Category: Medical Benefits

The claimant sought entitlement to a treatment plan for physiotherapy, and cost of examinations for a neurological assessment and a chronic pain assessment. Adjudicator Johal reviewed the medical records on file, which indicated numerous treating practitioners’ opinion that further physiotherapy would be beneficial, and concluded that the disputed treatment for ongoing physiotherapy was reasonable and necessary as the claimant did not have to prove his injuries were “substantive”, only that the need for the treatment was reasonable and necessary. Adjudicator Johal dismissed the claims for the denied examination for a neurology assessment as the treating neurologists on file did not recommend it in their records, and in fact, only recommended further physiotherapy. The chronic pain assessment was denied because while the treating practitioner diagnosed the claimant with chronic pain, there was no indication that a further assessment was required.

The claimant disputed her entitlement to a treatment plan for chiropractic services. Vice-Chair Farlam concluded that the disputed treatment plan was not necessary. Although the claimant consistently complained of back pain from 2015 to 2019, a review of the medical evidence did not show a direct relation to proposed treatments and subject accident as the claimant had pre-existing back pain, had been involved in two prior accidents, and the subject accident was only directly mentioned a few times; and at one point, was not mentioned for a period of two years.

The claimant disputed entitlement to two treatment plans for treatments focused on neurological and concussive injuries. Adjudicator Norris noted that the claimant appeared to have predominantly psychological injuries as a result of the accident. He cited the insurer examination reports of Dr. Smyth (neurologist) and Dr. Belfon (physician) as holding greater weight than the claimant’s evidence. Adjudicator Norris also noted that primary reason for the claimant’s visits to her family doctor was in fact to report psychological symptoms, and not symptoms related to neurological or concussive symptoms. He also gave little weight to the section 25 report of Dr. Horseman (chiropractor) as it was not accompanied by any records or test results to substantiate Dr. Horseman’s conclusions. Adjudicator Norris found the treatment plans not reasonable and necessary and denied any interest.

The claimant sought entitlement to the costs of three assessments for examinations and one treatment plan for assistive devices. Adjudicator Norris found that the claimant was not entitled to any of the benefits. Adjudicator Norris concluded that the Neurological, FAE, and In-Home Ergonomics assessments were not reasonable and necessary as a result of the accident. The claimant did not submit the disputed treatment plan, and as a result Adjudicator Norris had to rely on the IE report. Adjudicator Norris concluded that the treatment plan was not reasonable and necessary as the devices were predominately for neck, back, and shoulder injuries and the claimant reported no such impairments.

The claimant sought entitlement to the cost of a psychological assessment and a special award. Adjudicator McQuaid found that the assessment was reasonable and necessary, as the evidence from the ongoing adjustment of the claim supported the need for a psychological assessment. The result of assessments and examinations by four different doctors was a recommendation for psychotherapy treatment. Adjudicator McQuaid found the cost of the examination to be payable but did not grant a special award, finding the insurer’s denial of the cost of the examination was not per se frivolous and vexatious conduct.