Applicant Fails to provide a treatment plan, and fails to show others are reasonable and necessary - JR and Certas Home and Auto Insurance Company, 2017 CanLII 59503 ON LAT 16-003921

June 11, 2018, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

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

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

RECONSIDERATION OF DENIAL OF MEDICAL BENEFTIS: the applicant failed to provide a treatment plan; the applicant failed to show that the treatment plans provided were reasonable and necessary

JR was injured in car accident on July 12, 2013 and sought benefits from Certas pursuant to the Schedule. When the parties were unable to resolve disputes over benefits JR applied to the LAT.


  1. Is JR entitled to payment in the amount of $9,464.40 in respect of chronic pain treatment 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 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?


  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 Schedule requires the respondent to pay for medical benefits to or on behalf of JR so long as the benefits are reasonable and necessary. The onus is on JR to make his case.

The Adjudicator reviewed the evidence and noted that it is well accepted that relief of pain is itself a legitimate goal of treatment, even if the pain relief is not designed to promote recovery or lead to lasting improvement.  From the medical evidence in this case the relief of, and managing pain and maintaining current level of functioning appears to be the primary goal of the disputed treatment plans.  However, the proposed treatment must still be “reasonable and necessary.” The Adjudicator determined that JR provided 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 failed to submit a treatment plan for the chronic pain assessment.

On this basis the Adjudicator found the treatment plans of January 30, 2015 and September 8, 2015 are not reasonable or necessary.

Posted under Accident Benefit News, Automobile Accident Benefits, Car Accidents, LAT Case, LAT Decisions, Personal Injury, Physical Therapy, Treatment

View All Posts

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 or call us toll-free at 1-866-414-4878.

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.

Practice Areas

  1. Car accidents
  2. Motorcycle accidents
  3. Automobile accident benefits
  4. Catastrophic injury
  5. Brain or Head injury
  6. Paraplegia and Quadriplegia
  7. Spinal cord injury
  8. Drunk driving accidents
  9. Concussion syndrome
  10. Post Traumatic Stress Disorder
  11. Business Interruption Insurance
  12. Birth Trauma Injury
  1. Wrongful death
  2. Bicycle accidents
  3. Disability insurance claims
  4. Slip and fall injury
  5. Fractures or broken bone injury
  6. Pedestrian accidents
  7. Chronic pain
  8. Truck accidents
  9. Amputation and disfigurement
  10. Fibromyalgia
  11. Nursing Home Fatality Claims

Personal Injury Blog

Jul 02, 2020
Have you been hurt in a cycling accident? Did a car hit you or cause you to fall? You may be eligible for compensation.
Jun 30, 2020
81% of COVID-19 deaths in Canada were in long-term care – nearly double OECD average
Jun 25, 2020
Concepts of Legal Liability and Responsibility Have Not Adequately Kept Pace With Technological Advances
Jun 23, 2020
Ontario Government Agrees Drivers Should Get Auto Insurance Rebates According to Internal Memo
Jun 18, 2020
It’s no cup of tea – but spilling hot tea in the car is not considered a car accident in this case - M.P. v Allstate Insurance Company of Canada, 2020 CanLII 30398 (ON LAT)
Jun 18, 2020
Two recent child drownings highlight importance of water safety

More Personal Injury Articles » 
Review our services

Connect with us

Facebook Twitter Linkedin Youtube Google