Category: Medical Benefits

The claimant sought entitlement to two treatment plans, one for occupational therapy services and one for physiotherapy services. Adjudicator Manigat concluded that the denied treatment plans were not reasonable and necessary. With respect to the occupational therapy treatment plan, Adjudicator Manigat accepted that the claimant had to make certain adjustments to cope with some pain and use pacing strategies to resume her pre-accident activities. However, the adjudicator noted that any impact on the claimant’s ability to function had been remedied through the use of coping strategies, and that the claimant’s ongoing pain was not sufficient to render the treatment plan payable. With respect to the physiotherapy treatment plan, Adjudicator Manigat noted that the claimant had not submitted any physiotherapy requests for over 1.5 years prior to submission of the denied treatment plan, and there was no evidence to substantiate that further facility based treatment would result in additional benefit to the claimant.

The claimant sought entitlement to a chronic pain treatment program. Adjudicator Moten concluded that the claimant was entitled to the denied treatment plan, preferring the claimant’s expert report over the insurer’s IE reports. Notably, none of the IE assessors were pain medicine specialists and none of the IE reports specifically addressed the issue of chronic pain. Adjudicator Moten also noted that the treatment plan was targeted, concise, and for a proportionate amount of time.

The claimant sought entitlement to one treatment plan for physiotherapy services. Adjudicator Grant found that the proposed physiotherapy was not reasonable and necessary. He found that the claimant had previously undergone physiotherapy, there was a lack of evidence of benefit from the previous treatment, and that none of the medical evidence established the benefit of further physiotherapy.

The claimant sought entitlement to one treatment plan for chiropractic services. Adjudicator Grant found that the proposed treatment was not reasonable and necessary. He noted that a treating physician’s mention of a chronic pain condition, be it ‘syndrome’ or specific use of the term ‘chronic pain,’ is not enough to establish the necessity of a treatment plan. Adjudicator Grant found that references to chronic pain in the medical records appeared to be in reference to a non-accident-related condition, and the claimant failed to establish that due to ‘chronic pain’, the treatment was reasonable and necessary.

The claimant sought entitlement to four treatment plans for physical therapy and seven proposed assessments. Adjudicator Norris rejected all of the claims. He held that the evidence the claimant relied upon (an OT paper file review) was biased and not limited to the appropriate scope of an occupational therapist.