16-003519/AABS v State Farm Mutual Automobile Insurance

Jan 09, 2018

Adjudicator: Paul Gosio

After being injured in a motor vehicle accident the applicant sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010. The respondent, State Farm Mutual Automobile Insurance, denied the Treatment and Assessment Plans for myofascial appliance and for an adjustment to natural dentition based on a dental assessment it conducted, which determined they were not reasonable and necessary. Adjudicator Gosio ruled that the applicant had not met her onus of establishing on a balance of probabilities that she is entitled to the treatment and Assessment Plans as they were found not to be reasonable and necessary.

Adjudicator Gosio found that the applicant’s case was based entirely on counsel’s submissions, as no supporting medical evidence, not even the treatment plans in dispute, were provided to the Tribunal. Submissions are not evidence. Additionally, the insurer’s examination performed by a doctor of dental surgery outlined that the applicant’s temporomandibular joint pain began after a previous motor vehicle accident. The report explains that her existing pain has been exacerbated by the recent motor vehicle accident, despite having received a myofascial appliance and more than 20 sessions of adjustments to that appliance since its initial insertion. The assessor determined that it is unlikely the applicant would receive any benefit from continued similar treatment. As a result, he opined that the treatment plans in question were not reasonable and necessary.

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