Tribunal finds that benefits sought for four treatment plans are not reasonable or necessary
In a recent personal injury claim, the Ontario License Appeal Tribunal has opted to give little weight to a disability certificate issued by the applicant’s physiotherapist, whom the tribunal found was unqualified to diagnose the injuries.
In Desir v Certas Home and Auto Insurance, 2021 CanLII 2049 (ON LAT), the applicant was seeking benefits under the Statutory Accident Benefits Schedule, due to his involvement in a motor vehicle accident in April 2018. He specifically asked for medical benefits for physiotherapy services under a November 2018 treatment plan, for medical services under an April 2019 plan, for attendant care assessment and in-home assessment under a November 2018 plan and for a mental health or psychological assessment under a December 2018 plan.
The respondent insurance company determined that the applicant’s injuries were minor injuries under s. 3(1) of the Schedule, falling within the Minor Injury Guideline. The respondent submitted and the applicant did not dispute that, of the limit under the guideline, $82.25 remains unexpended. The respondent contended that the treatment plans proposed by the applicant were not reasonable and necessary.Upon an application to the Licence Appeal Tribunal - Automobile Accident Benefits Service, the tribunal found that the applicant’s injuries were predominantly minor injuries under the Schedule and subject to the $3,500.00 funding limit under s. 18(1) of the Schedule. The applicant was not entitled to the disputed balance of the physiotherapy treatment plan or the three other treatment plans, the tribunal said.
The tribunal found that, based on the weight of the medical evidence, all of the applicant’s injuries should be considered minor injuries. The applicant experienced knee pain, showed no obvious deformity on his knee, remained ambulatory and was discharged with a prescription for pain medication. While doctors subsequently diagnosed the applicant with lower back pain, the medical reports did not mention any accident-related injuries.
The tribunal accorded little weight to the disability certificate that described the applicant’s injuries as sprains, strains, headache, sleep disorders and other anxiety disorders because the certificate was issued by the applicant’s physiotherapist, who was not qualified to diagnose these injuries.The tribunal rejected the applicant’s contention that his pre-existing medical condition removed him from the scope of the Minor Injury Guideline because the applicant had failed to present compelling evidence from a health practitioner to this effect. The applicant was arguing that his injuries from the 2018 accident had worsened the injuries he’d sustained during a prior motor vehicle accident back in 2016, but the tribunal disagreed, stating that the applicant’s records showed that he had likely substantially or completely healed from the injuries sustained in 2016 by the time of the 2018 accident.
The tribunal stated that the applicant was not entitled to the unapproved balance of the physiotherapy treatment plan, as well as to the three other treatment plans, because the medical records failed to indicate that the applicant required the treatments and assessments sought, including physiotherapy, massage therapy, chiropractic care, attendant care assessment, in-home assessment and mental health or psychological assessment. These treatment plans were not reasonable or necessary, the tribunal found.
