16-004676/AABS v Certas Direct Insurance Company

Jan 08, 2018

Adjudicator: Chris Sewrattan

Issues:

1. Did the applicant sustain injuries that fall within the Minor Injury Guideline and are subject to a $3,500.00 cap on treatment under s. 18 of the Schedule?

2. Is the applicant entitled to a $2,825.00 cost of examination for a general practitioner’s assessment, recommended by Allied-Med Trauma Evaluations in a Treatment Plan dated November 23, 2015?

3. Is the applicant entitled to receive a $2,932.71 medical benefit for psychological services, recommended by Allied-Med Trauma Evaluations in a Treatment Plan dated November 23, 2015?

4. Is the applicant entitled to interest on overdue benefits?

Result:

1. The injuries sustained by the applicant fall within the Minor Injury Guideline. The applicant alleges that she suffers from both psychological impairments and chronic pain syndrome which would remove her from the guideline. The applicant fails to discharge her burden and provide the Tribunal with sufficient evidence to demonstrate that her injuries are not predominantly minor. No diagnosis of pain is provided, instead the Adjudicator is asked to make an inference which is not consistent with the burden of proof provided by the law.

2. The applicant is not entitled to payment for the general practitioner’s assessment. The insurer provided medical reasons for denying the assessment, specifically that the treatment plan was denied because of a lack of objective, compelling, supporting medical documentation. That response is sufficient to satisfy the medical reasons requirement under the Schedule.  

3. The applicant is not entitled to payment for the psychological services recommended. No psychometric tests were conducted nor did the Psychologist provide a cogent analysis that supported a diagnosis of a psychological impairment that would remove the applicant from the Minor Injury Guideline. The denial is thus reasonable because the Adjudicator does not find that the applicant suffers from a psychological impairment.

4. The applicant is not entitled to any interest as no payment amount is outstanding.

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