Applicant does not provide persuasive evidence addressing treatment and assessments to be reasonable or necessary - JR and Certas - 16-003921 v Certas Home and Auto Insurance Company, 2017 CanLII 5950

October 26, 2017, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

JR and Certas - 16-003921 v Certas Home and Auto Insurance Company, 2017 CanLII 59503 (ON LAT)

Date: August 15, 2017
Heard Before:  Adjudicator Cezary Paluch, Member

ENITITLEMENT TO BENEFITS: evidence does not show treatment or assessments are reasonable or necessary

JR was injured in car accident on July 12, 2013 and sought benefits from Certas. JR applied to LAT for dispute resolution services when claims were denied.  

Issues:

1. Is JR entitled to payment in the amount of $9,464.40 in respect of chronic pain treatment as recommended in a treatment plan dated January 30, 2015?
2. Is JR entitled to the payment in the amount of $1,312.63 for physiotherapy treatment as recommended in a treatment plan dated September 8, 2015?
3. Is JR entitled to the payment for a chronic pain assessment in the amount of $1,800.00?
4. Is JR entitled to interest for any overdue payment of benefits?

RESULT:

1. JR is not entitled to a treatment plan for chronic pain treatment in the amount of $9,464.40.
2. JR is not entitled to a treatment plan for physiotherapy treatment in the amount of $1,312.63.
3. JR’s failure to submit a Treatment and Assessment Plan (OCF-18) disentitles him to payment for a chronic pain assessment in the amount of $1,800.00.
4. JR is not entitled to interest.

The Adjudicator reviewed the law and noted that Sections 14 and 15 of the Schedule requires the respondent to pay for medical benefits to or on behalf of JR so long as JR sustained an impairment as a result of the accident; and the medical benefits are a reasonable and necessary expense incurred by JR as a result of the accident.

The only issue in dispute with respect to the two treatment plans is whether they are reasonable and necessary. Findings of impairment or causation issues have not been raised by the respondent and they are not contested in this hearing.

JR seeks payment for medical and rehabilitation benefits for physical rehabilitation and chronic pain treatment. It is well accepted that relief of pain is itself a legitimate goal of treatment. However, the proposed treatment must still be “reasonable and necessary.”

Taking the medical evidence as a whole, the Adjudicator found that there is a lack of information and insufficient evidence to conclude that the two treatment plans are reasonable and necessary from which JR suffers. The medical evidence supports the conclusion that JR has made significant progress in his recovery and reached maximum medical improvement.

JR bears the onus of proving his entitlement to a specific benefit that he is claiming on a balance of probabilities.  In this case, JR simply submits that he is entitled to this treatment plan for the purpose of reducing pain or eliminating the effects of JR’s injuries and to facilitate JR’s re-integration into the labour market.  He also submits that the medical evidence supports that the assessment is reasonable and necessary.  However, he has not stated what specific medical evidence he is relying upon that comes to this conclusion. His submissions or evidence are not persuasive. He has not addressed whether the assessment is 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.