I would like to congratulate Maka Metreveli, a paralegal that works with my office, on her success at the LAT on behalf of our client who had his treatment plans denied by his automobile insurer.
Ms. Metreveli successfully argued that Aviva Insurance failed to comply with s. 38(8) of the Statutory Accident Benefit Schedule as the insurer failed to provide the medical and other reasons why it considered the goods and services submitted not to be reasonable and necessary.
The adjudicator noted the following:
(i) Simply mentioning “injuries” in a denial notice does not automatically make it a “medical reason.” In all three of the denial notices, Aviva failed to provide specific details about Mr. Campbell’s injuries or conditions that formed the basis of Aviva’s decision despite Dr. Kopansky-Giles setting out the conditions that Mr. Campbell sustained as a result of the accident in her July 10, 2017 report. It also appears that Dr. Kopansky-Giles’ report was not enclosed in any of Aviva’s denial notices to Mr. Campbell despite it being referenced in each letter;
(ii) Although Aviva highlighted Dr. Kopansky-Giles’ opinion in each of its denial letters that no further facility-based treatment was recommended and, instead, Dr. Kopansky-Giles’s recommended that Mr. Campbell participate in an independent exercise program, Aviva failed to address the issue that the proposed treatment plans included, in part, an exercise program. Only in its written hearing submissions does Aviva provide a response to the proposed exercise programs by stating that the treatment proposed by Dr. Sugar in the three disputed OCF-18s did not mirror the independent exercise program recommended by Dr. Kopansky-Giles. This rationale regarding the reasonableness and necessity of the exercise portion of the proposed OCF-18s was not communicated to Mr. Campbell in any of Aviva’s correspondences; and
(iii) I also find that Aviva did not sufficiently identify information about the Mr. Campbell’s condition that it did not have but required in light of the information provided by Dr. Sugar in the additional comments portion of the OCF-18s which included range of motion testing and a list of resolved and unresolved injuries.
The adjudicator re-affirmed the decision of T.F. v. Peel Mutual Insurance Company 2018 CanLII 39373 (ON LAT):
an insurer’s “medical and any other reasons” should, at the very least, include specific details about the insured’s condition forming the basis for the insurer’s decision or, alternatively, identify information about the insured’s condition that the insurer does not have but requires. Additionally, an insurer should also refer to the specific benefit or determination at issue, along with any section of the Schedule upon which it relies. Ultimately, an insurer’s “medical and any other reasons” should be clear and sufficient enough to allow an unsophisticated person to make an informed decision to either accept or dispute the decision at issue. Only then will the explanation serve the Schedule’s consumer protection goal.