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Can Your Car Insurance Company Refuse to Pay for Treatment That Relieves Your Pain?

December 4, 2018

If you are injured in a motor vehicle accident in Ottawa or anywhere in Ontario, you are entitled to apply for no-fault accident benefits, which include medical and rehabilitation benefits. These benefits may cover services such as physiotherapy, chiropractic treatment, massage therapy, assistive devices, etc.  Your therapist (or other medical service provider) must submit a Treatment Plan to your insurer, requesting the services.  Your insurer will either accept or refuse to fund the proposed Treatment Plan.  Subject to your insurance limits, your insurer must pay for all “reasonable and necessary” expenses you incur as a result of the accident.

But what happens if the treatment you are receiving reduces your pain and makes you more functional, but these benefits are only temporary? In other words, can the insurance company refuse to pay for treatment because the treatment will not cure or improve your injury (but still helps you in the short term)?  Will this be considered “reasonable and necessary”?

Recent decisions from the Licensing Appeal Tribunal state that pain relief is a legitimate treatment goal.  A proposed Treatment Plan is “reasonable and necessary” where the proposed treatment provides pain relief to the injured person, even if the treatment does not effectively assist the injured person to recover.

For example, in 17-004828 v Aviva Insurance Canada, the injured person had undergone physiotherapy in the past with limited progress and no evidence of effectiveness.  When her physiotherapist submitted another Treatment Plan for physiotherapy, the insurer denied the request as a result of the lack of progress.  The Tribunal disagreed with the insurer’s decision, finding that “pain relief can be a legitimate treatment goal, and therefore reasonable and necessary even if it does not promote recovery.”

Similarly, in 17-003705 v Progressive American Insurance Company, the insurer denied a Treatment Plan for physiotherapy, stating that physiotherapy was no longer reasonable and necessary because it was “unlikely to render any additional significant benefits.” The Tribunal found that further physiotherapy was reasonable and necessary, stating that “pain relief is a legitimate treatment goal in and of itself.”

In 17-007626 v Aviva Canada Inc., the injured seamstress had already reached maximum medical recovery.  Nonetheless, the Tribunal found that she was entitled to continue chiropractic treatments, as they provided her with pain relief and were, therefore, reasonable and necessary. The Tribunal noted, “I find that pain relief is a legitimate goal for treatment and that an attempt at easing the pain of a 66 year old self-employed seamstress is reasonable.”

See also: 16-002861 v Aviva Insurance Company, 17-006108 v Unifund Insurance Company, and 16-000536 v Co-operators General Insurance Company.

 The Tribunal has also found in some cases that a Treatment Plan is not automatically reasonable and necessary merely because the injured person says that the proposed treatment provides him/her with relief.  Rather, the person’s assertion of pain relief must be supported by his or her treatment providers or their records. (See e.g. 17-000612 v Aviva Insurance and 16-003921 v Certas Home and Auto Insurance Company).

These decisions act as a reminder for people injured in a motor vehicle accident to continuously update their doctors and other medical service providers, advising them which treatments they are undergoing and whether the treatment is assisting in their recovery and/or pain relief.

If you have been injured in a motor vehicle accident and your insurer has refused to pay for your medical benef, you should contact an experienced personal injury lawyer.

For a free consultation, call SG Injury Law today at 613-518-2416 or contact us here.



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