“REASONABLE AND NECESSARY”: A REFRESHER

Posted November 5, 2018

If you are a health care professional who works with injured motor vehicle accident victims under Ontario’s statutory accident benefits system, you will no doubt have experienced an insurer’s denial of funding for a proposed treatment plan.

Often, the insurer’s reason is that the proposed treatment is not “reasonable and necessary,” which is the governing legal test for eligibility for medical and rehabilitation benefits.

Unfortunately, the phrase “reasonable and necessary” is not defined anywhere in the legislation. It is, perhaps, not susceptible to a straightforward definition. This is because a determination of what constitutes “reasonable and necessary” treatment not only varies from case to case but also among different clinical professional disciplines. It is also because the words themselves are ambiguous.

Determining what “reasonable” treatment is can be difficult. Does it simply mean any treatment that would logically or normally be given for a particular type of injury? Or does “reasonable” import a measure of moderation in the type or measure of treatment (i.e., only an appropriate kind or lesser degree of treatment should be allowed considering cost, benefit or risk)?

Determining what “necessary” treatment is can be equally challenging. Does it mean the treatment must be absolutely essential? Required? Can treatment that will merely alleviate (rather than eliminate) symptoms be essential or necessary?

There is no clear cut answer. Each case will rely on its unique facts. We can, however, find some guidance in the case law.

Objective medical evidence concerning the efficacy of the treatment is usually required. An injured person’s subjective belief in the benefit in the treatment will generally not be sufficient.[1]

Risky treatment that may cause further injury is unlikely to be considered reasonable.[2] However, if such treatment has the prospect of an excellent outcome, it may be found reasonable although it will be left to the injured person whether or not to undertake the risk of treatment.[3]

Frequency, as well as duration of treatment, is relevant. Shorter, fixed-term treatment with periodic re-evaluation is more likely to be considered reasonable and necessary.

One need not demonstrate that the efficacy of the proposed treatment is certain, provided that an injured person reports deriving some benefit and the clinician gives a favourable prognosis concerning the treatment goal.[4]

In one case, where there was no evidence to indicate the injured person benefited from treatment in the past, it was found that further similar treatment was not found to be reasonable and necessary.[5]

If a proposed treatment will only have modest, insignificant or inconsequential benefits, it may not be considered reasonable and necessary.[6]

However, the goal of treatment does not necessarily have to be full recovery. Treatment that provides even temporary relief of symptoms will usually be found to be reasonable and necessary.[7]

For example, in one case, an arbitrator found that reducing stress, which would help alleviate (but not cure) depression and anxiety, was a reasonable and necessary treatment objective.[8]

Similarly, if one of the goals of treatment is to reduce (rather than fully eliminate) pain so that the injured person is able to engage in normal daily activities, the treatment will be reasonable and necessary.[9]

By contrast, one adjudicator found that a treatment plan that did not provide any guidance as to how the injured person’s pain would be “resolved” was found not to be reasonable and necessary.[10]

If treatment intended to provide relief from symptoms such as pain promotes or results in inappropriate dependency on the treatment, it may not be reasonable and necessary.[11]

Where a proposed rehabilitation measure can be demonstrated to be the most effective way of improving the applicant’s functional ability and quality of life, it will be considered reasonable and necessary.[12]

Measures to improve quality of life must, however, relate to or fit within the scope of activities and measures described in section 16(3) of the Statutory Accident Benefits Schedule, which lists counselling, training, home, work or vehicle modifications, assistive devices and the like. In one case, an adjudicator rejected a rehabilitation plan for a catastrophically injured man in declining health living in a nursing home for whom a trip to Florida with his children was recommended to facilitate his reintegration into his family. The adjudicator found that for a benefit to be payable, the rehabilitation measure must be a service provided by a professional with a clear treatment goal, or be a modification or device that accommodates the needs of an injury victim.[13]

The cost benefit of a proposed treatment is also relevant. If a treatment is high cost but low result/success, it will not be reasonable and necessary.[14] Some adjudicators have found that the scope and cost of the treatment plan must be proportional to the injured person’s needs in order to be reasonable and necessary.[15] However, the injury victim has no obligation to use OHIP-funded treatment prior to seeking accident benefits.[16]

Each case, of course, relies on its unique facts and circumstances. To the extent health care professionals can anticipate an insurer’s questions and potential objections to the reasonableness and necessity of a proposed treatment plan, denials of medical and rehabilitation benefits can be pre-emptively avoided.

 

***

[1] LeClerc v. State Farm, [2009] OFSCD No 144 (FSCO Arb)

[2] Little v. Aviva, [2005] OFSCD No 130 (FSCO Arb)

[3] Cubello v. Guidolin, [2000] OJ No 1468, 19 CCLI (3d) 164 (Ont SCJ)

[4] Violi v. General Accident Assurance, [1999] OFSCID No 148 (FSCO Arb)

[5] L.D. v. Aviva, 2017 CanLII 46346 (ON LAT)

[6] Jaansoo v. Canadian General Insurance, [2000] 95 ACWS (3d) 154 (Ont CA)

[7] Cubello, supra

[8] M.G. v. Primmum Insurance, 2017 CanLII 33672 (ON LAT)

[9] S.S. v. Northbridge Insurance, 2017 CanLII 19189 (ON LAT)

[10] F.B. v. Dominion Of Canada General Insurance Company, 2017 CanLII 33680 (ON LAT).

[11] Amoa-Williams v. Allstate, [2000] OFSCID No 93 (FSCO Arb); 16-002818 v. Unifund Assurance Company, 2017 CanLII 39709 (ON LAT)

[12] L.D., supra

[13] 16-001811 v. Wawanesa Mutual Insurance Company, 2017 CanLII 9817 (ON LAT)

[14] Jaansoo, supra.

[15]17-005667 v. Aviva Insurance Canada, 2018 CanLII 81893 (ON LAT)

[16] 16-002818 v. Unifund Assurance Company, 2017 CanLII 39709 (ON LAT)

 

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