Volume. 8 Issue. 4 – January 24, 2024

This week we examine two instances wherein a single assessment “process” resulted in the production of two assessments/reports. In ‘One Assessment Engenders Two Distinct Reports‘, a two day assessment by the same assessor was found to have produced two distinct components of a CAT assessment.

In ‘Two Discrete Assessments in One Report‘ the Tribunal considers whether there was an obligation to pay for two assessments, despite there being only one report.

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Same Assessor Provides Two Reports From One Assessment

One Assessment Engenders Two Distinct Reports – Injured in an August 2020 MVA, the Applicant Isakow, in 22-006741 v Security National, sought entitlement to a mental and behavioural assessment, proposed as part of a CAT assessment. Security National took the position that said assessment was a duplication of the psychology assessment within the overall plan that had been approved. It was noted that both assessments had the same author, date of assessment, and goal, and were conducted by the same doctor on August 23-24, 2022. “They both also have the same purpose which is to address the applicant’s current psychological symptoms and associated impairments in functioning. Further, they both have the same methodology which includes a review of the medical documentation, review of the reports of the co-assessors, a clinical interview with the applicant, addition of input from the applicant’s spouse, the administration of psychometric measures, and a comprehensive file review.”

The Tribunal however disagreed with Security National’s contention that there was no distinction between the two assessments in question. Despite the similarities, and the fact that some of the same content was used in both reports, “it is clear to me that each assessment has a separate focus, different assessment framework, and unique result. There were found to be “three important areas of evaluative differentiation: the rubric, the framework, and the result contributed to the overall CAT assessment.” The psychological assessment was “evaluating against criterion seven, using the American Medical Association Guides (“the AMA Guides”) 6th ed, whereas the mental/behavioural assessment is evaluating against criterion eight using the AMA Guides 4th ed.”

The Tribunal did not agree with Security National that this ought to have constituted a single report. In each report submitted, “the content and the assessor’s commentary are framed differently, each leading towards a distinctive result with regard to the type of impairment analysis and rating.” The psychological report considered Isakow’s “current symptoms and functioning, behavioural observations, and a result of 10-15% WPI rating”. In contrast, the mental behavioural “discusses the behavioural observations with a focus on the four areas of evaluation, and produces a catastrophic impairment opinion under criterion eight of “Moderate to Marked (class 3 to 4) Impairment”. Accordingly, Isakow was entitled to the disputed mental/behavioural assessment component of the CAT assessment.

Insurer Obliged to Pay for Two Assessments From One Report

Two Discrete Assessments in One Report – In 20-014920 v. Certas, the Applicant Buckley sought entitlement to both a mental health assessment and a cognitive assessment submitted as two separate treatment plans, with Certas having approved only one. It was Certas’ contention that the request for a mental health assessment and a cognitive assessment, constitute different sections of one assessment. Certas noted that only one neuropsychological assessment was produced, amalgamating both the cognitive and psychological criteria. Certas contended that “the disputed treatment plans each contain standard components of a neuropsychological assessment; accordingly, the proposed testing and assessment are not distinct or substantially separate services.”

The Tribunal disagreed with this assertion, based upon the interview process. There were found to be cognitive issues encountered suggesting the reasonableness and necessity of cognitive testing, as well as emotional and psychological issues that were suggestive as to the reasonableness and necessity of psychological testing. It was found that the report in question “was divided and addressed the applicant’s neurocognitive assessment and the applicant’s psychological assessment as discrete issues.” A subsequent correspondence from the assessor “describes the assessment process for the applicant’s cognitive symptoms, proposing in an OCF-18, an assessment to evaluate the severity of the brain injury suffered by the applicant as a result of the accident, with a separate process for the diagnostic interview from the psychological evaluation”.

Further, the assessor stated that “although the two separate assessments are completed by the same practitioner, the purpose, methodology, test measures, and report content are distinct and contain separate clinical information. She states that while it is possible to combine these two separate evaluations into one multidisciplinary report, it is a matter up to the clinician’s discretion.”

Reference was made to a prior decision of the Tribunal, C.C. v Aviva, in which a neuropsychological assessment was comprised of two separate assessments within one report, including a neurocognitive assessment and a psychological assessment, as in the case herein. In that matter, it was determined that “that both the neurocognitive assessment and the psychological assessment, contained in the same report, were reasonable and necessary. They were to be paid for separately, as stand-alone reports.”

Accordingly, the Tribunal relied upon jurisprudence and the descriptions subsequently provided by the assessor in finding “that the two treatment plans are each reasonable and necessary as stand-alone assessments albeit contained within the same report.”

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