Licence Appeal Tribunal
Licence Appeal Tribunal File Number: 20-002074/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:
Chandrakumar Chandrasegari
Applicant
and
Aviva General Insurance Company
Respondent
DECISION
ADJUDICATOR: Ulana Pahuta
APPEARANCES:
For the Applicant: Davide Cortinovis, Counsel
For the Respondent: Maggie Morgan, Counsel
HEARD: BY WAY OF WRITTEN SUBMISSIONS
OVERVIEW
1Chandrakumar Chandrasegari, the applicant, was involved in an automobile accident on November 13, 2017 and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”). The applicant was denied benefits by the respondent, Aviva General Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issues in dispute are:
i. Is the applicant entitled to $3,022.93 for a chronic pain assessment, proposed by Dr. Stephen Brown at Synoptic Medical in a treatment plan (“OCF-18’) dated January 14, 2020?
ii. Is the applicant entitled to $7,793.66 ($12,040.98 less $4,247.32 approved) for a chronic pain management program, proposed by Scarborough Physiotherapy and Rehabilitation in an OCF-18 dated January 10, 2020?
iii. Is the respondent liable to pay an award under s. 10 of Regulation 664 because it unreasonably withheld or delayed payments to the applicant?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3I find that:
i. The applicant is not entitled to the OCF-18 dated January 14, 2020 for a chronic pain assessment;
ii. The applicant is entitled to a portion of the outstanding balance of the OCF-18 dated January 10, 2020 in the amount of $6,896.00, for a chronic pain management program, plus interest in accordance with s. 51 of the Schedule;
iii. The applicant is not entitled to an award.
4To receive payment for a treatment and assessment plan under s. 15 and 16 of the Schedule, the applicant bears the burden of demonstrating on a balance of probabilities that the benefit is reasonable and necessary as a result of the accident. To do so, the applicant should identify the goals of treatment, how the goals would be met to a reasonable degree and that the overall costs of achieving them are reasonable.
The applicant has not established entitlement to the OCF-18 for a chronic pain assessment
5The applicant submitted an OCF-18 dated January 14, 2020 for a chronic pain assessment, in the amount of $3,022.93. By way of Explanation of Benefits dated January 17, 2020, the respondent denied this OCF-18, stating that it had already approved a previous chronic pain assessment on April 25, 2019, and