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Applicant shows treatment reasonable and necessary - Applicant v Unifund LAT 16-002346

February 06, 2018, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

16-002346 v Unifund

Decision Date: November 22, 2017
Heard Before:  Adjudicator Paul Gosio

ENTITLEMENT TO TREATMENT: Applicant satisfies Arbitrator that treatments are reasonable and necessary


The applicant was injured in a car accident on January 19, 2016. He was 25 years old at the time, and was driving on the highway when a car struck the passenger side of his vehicle causing him to hit the centre divider. When Unifund denied claims for benefits pursuant to the SABs the applicant applied to the LAT.

Issues:

  1. Is the applicant entitled to receive a medical benefit in the amount of $3,129.48 for psychological treatment in a treatment plan dated June 27, 2016 and denied on August 18, 2016?
  2. Is the applicant entitled to receive a medical benefit in the amount of $350.10 for medical services in a treatment plan dated May 30, 2016 and denied on June 10, 2016?
  3. Is the applicant entitled to payments for the cost of examinations in the amount of $2,200.00 for a psychological in a treatment plan dated April 20, 2016 and denied on July 12, 2016?
  4. Is Unifund liable to pay an award under regulation 664 because it unreasonably withheld or delayed payments to the applicant?
  5. Is the applicant entitled to interest on any overdue payment of benefits?

Result:

  1. The applicant is entitled to a payment in the amount of $3,129.48 for psychological treatment.
  2. The applicant is entitled to receive a payment in the amount of $350.10 for medical services.
  3. The applicant is entitled to a payment in the amount of $2,200.00 for a psychological assessment.
  4. Unifund is not liable to pay an award under regulation 664 to the applicant.

The applicant was a part time student at the time of the accident. He drove a taxi in November and December 2015 at a rate of approximately 20 hours per week but stopped so he could attend college.

Following the accident on January 22, 2016,  the applicant went to see his family Doctor who noted the following: “post mva…hit head, no loss of consciousness, bruising now present, pain head, had headache, no n/v, no dizziness.”  He also noted that the applicant looked tired/anxious, decreased neck and recommended Tylenol and reassurance physio.  On February 22, 2016, an initial Disability Certificate (OCF-3) was submitted by Dr. S (Family Physician) who noted the following injuries and impairments as a direct result of the motor vehicle accident: whiplash neck, PTSD, headaches, and lower back pain.  A subsequent Disability Certificate (OCF-3) was submitted by Dr. S on May 30, 2016, wherein he noted the following injuries and impairments as a direct result of the motor vehicle accident: neck pain/whiplash, PTSD/Anxiety, headaches, and lower back pain. Dr. S then recommends a psychiatrist.

The Arbitrator reviewed two psychological assessment/reports before.  One is from Dr. P, the psychologist who submitted the treatment plan for psychological services.  The other is from Dr. K (which included an addendum), a psychologist retained by Unifund to conduct an independent medical examination in relation to the applicants request for benefits.

Upon review of the assessments the Arbitrator determined that he preferred the evidence of Dr. P and concluded that the applicant has met his onus in establishing that the psychological assessment and corresponding treatment is reasonable and necessary.

Posted under Accident Benefit News, LAT Case, LAT Decisions, Minor Injury Guidelines

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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 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.

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  10. Fibromyalgia
  11. Nursing Home Fatality Claims

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