Citation: Silva v. Wawanesa Insurance, 2022 ONLAT 20-007232/AABS
Licence Appeal Tribunal File Number: 20-007232/AABS
In the matter of an Application pursuant to subsection 280(2) of the Insurance Act, RSO 1990, c I.8., in relation to statutory accident benefits.
Between:
Manuel Silva
Applicant
and
Wawanesa Insurance
Respondent
DECISION AND ORDER
VICE-CHAIR: Chloe Lester
APPEARANCES:
For the Applicant: Jack Parsekhian, Counsel
For the Respondent: Darrell March, Counsel
Court Reporter: Ramin Daneshvar
Heard by Videoconference: October 25-29, 2021 and December 6-8, 2021
REASONS FOR DECISION AND ORDER
BACKGROUND
1The applicant, Manuel Silva, was involved in a car accident on May 18, 2006. He and his wife were hit from behind by a TTC bus when they were stopped at a red light. As a result, Mr. Silva alleges he sustained physical and psychological injuries. Because of those injuries, he stopped working. Mr. Silva applied to the respondent, Wawanesa Mutual Insurance Company (“Wawanesa”), for income replacement benefits (IRB) in accordance with the Schedule and they were paid.1
2After paying the benefit for approximately 13 years, Wawanesa re-assessed Mr. Silva’s entitlement. After a series of s. 44 assessments, Wawanesa determined that Mr. Silva no longer met the test for IRBs and terminated the benefit.
3Mr. Silva disagreed and filed an application for dispute resolution with the Tribunal.2
ISSUES IN DISPUTE
4The questions to be determined are:
(a) is Mr. Silva entitled to receive a weekly IRB from May 13, 2019 onward?
(b) is Mr. Silva entitled to interest?
(c) Is Wawanesa entitled to costs for the hearing pursuant to Rule 19 of the Licence Appeal Tribunal’s Common Rules of Practice and Procedure (the “Rules”)?
RESULTS
5Mr. Silva is entitled to an IRB in the amount of $200.62 per week from May 13, 2019, onward. The parties agree that any ongoing weekly rates will be subject to CPPD deductions.
6Mr. Silva is entitled to interest.
7Wawanesa is not entitled to costs.
PROCEDURAL ISSUES
The IE Assessors’ Records and the Admittance of New Evidence
8Mr. Silva brought a motion requesting the production of clinical records previously requested at the case conference one year earlier. Wawanesa had agreed to produce the records by April 12, 2021 but did not comply with that agreement.
9Mr. Silva argued that, without the clinical records, he would be prejudiced at the hearing. If the clinical records could not be produced, he argued, the assessors and reports should be excluded from the hearing pursuant to Rule 9.4.3
10Wawanesa objected to the motion and any adjournments of the hearing as the motion was not served ten days before the hearing pursuant to Rule 15.2.4
11Since additional hearing dates were required, I ordered Wawanesa to produce the clinical notes and records by November 22, 2021, as it would provide enough time for both parties to review the potential relevancy of them.
12The assessment facility confirmed that it did not have clinical records for any of its assessors, except for those of Ms. Westbrook and those records were received by Mr. Silva on November 22, 2021.
13The hearing continued from December 6-8, 2021. Just prior to the cross-examination of Ms. Westbrook, Mr. Silva requested that the clinical records be admitted into evidence. Wawanesa opposed. It argued that being ordered to produce a clinical record during a hearing is acceptable, but that it would be procedurally unfair to admit them into evidence. Wawanesa argued that, if Mr. Silva wanted to rely on a clinical record as evidence, he should have disclosed it 30 days prior to the hearing.
14Mr. Silva highlighted that Wawanesa’s argument would make it impossible for him to comply with such a rule since the records were not produced to him until the middle of the hearing despite its numerous earlier requests.
15Ultimately, I allowed the clinical records into evidence. Mr. Silva requested the production of them since the case conference and had followed up with Wawanesa regarding them on three occasions. Moreover, Wawanesa was relying on Ms. Westbrook’s report to defend its position, meaning that, as a matter of procedural fairness, it ought to have produced the underlying clinical records in advance of the hearing. As already established, the clinical records were not produced in advance of the hearing, despite Wawanesa’s repeated attempts. Wawanesa had these records in its possession approximately 10 days prior to the continuation of the hearing and it had ample time to review them. The records were the very basis for Ms. Westbrook’s occupational therapy report. Ms. Westbrook was summonsed as a witness and therefore Wawanesa would have an opportunity to question her on the records. I saw no prejudice against Wawanesa, and the records were admitted into evidence.
Mr. Silva’s Request to Summons Wawanesa’s Witness
16Wawanesa did not call Ms. Westbrook, its occupational therapist as a witness and intended to rely on the IE report. Mr. Silva summoned the witness to testify. The parties disagreed on who had the right to cross-examination.
17Wawanesa argued that, since Ms. Westbrook was summoned by Mr. Silva, she was his witness, and he could only ask her questions in examination-in-chief. Mr. Silva disagreed. He argued that, because Wawanesa was relying on Ms. Westbrook’s report, Mr. Silva had a right to cross-examine her.
18I agreed with Mr. Silva. In this case, Wawanesa is relying on Ms. Westbrook’s report to support its position. Mr. Silva has a right to cross-examine the veracity of the report. Wawanesa did not summons the assessor, but Mr. Silva did to ensure the witness was present at the hearing for cross-examination of the report.
ANALYSIS
The Parties’ Submissions and the Law
19Mr. Silva stopped working because of the injuries he sustained in the car accident. Wawanesa paid him IRBs for approximately 13 years. However, in 2019, after a series of s. 44 IEs, Wawanesa terminated the benefit. Mr. Silva claims entitlement to an IRB in the amount of $200.62 per week from May 13, 2019 onward.
20Mr. Silva submits he meets the test for entitlement for a post-104 IRBs. He argues his impairments prevent him from working. Mr. Silva argues that his low back pain, sleep issues, depression, low motivation, and memory issues prevent him from working full-time. To manage his pain, he takes opioids daily and receives frequent pain injections. This provides temporary relief to complete some daily activities. Mr. Silva argues that the more activities he does, the more drugs he must take, which affects his memory and thoughts.
21He claims his training, education, and experience are only suitable for manual labour jobs. He is unemployable because he has a grade 9/10 education. He has attention deficit disorder (“ADD”). His reading, writing, and math abilities are at a low level. And he has not worked in 15 years.
22Lastly, Mr. Silva argues that his treating practitioner, Dr. Rozen, supports his inability to return to work. The various Disability Certificates (OCF-3) completed over the last few years indicate that Mr. Silva could not work because of permanent nerve damage and chronic low back pain. Mr. Silva is on two opioid pain relievers and an antidepressant for those injuries.5
23Wawanesa denied entitlement to the IRBs because the s. 44 assessors opined that Mr. Silva did not have any limitations or restrictions that prevented him from working and that suitable work alternatives were proposed based on his training, education, and experience.
24Wawanesa relies on two decisions suggesting that Mr. Silva must prove positive evidence of his inabilities.6 Wawanesa argues that Mr. Silva has provided no evidence of alternative suitable employment, no evidence of whether there was employment that could work around the alleged impairments, and no evidence of any effort to identify suitable employment or attempt to work at the suitable employment.
25To be entitled to the benefit, Mr. Silva has the onus to prove, on the balance of probabilities, that he satisfies the IRB test. Mr. Silva’s onus is echoed in various decisions issued by the Tribunal.7 In this case, entitlement to a post-104 week IRB is outlined in s. 6(2)(b) of the Schedule, which states that Mr. Silva must prove that:
as a result of the accident, [he] is suffering a complete inability to engage in any employment or self-employment for which he…is reasonably suited by education, training, or experience.
26In other words, the question I must answer is whether the impairments sustained in the accident prevent Mr. Silva from working in any occupation that he is reasonably suited for in light of his education, training, and experience.
27For that reason, Wawanesa asked Mr. Silva to attend a series of s. 44 assessments in March 2019. The resulting report issued on April 12, 2019 indicated the following:
(a) Mr. Silva suffers from chronic, non-specific low back pain. Mr. Silva does not have any physical limitations or restrictions that prevent him from returning to work;
(b) Mr. Silva does not have any psychological impairments;
(c) Mr. Silva is capable of light work duties, although Wawanesa’s assessor could not determine whether Mr. Silva could work an 8-hour day;
(d) a series of light jobs were recommended as suitable work options; and
(e) that he did not meet the test for post-104 IRBs.8
28Wawanesa issued a denial letter on April 22, 2019, stating that Mr. Silva no longer met the IRB test and, thus, the benefit would be terminated on May 13, 2019.9
Mr. Silva’s Background – Education, Training, and Experience
29As already noted above, Mr. Silva has a Grade 9/10 level of education and his reading, spelling, and math skills are at a Grade 4, 2, 3 level respectively.
30At the time of the accident, Mr. Silva was 29 years old10 and was working as a pipe layer,11 an extremely heavy, labour-intensive construction job. Over the years, Mr. Silva advanced his career through on-the-job training. He testified that he began as a labourer, and then by the time of the accident, he had become a pipe layer. He was making approximately $30 per hour. He had been previously employed as a cleaner and worked one winter snowplowing.12
31Mr. Silva has completed numerous health and safety certificates and, at one time, held an AZ license.13
Mr. Silva’s Impairment Complaints
32Mr. Silva’s impairment complaints are outlined in various clinical notes and records and in the assessment reports. They are also echoed in his and his wife’s testimony at the hearing.
33The word impairment is defined in s. 3(1) of the Schedule as “a loss or abnormality of a psychological, physiological or anatomical structure or function”.
34Mr. Silva testified that he has low back pain, sleep issues, depression, low motivation, and memory issues. He cannot sustain full-time work hours, and productivity. He has an inability to grasp things. The more activities he does, the more his pain increases, and the more opioids he must take, which affects his memory and cognition.
35Mr. Silva relies on the clinical notes and report of Dr. Rozen, an anesthesiologist, specializing in pain medicine and chronic pain. Wawanesa relies on the report of Dr. Devlin, physiatrist and Dr. Tucker, psychiatrist. All three doctors testified during the hearing.
36Dr. Rozen has been treating Mr. Silva for over nine years and produced a supplementary report regarding Mr. Silva’s diagnosis, and the impact of the car accident on his life and his ability to work. Dr. Rozen was initially qualified as an expert. Wawanesa argues that no weight should be given to Dr. Rozen’s testimony and report, since he admitted during his testimony that he is an advocate for Mr. Silva and, secondly, he did not conduct an assessment to write his report. Dr. Rozen did admit during his cross-examination to being an advocate for Mr. Silva but, contrary to Wawanesa’s submissions, Dr. Rozen did conduct an assessment in order to write his report. The report notes that Dr. Rozen’s opinion is based upon “conducting physical testing including a physical range of motion assessment”.14 However, because Dr. Rozen admitted to being an advocate, I will not rely on his report and will consider his testimony as that of a treating practitioner, a participatory witness. Dr. Rozen’s evidence will be limited to his clinical notes and his testimony of the facts.
37I prefer Dr. Rozen’s clinical notes and testimony regarding Mr. Silva’s ability to work over Wawanesa’s physiatry report authored by Dr. Devlin15. I also find the clinical notes of Dr. Rozen supportive of Mr. Silva and his wife’s testimony.
38Dr. Rozen specializes in the medical field in which Mr. Silva is having difficulties. He specializes in pain medicine and chronic pain. Whereas Dr. Devlin testified that chronic pain syndrome is not within his area of expertise.
39I find that since Dr. Rozen has been treating Mr. Silva for nine years, he has direct knowledge of Mr. Silva’s capabilities and inabilities. Although not thoroughly detailed in his clinical notes, Dr. Rozen testified that during his appointments he would ask Mr. Silva how things were going and, through those conversations, he understands what Mr. Silva can and cannot do.
40I find that Dr. Devlin fails to take Mr. Silva’s pain complaints into consideration. Dr. Devlin testified that, during his interview and assessments, he does not canvas the individual regarding their pain intensity. He said that he finds there is no good correlation between pain and functionality. He stated that pain is subjective: some people choose to work despite the pain, and others do not.
41I agree with Dr. Devlin that there are some individuals who work despite being in pain. However, when the pain results in functional limitations or restrictions, there must be other factors to consider. Dr. Rozen’s clinical notes and records indicate that injections would reduce Mr. Silva’s pain level from a 7 to a 3/4. The pain reduction would last anywhere from 7-10 days. This allowed Mr. Silva to maintain or improve his physical functioning, relationships, mood and sleep patterns for that period of time. There is absolutely a correlation between the level of pain one feels and their functionality. Mr. Silva and his wife testified and gave repeated examples of how his increased level of activity would intensify his pain, the more pain he experienced, the more medications he would have to take, which affected his memory. Mr. Silva testified that if he did not want to take an increased number of opioids then he would limit his activities. It is obvious that pain levels and functionality should be considered in determining impairments, restrictions, and limitations.
42Wawanesa asserts causation is at issue. He points me to a consultation report dated December 20, 2007, which was produced after Mr. Silva attended William Osler Hospital and complained that three months before, he was moving items in his home and hurt his back.16 I find there is no causation issue as Dr. Devlin considered these records and it had no impact on his opinion that Mr. Silva’s restrictions in his range of motion of the lumbar spine were from the car accident.17
43Wawanesa argues that I should make an adverse inference regarding Mr. Silva’s impairments as there are no clinical records or reports from the family doctor. I see no need to do this. According to the OHIP records, Mr. Silva barely saw his family doctor in the years before the termination of the benefit.18 Even the family doctor, Dr. Grossman, asked Dr. Rozen to fill out an insurance form for Mr. Silva because Dr. Rozen had been treating Mr. Silva’s accident-related injuries.19
Do the Accident-Related Impairments Cause a Complete Inability to Engage in Employment that Mr. Silva is reasonably Suited by Education, Training or Experience?
44The question in this hearing really comes down to whether Mr. Silva can be competitively employed and whether he can maintain employment.
45Wawanesa alleges that, because Mr. Silva admitted to jet skiing/snowmobiling a few times, driving a boat, driving his truck, taking two trips, driving for long periods to his cottage or to Toronto, welding for a few hours, and lifting a heavy canister, that he is not forthcoming about his abilities. Wawanesa argues that video surveillance is a clear indicator of his capabilities.
46I agree with Wawanesa that Mr. Silva has demonstrated some capabilities. However, I do not give this evidence much weight because out of the 21 days of surveillance, Mr. Silva was seen only six times.20 Out of those six occurrences, he was only seen performing noticeable activities five times. On four of these occasions, he was welding/sanding for periods of no more than four hours (on one of those days he was seen rolling a canister and maneuvering in and out of his truck). The video surveillance of Mr. Silva welding/sanding does not contain a clear view of how Mr. Silva is working or whether he is compensating movements for his injuries.
47On the last occasion, he went to Home Depot with his wife and daughter for approximately 40 minutes.21 The video surveillance at Home Depot is interesting because you have a clear view of Mr. Silva walking around, grabbing items, and pushing a cart. Mr. Silva is clearly using the cart to assist his back and he is constantly viewed as weight bearing on his right leg.22 These actions would be considered compensating pain movements.
48That being said, Mr. Silva admitted that over the last 15 years he could complete all those activities. But he also said when he does complete physical activities, he will end up paying for it. It results in him taking more painkillers or resting on a couch for several hours or days. Mr. Silva testified that he could stand for 10-20 minutes or even up to 2 hours depending on the medications he has taken. For example, once he receives injections from Dr. Rozen he could temporarily tolerate more activity. Once his back is aggravated, Mr. Silva testified that he must lie down. He testified that the epidural injections help to mask the pain and help with movement but those can only be given 4-5 times a year. Mr. Silva gave an example of how he may assist his wife around the house by cutting the grass, he would need to take two Percocet to do it. He would not be able to do any more activities in the house otherwise it would require taking more Percocet. He testified that as he increases his activities the more Percocet he requires. The more he takes the more it affects his cognition. In his words, he “does not know if he is coming or going”. His recounts are corroborated by his wife. She testified that Mr. Silva would cut the grass, shovel snow or play with the kids but then he will pay for it later. He will lie down and take more medications; the pain will be worse.
49Even during Ms. Westbrook’s assessment, Mr. Silva’s inability to work an 8-hour day is demonstrated that during a less than 3-hour evaluation, Mr. Silva took several rest periods and occasionally laid on the floor to rest.23 Ms. Westbrook, also observed Mr. Silva favouring his weaker left leg during the FAE.24 Sitting was also a problem during Mr. Silva’s treatment sessions. Mr. Silva’s psychologist’s progress report states that during the treatment sessions Mr. Silva would lie down on the floor because sitting was too painful.25
50Mr. Silva also has an inability to perform tasks in a normal timeframe; pacing is required. Mr. Silva testified that before the accident he could quickly complete a brake job on a car. Now he requires assistance from his kids, and it takes all day. Mr. Silva reported similar information to Dr. Devlin during the IE assessment that he needs to pace his activities.26
51Mr. Silva testified his depression medication alleviates his symptoms but he is always tired and lacks motivation. He testified that he cannot sleep because his back hurts. Mr. Silva’s wife testified that she normally sleeps on the couch because Mr. Silva can barely sleep.
52Mr. Silva also has an inability to concentrate, poor attention, lack of energy, fogginess, poor memory and low mood. In Dr. Tucker’s psychological report and testimony, she reiterated that Mr. Silva’s use of narcotic analgesic medications is likely contributing to this. She raised concerns regarding the dosages of the medications as they have addiction potential and can affect alertness.27 Again, his inability to remember items was substantiated by his wife’s testimony. She stated they will frequently get into fights over things he had just asked her about. As indicated above, the more narcotics Mr. Silva takes, the more it affects his cognition and alertness.
53I do not see a correlation between his ability to do some activities for short periods of time and his ability to work in a full-time position. I agree with Wawanesa that Mr. Silva has capabilities, however, I find he does not possess enough abilities to remain competitively employed.
54Based on Mr. Silva’s impairments, his inabilities, and what would be considered reasonably suited jobs because of his training, education, and experience, I find he meets the IRB test.
55I find based on Mr. Silva’s training, education and experience, he is only suited for physical jobs, construction jobs, and manual labour jobs.
56Mr. Silva is unable to work an eight-hour day, five days a week; unable to sit or stand for prolonged periods; unable to perform repetitive motions; unable to perform tasks in a normal timeframe, pacing is required; has a lack of motivation, endures poor sleep; unable to concentrate, poor attention, lack of energy, fogginess, and has low mood.
57As a result of these impairments, I find Mr. Silva unsuitable for any employment. He is not capable of providing predictable and reliable employment, a basic expectation of any employer. The factory-type jobs being suggested by Wawanesa would require completing the work within a reasonable timeframe. Mr. Silva would not be able to meet this job requirement as he requires pacing to complete a task.
58Mr. Silva relies on the Tribunal’s decision in VHT and Certas Home and Auto Insurance Company to support his position that any potential employment opportunities must have a real-world component. He quotes paragraph 18:
“It is well established, in the jurisprudence, that reasonably suited employment means employment “in a competitive, real-world setting, taking into account employer demands for reasonable hours and productivity.” The work should also be comparable in terms of status and wage.”28
59Lastly, any of the suggested occupations by Wawanesa were entry-level, light physical demands, minimum wage type jobs. Mr. Silva has no training, experience, or education for any of those jobs or fields. He would be considered over-qualified, and they would not be considered comparable in stature.
60The jobs suggested by Wawanesa did not factor in any real-world components. This would include a labour market survey that considers whether there are vacancies, are those vacancies within a reasonable commuting distance to Mr. Silva’s home, wages commensurate with what Mr. Silva previously made, and actual job requirements.
61The jobs proposed by Wawanesa allegedly did not require a high school education or any special requirements/skills but absent any real job descriptions it is difficult to know whether Mr. Silva possesses the required skills and education to acquire the jobs.
62Mr. Silva currently lives two hours and 20 minutes from Toronto. It would be unreasonable to suggest jobs that are not within commuting distance of his home. I have no evidence to suggest whether these proposed jobs are within a reasonable distance from his home.
63Also, since all these jobs were described by Mr. Zervas as entry-level jobs, the wages would not be commensurate with what Mr. Silva had previously made, almost $30 per hour.29 Since Mr. Silva had no experience in these fields, I cannot see how he would make anything but minimum wage.
Is Wawanesa entitled to costs for the hearing?
64At the end of the hearing, Wawanesa requested that costs be awarded against Mr. Silva. It argues that costs were incurred to have the witnesses attend for the purposes of cross-examination. Wawanesa asserts Mr. Silva conducted a poor cross-examination of the witnesses and that there was no need to have them present.
65Mr. Silva responded that his conduct does not amount to anything that warrants costs, and this was a proper hearing before the Tribunal.
66For costs to be granted, pursuant to Rule 19 a party must have acted unreasonably, frivolously, vexatiously, or in bad faith during the proceeding.30 This is a high bar to meet.
67Mr. Silva had a right to cross-examine Wawanesa’s assessors on the report. Even if that cross-examination was not effective, a proposition on which I make no comment, that is not behaviour that attracts costs. No costs will be awarded.
CONCLUSION
68I find Mr. Silva is entitled to IRBs in the amount of $200.62 per week, less any CPPD deductions.
69Since the payments are considered overdue, in accordance with s. 51(2), I order Mr. Silva is entitled to interest.
Released: May 30, 2022
Chloe Lester Vice-Chair
Footnotes
- Statutory Accident Benefits Schedule – Effective September 1, 2010, O. Reg. 34/10. (the “Schedule”)
- Tribunals Ontario, Safety, Licensing Appeals and Standards Division, Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”)
- License Appeal Tribunal (LAT) Rules of Practice and Procedure
- License Appeal Tribunal (LAT) Rules of Practice and Procedure
- Applicant’s Brief Tab 10 OCF-3 February 20, 2019; Tab 14 page 131 OCF-3 January 15, 2018; Tab 14 page 144 OCF-3 September 16, 2016
- 16-002234 v Unica Insurance Inc., 2017 CANLII 93459, and HV v Unifund Assurance Company, 2019 CANLII 10161
- Decision of Vice-Chair Chloe Lester December 1, 2021; El-Saikali v. Co-operators General Insurance Co., [2003] O.F.S.C.I.D No. 35; 17-007972 v RSA Insurance, 2018 CanLII 110943 (ON LAT); 17-004229 v The Guarantee Company of North American, 2018 CanLII 112115 (ON LAT)
- Ex 1 Respondent’s Brief Tab 12 – West Park Assessment Centre -report dated April 12, 2019
- Respondent’s Brief Page 49 IRB Denial Letter dated April 22, 2019
- Ex 1 Respondent’s Brief Tab 1 page 2 Application by an Injured Person
- Ex 1 Respondent’s Brief Tab 8 Page 43 OCF-1 Application for accident Benefits and Tab 29 OCF-2 page 1690
- Applicant’s Testimony
- Ex 1 Respondent’s Brief Tab 12 Page 258 – Vocational Evaluation April 12, 2019
- Respondent’ Brief Tab 19 Page 1309 – Dr. Rozen Report
- Respondent’s Brief Tab 12 Page 206
- Ex 1 Respondent’s Brief Page 426 – Records from William Osler Hospital
- Ex 1 Respondent’s Brief Page 192 and 201 – IE Summary Report dated April 12, 2019
- Ex 1 Respondent’s Brief Tab 24 OHIP Summary
- Ex 2 Applicant’s Brief page 855 – Note from Dr. Grossman to Dr. Rozen January 11, 2018
- Surveillance dates ranging from September 19, 2018 to October 17, 2020
- Ex 1 Respondent’s Brief Tab 37 Beginning page 1804 Reed Research Investigative Reports
- Video Surveillance October 17, 2018- weight bearing on right leg – time stamp on video: 6:30; 6:48; 8:47; 8:58-9:15; 9:30-9:45; 10:10-10:20; 10:44; grabbing cart for support 9:25
- Respondent’s Brief Tab 12 Page 250 Mrs. Westbrook’s FAE April 12, 2019
- Respondent’s Brief Tab 12 Page 247, 248, 249 Mrs Westbrook April 12, 2019
- Ex 1 Respondent’s Brief Page 1430- Dr. Geller Psychologist Progress report
- Applicant’s Brief Tab 18 a page 1493
- Respondent’s Brief Tab 12 Page 303, Dr. Tucker IE report dated April 12, 2019
- VHT and Certas Home and Auto Insurance Company, 2017 CanLII 69444 (ONLAT)
- I note 1 job did not have any wages listed.
- License Appeal Tribunal’s Rules of Practice and Procedure Rule 19

