https://www5.fsco.gov.on.ca/AD/4558
Dr. Platnick carried out a paper review and on the basis of Dr. Platnick’s assessment, the Insurer determined, on February 4, 2013, in a letter to the Claimant, the OCF-18 was not reasonable and necessary to treat the impairment arising out of the March 5, 2008 motor vehicle accident. For specific details of the denial, the Applicant was referred to “a report of examination under Section 44 dated January 15, 2013, and completed by Dr. Howard Platnick, Physician”.
Before I proceed to my analysis, I have to comment on the assignment of a general practitioner by Primmum to conduct this Section 44 Assessment. The Insurer’s denial, and the origin of this dispute, was based on Dr. Platnick’s conclusions that the cost of the private school funding was not reasonable and necessary. Dr. Platnick’s reports are found in the Joint Brief at Tab 31(e) and 31(f). The reports in the Joint Brief are described, incorrectly, as “Physiatry” Paper File Review Report of Dr. Platnick, MD.
Dr. Platnick’s reported expertise, as set out in the preamble of his report, has no relation to the expertise required to assess the Applicant’s OCF-18. His expertise, as a family physician, as stated in his “Assessor Qualifications”, is described as having a special interest in neuromusculoskeletal disorders, disability management and rehabilitation. He treats adult, pediatric, and geriatric populations and is involved in the treatment of chronic pain (chronic non-malignant pain – musculoskeletal and neuropathic) and headache patients including narcotic and adjunct medication prescribing/monitoring.
By the time of Dr. Platnick’s report in January 2013, almost five years had elapsed since the motor vehicle accident in 2008. The medical reporting, the exchange of letters between the Applicant’s counsel and Primmum, and prior Section 44 assessments during this timeframe indicated that the impairment symptoms in this very young Applicant were related to anxiety and its interaction with her learning disability, socialization and mood related issues and sleep disturbances. The school records at the time of his assessment reported early learning and fine motor skills development delays as well as below grade level academic performance.
With the exception of a more recent report from a treating psychologist, the Joint Brief indicates that the Insurer had access to most of the medical and school records as I have before me at the time Dr. Platnick completed his assessment.
By contrast, all prior Section 44 assessments – six are listed in the Joint Brief – were conducted by Dr. Amena Syed, an assessor with more relevant expertise. Dr. Syed states her qualifications in the preamble, as a registered psychologist with areas of competence in clinical, rehabilitation and neuropsychology. Her resume states she is qualified to provide these services to children, adolescents and adults. She has experience working with genetic, neurological, developmental and psychiatric/psychological illnesses providing consulting, assessment and treatment services.
The Insurer had to be aware of the required Section 44 assessment expertise when the OCF-18 Treatment Plan of August 2012 was submitted to the Insurer by Dr. Bremermann. The doctor made it clear in the Form that her patient:
is having learning difficulties and anxiety arising from the motor vehicle collision on March 5, 2008 which is affecting her studies at school. She is requiring private school funding to support her learning needs.
From the statements made by Dr. Bremermann on the submitted OCF-18 and the prior reporting history, showing the nature of the impairment and the numerous assessments of Dr. Syed, (seven are listed as having been reviewed by Dr. Platnick) it had to be evident to Primmum what the required Section 44 assessment expertise was to be. But for some reason, the Insurer selected a family physician.
Dr. Platnick concluded from the paper review that the treatment plan was not reasonable and necessary. The medical documentation in his view did not support a “head-trauma-acquired brain injury as a result of the MVA”, consequently, there was no organic-based, cognitive, accident-related impairment that would require the proposed “goods and services”, i.e., the tuition fees for Tall Pines School. Included in this conclusion, Dr. Platnick reviewed a neuropsychological assessment report prepared by Dr. Janine Hay, C. Psych., Clinical Neuropsychologist.
Dr. Hay’s report was not an assessment of a neuromusculoskeletal disorder. Prior to Dr. Platnick’s assignment in January 2013, the Insurer agreed to fund a neuropsychological assessment on the Applicant and her report was not available to Dr. Platnick at the time so his conclusions were delayed until he completed his review of Dr. Hay’s report.
Again, as with Dr. Syed, Dr. Hay’s expertise is more in keeping with the assessment requirements. Dr. Hay works at Holland Bloorview Kids Rehabilitation. Her expertise, as stated in her testimony at this Hearing, is carrying out neurological assessments to assess cognitive functioning with respect to brain behaviour relationships and to understand the cognitive profiles, learning profiles and make recommendations for academic planning and rehabilitation.
It has to be questioned then, why the Insurer assigned a family doctor, with an interest in neuromusculoskeletal disorders, to review, comment, and making findings on a neuropsychological assessment report. It also has to be noted that the history of the claim in this case did not centre on a neuromusculoskeletal disorder but rather the interaction of anxiety and behavioural concerns with developmental learning skills.
Other documents in the Joint Brief show that the Insurer was aware that the Applicant’s anxiety and related issues were interrelated with the Applicant’s learning and educational development.
On August 9, 2012, five months prior to Dr. Platnick’s assessment, Ms. Edmonds wrote that in her view, the force of the impact “were sufficient to cause brain injury whether or not Kristen exhibited any signs of it immediately after the collision”. She goes on to write: “Your Neuropsychologist has already commented that there is evidence of symptoms of post-traumatic stress disorder and anxiety as well as developmental and cogitative impairments”. Again, in a letter to Primmum, dated October 9, 2012, Ms. Edmonds wrote: “The purpose of Dr. Hay’s Assessment is to determine the nature and etiology of Kristen’s cognitive impairment, learning difficulties and anxiety”. In explaining the hoped for outcome of Dr. Hay’s assessment Ms. Edmonds stated:
I must determine whether her assessment, which is directed to cognitive problems and learning disabilities, will focus sufficiently on emotional and anxiety issues, as it is my understanding that the purpose of the Psychological assessment was not only to assess Kristen’s difficulties and determine their relationship of them to the collision, but to formulate a treatment plan.
On October 22, 2012, the prior Section 44 assessor, Dr. Syed, wrote Primmum a clarification letter to show the difference between Neuropsychological assessment and a Psychoeducational assessment. Writing about the investigation of Kristen’s symptom aetiology, she stated: “The aetiology of her symptoms need to be understood from a brain behaviour perspective and investigated as such”.
From the history of the Applicant’s symptoms in the intervening almost 5 years, as documented in the Joint Brief; the medical reporting; and the investigations and assessments by the Insured, it is reasonable to infer that the Insurer was in error by assigning Dr. Platnick and accordingly, his conclusions can not to be relied upon. Dr. Platnick has neither the qualifications to review the submitted OCF-18, dated August 27, 2012, nor the qualifications to review Dr. Hay’s Neuropsychological Assessment Report. The reasons Primmum relied on in denying the Applicant’s claim have to be removed from consideration.