Why LAT denied benefits for medical cannabis costs in auto accident case

A person involved in a 2020 auto accident cannot claim benefits for medical cannabis, in part because the insurer provided some evidence the treatment may not have been helpful, according to an Apr. 16 decision by Ontario’s Licence Appeal Tribunal (LAT).

TD General Insurance denied benefits for a treatment plan submitted by Amit Missra, who claimed benefits for medical cannabis proposed by a doctor in 2022 as well as a social work assessment claim in 2022. LAT adjudicator Jeff Chatterton upheld the insurer’s denial of the medical cannabis claim, but did grant payment for the social work assessment and related interest costs.

Missra noted treatment plans calling for medical cannabis pharmaceuticals were prescribed by pain specialist Dr. Mansimram Bhatti and Dr. Eric Grief. The doctors felt the plan would reduce pain and help with depression, allowing Missra to return to normal life activities. Missra argued Dr. Bhatti made clear cannabis was important to treating his chronic pain and assisting him with depression and a sleep disorder.

A December 2022 Insurer’s Examination (IE) report conducted by Dr. Chris Aldridge for TD General Insurance argued medical cannabis was not reasonable or necessary. But Missra argued Dr. Aldridge is not an expert in chronic pain or psychological issues. As such, he said, the report should receive less weight.

“While I am alive to the argument that Dr. Aldridge is not an expert in chronic pain or psychological issues, I find his report to be of significance in relation to the [Missra’s] reporting about his experience of medical cannabis,” Chatterton wrote in Missra v. TD General Insurance Company.

“During the IE, on Nov. 25, 2022, [Missra] reported having used cannabis for four weeks, but was unable to describe any clear benefit. Conversely, [he] reported that [the antidepressants] Cymbalta or Wellbutrin provided some benefit to his mood.”

Further, the decision noted, “[Missra] was re-assessed four years post-accident, on Dec. 19, 2024, by Dr. Aldridge. In this session, [Missra] reported that cannabis produced only mild benefits (approximately 10%) versus Tylenol, which created 20[%] to 30% reduction in symptoms.

“As [Missra] has reported he is receiving little net benefit from the use of medical cannabis, I find [he] has not, on the balance of probabilities, met his onus to establish that the treatment plans or OCF-6 [expense claim] for medical cannabis are reasonable and necessary.”

Social work claim

As for the denial of the social work assessment claim, Missra argued a Nov. 2022 denial letter from his insurer was difficult to understand and “provided only a ‘boilerplate’ reasoning for denying the benefit,” according to the text of the decision.

Chatterton agreed the insurer’s letter did not comply with Section 38 of the Statutory Accident Benefits Schedule (SABS) because it did not provide sufficient medical reason for the claim denial.

“The phrase, ‘[b]ased on the medical documentation we have on file, it does not support the requested treatment plan,’ is boilerplate language which does not speak to the [insurer’s] rationale for denying the specific treatment plan in dispute or the applicant’s specific condition,’” Chatterton’s decision reads.

“While I am alive to the arguments put forward by the [insurer] in its written submissions, the fact remains there was no reference to these reasons, such as a duplication of services, in the November 2022 Explanation of Benefits such that the requirements of s. 38(8) would be met.”

For this reason, he wrote, “The treatment plan for a Social Work Assessment…is payable under s. 38 of the Schedule [and] Interest is payable as per s. 51 of the Schedule.”