Housing Needs Assessment Subject to SABs $2000 limit - 17-006934 RG v State Farm Insurance, 2019 CanLII 18340 (ON LAT)

May 03, 2019, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

17-006934 RG v State Farm Insurance, 2019 CanLII 18340 (ON LAT)

Date:   2019-01-20
Heard Before: Paul Gosio, Adjudicator

SABs - payment for assessments capped; are home renovations for accessibility and alternative housing assessments subject to $2000 cap placed on assessments and examinations; is a housing assessment considered a treatment plan under the SABs;


The parties have asked LAT to decide whether home accessibility and alternative housing assessments are subject to the $2,000.00 cap placed on assessments and examinations under Schedule. RG was involved in a car accident on January 17, 2009, and she was deemed to be catastrophically impaired by State Farm in February 2012.

RGs treating occupational therapist submitted a Treatment Plan in the amount of $8,381.20 for the completion of an analysis and report identifying: the home modifications that would be necessary to accommodate RG’s injuries, the cost of the home modifications and an opinion as to whether those home modifications could be made by renovating RG’s existing home.

State Farm informed RG that the home accessibility Treatment Plan was partially approved up to the $2,000.00 limit under the 2010 Schedule as well as Superintendent’s Guideline 08/10.

RG had a home accessibility assessment and report completed by Adapt-Able. The report concluded that the required home modifications would not be possible through renovating RG’s existing residence. As a result, a further Treatment Plan was submitted by RG’s treating occupational therapist in the amount of $5,002.50 for the completion of an alternate housing assessment and report.

State Farm notified RG that the alternate housing Treatment Plan was denied in full as it was a duplication of the home accessibility Treatment Plan previously submitted and already partially approved up to the maximum allowed.

RG disagrees with State Farm’s position and argues that the home accessibility and alternative housing assessments submitted are not subject to the $2,000.00 cap placed on assessments and examinations pursuant to Section 25(5)(a) of the 2010 Schedule.

ISSUE

  1. Are the home accessibility and alternative housing assessments subject to the $2,000.00 cap placed on assessments and examinations under section 25(5)(a) of the 2010 Schedule[2].

RESULT

  1. The home accessibility and alternative housing assessments sought by RG are subject to the $2,000.00 cap placed on assessments and examinations pursuant to Section 25(5)(a) of the 2010 Schedule.

ANALYSIS

The parties are in agreement that RG applied for a home modification benefit pursuant to Section 25 of the SABs, and that section 25 governs the costs of the examinations sought by RG.  Section 25 must be read in conjunction with Superintendent’s Guideline 08/10. Section 25 clearly states that:

(5) Despite any other provision of this Regulation an insurer shall not pay,

(a) more than a total of $2,000 in respect of fees and expenses for conducting any one assessment or examination and for preparing reports in connection with it, whether it is conducted at the instance of the insured person or the insurer

SG08/10 makes further note that fees and expenses for conducting any one assessment includes all costs fees etc. incurred by or on behalf of the health care provider who conducted the assessment or examination.

RG submits that SG08/10 clarifies that when section 25(5)(a) of the 2010 Schedule refers to “any assessment or examination”, it means a medical assessment or evaluation performed by a health care practitioner in a medical context.  Furthermore, to fall under section 25(5)(a) of the 2010 Schedule, the assessment or examination must be a “clinical evaluation or appraisal of a claimant’s health status”.

RG submits that no one from Adapt Able is a health practitioner, that there is no assessment of RG’s health status in a clinical setting by anyone from Adapt-Able and that Adapt-Able does not assess RG’s health status or medically evaluate her in any manner. As such, RG submits that each treatment plan in dispute is not subject to the $2,000.00 cap placed on assessments and examinations under section 25(5)(a) of the 2010 Schedule.

State Farm submits that a housing assessment is, by its very nature, an appraisal of RG’s health status and that the author of both treatment plans in dispute is an occupational therapist. As such, State Farm submits that each treatment plan in dispute is subject to the $2,000.00 cap placed on assessments and examinations under 25(5)(a) of the 2010 Schedule.

The Adjudicator found that section 25(5)(a) of the 2010 Schedule is clear in its language. It places a $2,000.00 cap on the fees and expenses charged for conducting any one assessment or examination and for preparing reports in connection with it. The assessments in dispute in this case fall within the definition of an “assessment” and “examination” under SG08/10. The Treatment Plan’s in question were submitted by RG’s occupational therapist. The Treatment Plans recommended the services of Adapt-Able. Adapt-Able made recommendations with respect to the home modifications that would be necessary to accommodate RG. Adapt-Able’s recommendations were based on: the medical information provided to it, a meeting with RG, a home site visit, consultation with treating rehabilitation professionals and an investigation of zoning restrictions for the property. I find that this, by its very nature, involves an appraisal of RG’s health status.

The Adjudicator was not persuaded by RG’s submission that SG08/10 clarifies that when section 25(5)(a) of the 2010 Schedule refers to “any assessment or examination”, it means a medical assessment or evaluation performed by a health care practitioner in a medical context. This position is not supported by a plain reading of section 25(5)(a) of the 2010 Schedule or SG08/10.

CONCLUSION

The home accessibility and alternative housing assessments sought by RG are each subject to the $2,000.00 cap placed on assessments and examinations pursuant to Section 25(5)(a) of the 2010 Schedule.

Posted under Accident Benefit News, LAT Decisions

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