The applicant sought various medical benefits, as well as an award pursuant to section 10 of O. Reg 664. Adjudicator Truong held that the applicant was entitled to the balance of the treatment plan for a total body assessment and documentation, but was not entitled to medical benefits for physiotherapy. The adjudicator held that the diagnoses listed in the physiotherapy treatment plan were not accident related. The adjudicator also held that the applicant was entitled to an award in the amount of 50 percent of the amount payable plus interest due to: Aviva’s handling of the first treatment plan; Aviva specifically refusing to pay the fees for a progress report it approved; and not providing an updated notice with medical reasons for denying the total body assessment. Aviva had partially approved a treatment plan for documentation and two physiotherapy sessions, and further costs for a progress report as long as a copy would be provided to Aviva. The progress report was provided to Aviva, however, Aviva argued that the report was completed in contemplation of the second treatment plan in dispute. Adjudicator Truong held that it logically follows that a progress report would contemplate further treatment, and the approval letter was ambiguous about what a progress report should include. The adjudicator resolved the ambiguity in favour of the applicant. With respect to the total body assessment, Aviva argued that it was for the purpose of completing the treatment plan, and was subject to the $200 limit per the FSCO Guideline for the completion of an OCF-18. Adjudicator Truong held that no medical reasons were given for denying the total body assessment, thus Aviva was in non-compliance with subsection 38(8) and the assessment was payable pursuant to subsection 38(11).
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