is reasonable and necessary.

Regarding the treatment Plan # 2: For psychological services in the amount of $1,046.34, the Adjudicator found that MZ has met her onus and accept that she would benefit from comprehensive psychological treatment. Therefore, the treatment plan in dispute to be reasonable and necessary in its proposed form.

Regarding treatment Plan # 3: For vocational assessment in the amount of $1,496.25 the Adjudicator found that the treatment plan is necessary to assist MZ in evaluating her current limitations as they pertain to nursing school and potential career as a nurse. Therefore, this treatment plan is reasonable as well as 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.