Applicant Shows Treatments Are Reasonable and Necessary - Applicant v State Farm LAT 16-004375

January 31, 2018, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

Applicant v State Farm LAT 16-004375

Decision Date: December 8, 2017
Heard Before: Adjudicator Avvy Go

ENTITLEMENT TO BENEFITS: respondent selectively choses information from medical assessments; applicant makes case that treatments are reasonable and necessary

The applicant was injured in a car accident on September 17, 2014. He applied for SABs. Among the benefits the applicant initially sought from his insurer were a number of medical benefits as well as IRBs.

When these benefits were denied, the applicant applied to the LAT.

ISSUES

Is the applicant entitled to a medical benefit in the amount of $2,300.58 for physiotherapy as submitted on January 11, 2017?

Is the applicant entitled to a medical benefit in the amount of $2,520 for physiotherapy services as submitted on December 19, 2016?

Is the applicant entitled to a medical benefit in the amount of $6,610.50 for a Psycho-Vocational and Functional Abilities Evaluation as submitted on December 19, 2016?

Is the applicant entitled to a medical benefit in the amount of $1,728.75 for an in-home assessment by as submitted on December 13, 2016?

RESULT

1. The applicant is entitled to the medical benefit in the amount of $2,300.58 for physiotherapy services
2. The applicant is entitled to the medical benefit in the amount of $2,520 for physiotherapy services
3. The applicant is entitled to the medical benefit in the amount of up to $4,000.00 for a Psycho-Vocational and Functional Abilities Evaluation
4. The applicant is entitled to the medical benefit in the amount of $1,728.75 for an in-home assessment

ANALYSIS

The Schedule provides in part that the insurer shall pay for all “reasonable and necessary expenses” incurred by an insured person as a result of the accident for such services as medical, chiropractic, psychological, occupational therapy and physiotherapy services. This section will guide me in my analysis below.

The Arbitrator reviewed all the medical evidence and the law and determined that the medical evidence presented by the applicant was preferable, and that State Farm was not reasonable in its interpretation of the medical evidence.

The applicant has shown that the benefits requested are reasonable and necessary to recovery.

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.