17-003290 v State Farm Insurance, 2017 CanLII 87153

Dec 22, 2017

Adjudicator: Christopher A. Ferguson

The applicant, who has been determined catastrophically impaired under s.40 of the Statutory Accident Benefits Schedule – Effective September 1, 2010, applied for medical and rehabilitation benefits and was denied by the insurer.

Firstly, Adjudicator Ferguson denied payment in excess of what was pre-approved by the insurer. While the costs in despite were incurred in good faith for services that were needed (e.g., demonstrating use of assistive devices), no authority was identified that would find the insurer liable to pay costs above amounts approved in treatment plans.

Secondly, the applicant failed to meet her onus to prove her entitlement to the amounts denied by the insurer on the basis that they exceed or are not covered by the Professional Service Guideline.

Thirdly, the applicant’s claim that she needs an OT to plan, advise, monitor and supervise active therapy is denied on the basis that the insurer demonstrated it was duplicative and redundant given the other benefits she received.

Fourthly, the applicant’s argument that a review of medical documentation is inadequate evidence is rejected.

Fifthly, the applicant’s argument that an in-home OT assessment and a situational/community OT assessment are two different things, even if they are conducted by the same practitioner is accepted.