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I.D.F. v. Aviva General Insurance Company (19-008993)

  • August 6, 2020

The claimant sought entitlement to four treatment plans for physiotherapy and other goods and services. The claimant submitted that he suffered from chronic back pain and required constant treatment. He argued that without treatment and medication, his condition would regress and his daily activities and function were reduced. Adjudicator Boyce found that the claimant’s reports of pain were consistent throughout the clinical file and his back-pain flare ups were documented in the records of his family physician. Further, Adjudicator Boyce agreed that the claimant’s timeline provided support for his contention that the cessation of treatment led to regression and an increase in pain. Therefore, Adjudicator Boyce found it reasonable to permit the claimant to undergo one more slate of physiotherapy and massage treatment in order to address his lingering pain. The goals of the plan were achievable and the cost was not exorbitant. Also, the claimant submitted that his previous anti-inflammatory and muscle relaxant did not provide adequate pain relief, necessitating a prescription for CBD oil. Adjudicator Boyce agreed that the medical records demonstrated that other pain-relief medicines had already been prescribed and had been shown to be ineffective. The treatment plan was clear on what was being prescribed and the report from Spark Cannabis confirmed that CBD oil was prescribed. Accordingly, Adjudicator Boyce held that the claimant was entitled to partial payment in the amount of $1,370.00 for the CBD oil treatment plan. The items listed as “assessment” and “prescription” were not reasonable and necessary expenses. The claimant was not entitled to the remaining treatment plans.

Full decision here

TGP Analysis

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  • FILED UNDER Medical Benefits
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