Applicant fails to Provide Treatment Plans to Show Treatments are Reasonable and Necessary - AH v Belair - 16-001063 v Belair

October 25, 2017, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

AH v Belair - 16-001063 v Belair Direct Insurance Company, 2017 CanLII 56675 (ON LAT)

Date of Decision: August 8, 2017
Heard Before:  Adjudicator Lori Marzinotto

ENTITLEMENT TO BENEFITS: entitlement to ACBs; OCF-18s not provided to LAT; individual treatment plans not addressed; insufficient evidence to prove treatments reasonable and necessary

AH was injured in a car accident on June 19, 2014, and he applied for benefits from Belair. AH was deemed catastrophically impaired on March 16, 2015. He suffered a significant injury to his left arm and specifically his left elbow which he described as “totally smashed”. He required several surgeries. He also required bone grafts, a total elbow arthroplasty and metal plates. His left arm is now four centimetres shorter and he is unable to straighten his arm and has no elbow pronation and supination. AH is right handed. Before the accident AH was a sales supervisor in a call centre. He returned to work in August 2014.

In addition to several medical benefits and assessment costs, AH sought entitlement to ACB.  Belair partially approved several treatment plans, denied others and paid ACB in the amount of $33,034.66 from July 2014 until December 18, 2015.  AH applied to the LAT for payment of the denied and/or partially approved treatment plans and as well as additional ACB.

Issues:

1. Is AH entitled to the following attendant care benefits:
   1. $3,000 per month from June 2014 to March 2015?
   2. $6,000 per month from March 2015 and ongoing?
2. Is AH entitled to the following medical benefits/treatment plans:
   1. a partially approved physiotherapy treatment plan submitted February 25, 2015 in the amount of $2,450 less $1,870.47?

(iv)a partially approved physiotherapy treatment plan submitted March 27, 2015 in the amount of $4,200.00 less $2,533.76?

(v)a partially approved physiotherapy treatment plan submitted June 23, 2015 in the amount of $4,200.00 less $2,165.95?

(vi)a partially approved physiotherapy treatment plan submitted June 23 in the amount of $4,200.00 less $2,165.94?

3. Is AH entitled to the following medical benefits/cost of Examinations:

1. an occupational therapy assessment outlined in a treatment plan submitted January 25, 2015 in the amount of $2,200.00?
2. an impairment assessment outlined in a treatment plan submitted November 04, 2015 in the amount of$1,988.64?
3. a physiatry assessment outlined in a treatment plan submitted December 04, 2015 in the amount of $2,000.00?
4. an assessment outlined in a partially approved treatment plan submitted October 30, 2014 in the amount $2,203.72 less $1,703.72?
5. the cost of a functional abilities evaluation outlined in a treatment plan submitted September 23, 2014 in the amount of$1,345.95?
6. an attendant care assessment outlined in a treatment plan submitted June 12, 2015 in the amount of $902.23?
7. an attendant care assessment outlined in a partially approved treatment plan submitted March 07, 2016 in the amount of $1,538.75 less $1,496.75?

4. Is AH entitled to interest on any overdue payments?

RESULT:

AH is not entitled to the following:

1. additional ACB from June 2014 – March 2015.
2. additional ACB from March 2015 to January 31, 2016.
3. payment of the balance of treatment plans listed as issues #2, 3, 4, 5, 6, 8, 11, 12, 16 and 19.
4. payment of the treatment plans listed as issues #7, 9, 14, 15 and 18.
5. payment of the treatment plan listed as issue #10.
6. the treatment plan listed as issue #13 is not properly before the Tribunal.
7. the treatment plan listed as issue #17 has been paid and therefore not an issue in dispute.

The Adjudicator reviewed the request for medical benefits and found that there was a general insufficiency of evidence that did not allow her to find for AH.  In order for treatment plans to be payable by the insurer, they must be reasonable and necessary according to section 18 of the Schedule.  AH did not individually address each treatment plan in dispute in the written submissions. AH submitted that based on medical evidence and several recommendations from medical practitioners in medical reports, that the recommended treatments in the Treatment and Assessment Plans (“OCF-18s”) are necessary.  The LAT had not been provided with any of the OCF-18s that are in dispute, and therefore the Adjudicator was unable to evaluate the recommended treatment with any treatment plans in order to assess whether they are reasonable and necessary and decline to order that they be paid.

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.