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Insured failed to show that treatment was reasonable and necessary

July 18, 2015, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

Heard Before: Adjudicator Maggy Murray

Date of Decision: December 10, 2014

 

Sagal Ibrahim was injured in a car accident on October 21, 2010 when her vehicle was rear-ended while she was stopped at a red light.  Her injuries included pain in her neck, back and left wrist. She applied for and received statutory accident benefits from State Farm Mutual who subsequently terminated various benefits. Ms. Ibrahim applied for arbitration at the Financial Services Commission of Ontario after the parties were not able to resolve their dispute.

 

The issues in this hearing are:

 

  1. Is Ms. Ibrahim entitled to the following medical benefits, pursuant to s.15 of the Schedule, from Osler Rehabilitation Centre:

  2. $3,966.89 for a therapy and exercise treatment plan dated November 9, 2010

  3. $982.56 for a massage therapy treatment plan dated November 10, 2010

  4. $840 for an acupuncture treatment plan dated November 15,

  5. $1,978.09 for a therapy and exercise treatment plan dated December 31, 2010

  6. $591.28 for a massage therapy and education treatment plan dated January 5, 2011

  7. $996.54 for an exercise treatment plan dated January 10, 2011

  8. $456.73 for a TENS Unit treatment plan dated January 24, 2011

  9. $1,299.98 for therapy and exercise sessions in a treatment plan dated January 31, 2011

  10. $973.59 for an exercise treatment plan dated February 8, 2011

  11. Is Ms. Ibrahim entitled to interest for the overdue payment of benefits pursuant to section 51 of the Schedule?

3.     Is State Farm liable to pay a special award pursuant to subsection 282(10) of the Insurance Act because it unreasonably withheld or delayed payments to Ms. Ibrahim?

 

Result:

 

  1. Ms. Ibrahim’s claims for treatment from Osler Rehabilitation Centre are dismissed.

  2. Ms. Ibrahim is not entitled to interest.

  3. State Farm is not liable to pay a special award.

 

EVIDENCE AND ANALYSIS:

 

Ms. Ibrahim testified on her own behalf and called no other witnesses. It was Mrs. Ibrahim’s position that the treatment she received at Osler’s helped her. According to Mrs. Ibrahim, once her injuries fell outside the MIG, the cost of treatment up to $50,000 was payable

 

State Farm initially denied the treatment plans on the basis that Mrs. Ibrahim was within the Minor Injury Guideline (MIG), which limits medical and rehabilitation claims to $3,500 for minor injuries.  At the pre-hearing in this matter, State Farm advised her that it was no longer of the opinion that her injuries fell within the MIG. State Farm did not find the treatment plans reasonable or necessary.

 

The day after her accident Mrs. Ibrahim attended her family doctor who referred her for physiotherapy. She chose the clinic upon the recommendation of a friend.  At issue are nine treatment plans, authored over a period of 12 weeks.

 

The burden of proof rests with Ms. Ibrahim to show on a balance of probabilities that as a result of the car accident she is entitled to her claim for medical benefits pursuant to s.15 of the Schedule. For the following reasons, the Arbitrator found that Ms. Ibrahim has not met her burden of proof.

 

Ms. Ibrahim provided little evidence to support her claim. No clinical notes and records were not produced.  Ms. Ibrahim did not explain how the treatment “helped” her, what her level of functioning was before and after the accident, or how her functioning improved after a treatment session, or for what length of time after a treatment her functioning improved. None of the treatment plans were for therapies recommended to Mrs. Ibrahim by her treating physicians.

 

There was inadequate evidence produced to conclude how much treatment Ms. Ibrahim received, or whether that treatment was reasonable and necessary, because the Arbitrator could not rely on the invoice from treatment facility which contains numerous inconsistencies with other evidence and gave them no weight. A health care provider form the clinic appeared before the tribunal with no clinical notes and was not able to identify or recall Mrs. Ibrahim.

Posted under Accident Benefit News, Automobile Accident Benefits, Car Accidents, Chronic Pain, Fractures, Minor Injury Guidelines, Pain and Suffering, Pedestrian Accidents, Physical Therapy, Treatment

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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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