16-004375 v State Farm Mutual Automobile Insurance Company

Dec 05, 2017

Adjudicator: Avvy Go

The applicant was injured in a motor vehicle accident on September 17, 2014 and applied for medical benefits.

Issues: 

  1. Is the applicant entitled to a medical benefit of $2,300.58 for active physiotherapy services?
  2. Is the applicant entitled to a medical benefit of $2,520 for physiotherapy services ?
  3. Is the applicant entitled to a medical benefit of $6,610.50 for a Psycho-Vocational and Functional Abilities Evaluation?
  4. Is the applicant entitled to a medical benefit of $1,728.75 for an in-home assessment by Mr. Tamir?

Issue One:

  • Dr. Millard assessed the applicant approximately 4 months after the accident,  stating that a barrier to recovery was the applicants focus on passive modalities in treatment. This comment applied only  to the treatment the applicant was receiving in February of 2015. 
  • It is not reasonable for the respondent to refuse the treatment plan submitted in 2017 based on a comment made by an assessor about treatment received two years prior.

Issue Two:

  • This treatment plan in dispute is for 18 sessions of laser spinal decompression therapy. The Adjudicator determines that laser treatment is an active form of therapy thus there is no cause for concern

Issue Three:

  • Applicant seeks payment for an assessment by the Read Clinic which addressed his ability to return to work
  • Prior to the submission of the Read Clinic report, the respondent had not requested any examination to address the applicant’s post 104 weeks income replacement entitlement

The Applicant is entitled to the following:

  • A medical benefit of $2,300.58 for physiotherapy services from Physiomed
  • A medical benefit of $2,520 for physiotherapy services from Physiomed
  • A medical benefit of $4,000 for a Psycho-Vocational and Functional Abilities Evaluation
  • A medical benefit of $1,728.75 for an in-home assessment by Mr. Tamir

Issue Four

  • Both parties referred to Kelly v Guarantee , Adjudicator does not find this case relevant as it has not been established whether the applicant has been catastrophically injured

Based on the evidence it appears that the applicant is or may be entitled to said benefits past the 104 week mark and this should not be precluded from submitting the in-home assessment plan at this time