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.

Issues:

  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?

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 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

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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 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
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  4. Catastrophic injury
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  7. Chronic pain
  8. Truck accidents
  9. Amputation and disfigurement
  10. Fibromyalgia
  11. Nursing Home Fatality Claims

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