Medical Reports Fail to Make Case the Treatments are Reasonable and Necessary - Applicant and Co-operators - 16-003564 v The Co-operators

October 20, 2017, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

Applicant and Co-operators - 16-003564 v The Co-operators General Insurance Company, 2017 CanLII 62159 (ON LAT)

Date of Decision: August 25, 2017
Heard Before: Adjudicator Lori Marzinotto

ENITLTEMENT TO TREATMENT: applicant fails to prove treatment reasonable and necessary


The Applicant was involved in a car accident on June 19, 2014, and sought medical and rehab benefits benefits pursuant to the SABs. Co-operators denied the benefits and the Applicant appealed to the LAT.

Issue:

  1. Is The Applicant entitled to a medical benefit in the amount of $698.83 for psychological services recommended in a treatment dated November 13, 2015?

RESULT

  1. The Applicant is not entitled to the proposed treatment plan.

The Adjudicator reviewed the law. He noted that the Schedule provides that an insurer is liable to pay for all reasonable and necessary medical and rehabilitation expenses that are incurred. The Applicant bears the onus of proving on a balance of probabilities that the treatment plan is reasonable and necessary.

The Adjudicator then reviewed The Applicant’s evidence. The Adjudicator agreed with Co-operator’s position that the “Documentation, Support Activity” fee has not been explained in the Applicant’s submission.  Contrary to what is stated in the Affidavit of Mr. S, Dr. M’s letter does not indicate that this fee is for drafting the Progress Evaluation report.  If this fee was meant to be for the 4 Progress Evaluations, I would have expected a claim for 4 progress evaluation reports.

The Applicant has not met his onus and therefor the outstanding amount of $250 of the OCF-18 is not payable.

The Adjudicator reviewed the claim for 3 progress evaluations. The Applicant submits that the 3 denied Progress Evaluations are reasonable and necessary because they allow a psychologist to see if the techniques being used are improving the patient’s recovery. While the Adjudicator agreed that this supports why progress reports are required, the referenced OPA Guideline in Dr. M’s Letter does not provide the evidence to support a finding that 3 additional Progress Evaluations are reasonable and necessary.

Posted under Accident Benefit News, Automobile Accident Benefits, Car Accidents, LAT Case, LAT Decisions

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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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