In May 2017, the applicant was catastrophically impaired due to sustaining a brain injury from a severe motor vehicle collision. This tragic incident necessitated many treatments, therapies, and rehabilitation services to aid her recovery, subsequently leading to many accident benefit claims. However, the applicant’s insurer, Intact Insurance Company, denied some of her claims. As a result, a legal dispute was filed with the Licence Appeal Tribunal (LAT), aiming to procure outstanding costs for the services provided to the client to aid her recovery.[1]
Issue
The primary issues involved nine specific Treatment and Assessment Plans (OCF-18s) that Intact had partially denied. These encompassed a diverse range of services, including, but not limited to, occupational therapy, social rehabilitation counselling and physiotherapy assessments. The crux of the partial denials revolved around fees associated with out-of-session services such as form completion, brokerage time and the preparation of reports.[2]
Analysis
Adjudicator Pahuta thoroughly examined each contested benefit claim, scrutinizing the disputed treatment plans. His analysis revealed that specific brokerage fees, encompassing activities like medical file review and consultations, were valid due to their intricacy and depth of detail. However, others were denied due to insufficient justification or a lack of specifics supporting their reasonableness and necessity.
Brokerage Services Fees
Adjudicator Pahuta sided with the applicant when evidence showed the brokerage fees were reasonable and vital for enabling communication among the patient’s care providers. For instance, a supplemented letter to one OCF-18 detailed how the claimed brokerage time within the treatment plan included activities like medical file review and consultations with the client and healthcare team.[3] Adjudicator Pahuta agreed with the applicant, asserting that the claimed brokerage fees covered the interactions between the OT and case manager, and other team members.[4]
In another instance, Adjudicator Pahuta approved brokerage fees presented in a different OCF-18, finding them necessary and reasonable given the patient’s complex condition and the coordination required for arranging community sessions.[5] He recognized that brokerage service fees were crucial for efficient communication between the treatment provider and case manager, particularly in complex cases involving catastrophically impaired patients. Adjudicator Pahuta found that such cases require extensive coordination across multiple treatment providers, an aspect previously overlooked by Intact in their denial of brokerage service fees.
Documentation Support Activity Fees
Adjudicator Pahuta confirmed that the time stipulated in an OCF-18 for documentation support was reasonable and necessary. This decision was influenced by a letter from the OT service coordinator, which validated these expenses due to their association with creating a detailed progress report.[6]
Form Completion Fees
Adjudicator Pahuta overruled the insurer’s refusal of form completion charges. He granted these expenses because the form was based on the OT’s recommendations and required significant collaboration among the OT, RSW, and supervisors, thus justifying the total approval of the $200 fee for form completion.[7]
The LAT’s Findings
As such, Adjudicator Pahuta approved the majority of the disputed claims relating to the treatment plans. He deemed most of the contested fees, such as out-of-session services, form completion, brokerage time and report preparation, reasonable and necessary for such a complex case.
He highlighted the importance of brokerage fees in facilitating communication and coordination in complex cases and approved most of these fees when they were justified. He also acknowledged the significance of documentation support and form completion fees, especially in cases involving catastrophically impaired clients. However, the denial of some fees was upheld due to the applicant’s lack of adequate explanation about their necessity and reasonableness.
Implications
This decision establishes an important legal precedent concerning the validity of fees associated with documentation, form completion and brokerage services. In particular, it demonstrates a balanced approach by the LAT, acknowledging the extensive services involved in providing care for catastrophically impaired clients.
This decision also emphasizes the duty of thorough documentation, especially when multiple healthcare providers collaborate in treating a catastrophically injured applicant. It is a strong incentive for treatment providers to keep comprehensive records to substantiate these charges. Moreover, it provides service providers with detailed insight into what adjudicators consider when evaluating denials related primarily to administrative services, a topic that has not been addressed in detail.
[1] HR v Intact Insurance Company, 2023 ONLAT 21-006448/AABS at paras 1-2.
[2] Ibid at para 3.
[3] Ibid at para 9.
[4] Ibid.
[5] Ibid at para 35.
[6] Ibid at para 10.
[7] Ibid at para 15.
