Licence Appeal Tribunal File Number: 21-001388/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:
Conroy Williams
Applicant
and
Aviva Insurance Company of Canada
Respondent
DECISION
ADJUDICATOR:
Derek Grant
APPEARANCES:
For the Applicant:
Camille Narine-Ramrattan, Paralegal
For the Respondent:
Jessica Bacolulos, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Conroy Williams (“C.W.”), the applicant, was involved in an automobile accident on August 17, 2018, 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, 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 C.W. entitled to the following treatment proposed by Midland Wellness as follows:
a) $2,029.61 for physiotherapy treatment, proposed in a treatment plan (OCF-18) denied on March 24, 2020?
b) $2,499.83 for physiotherapy treatment, proposed in an OCF-18 denied on January 29, 2020?
c) $1,203.26 for physiotherapy treatment, proposed in an OCF-18 denied on November 5, 2019?
d) $1,527.98 for physiotherapy treatment, proposed in an OCF-18 denied on August 23, 2019?
e) $1,852.70 for physiotherapy treatment, proposed in an OCF-18 denied on July 8, 2019?
f) $2,148.20 for physiotherapy treatment, proposed in an OCF-18 denied on May 7, 2019?
g) $2,768.50 for physiotherapy treatment, proposed in a OCF-18 denied on December 3, 2018?
h) $2,443,94 for physiotherapy treatment, proposed in a OCF-18 denied on February 22, 2019?
ii. Is C.W. entitled to interest on any overdue payment of benefits?
RESULT
i. C.W. is not entitled to the OCF-18s in dispute;
ii. No interest is payable;
3The application is dismissed.
ANALYSIS
Are the OCF-18s reasonable and necessary?
4Sections 14 and 15 of the Schedule provide that the insurer shall pay medical benefits to, or on behalf of, an applicant so long as the applicant sustains an impairment as a result of an accident and the medical benefit is a reasonable and necessary expense incurred by the applicant as a result of the accident.
5To receive payment for a treatment plan under 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. 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 same are reasonable.
6I find that C.W. has failed to prove on a balance of probabilities that the disputed OCF-18s are reasonable and necessary for the following reasons:
i. The submissions, which are not evidence, refer to various clinical notes and records from the family physician (and other medical records), fail to demonstrate that the goal of treatment; and how the goals would be met to a reasonable degree; and the cost of same are reasonable;
ii. There is no analysis for how each of the treatment plans will address the accident-related injuries;
iii. The family physician records note August 27, 2018 and April 2, 2019 visits, for accident-related pain complaints, with no other accident-related presentations;
iv. While C.W. submits that he has ongoing pain, and despite receiving approximately 120 sessions of treatment from Midland Wellness Centre, there is no evidence that the treatment was providing any notable relief. In my view, the pain was ongoing, and on occasion noted to be worse, despite the number of treatment sessions received;
v. C.W. submits that he suffers psychological impairments as a result of the accident. Specifically, he relies on an October 25, 2019 psychological report from Midland Wellness Centre. However, as there are no claims for psychological treatment in dispute, I assign very little weight to these arguments (and related evidence). In addition, the psychological evidence is not relevant to whether or not the OCF_18s for physiotherapy are reasonable and necessary;
vi. C.W. does not direct me to any reports or evidence to refute the s. 44 insurer examination reports, in which Dr. Belfon, general physician, opined that further facility-based treatment would not be beneficial, in turn, recommending that he continue with home-based stretching and conditioning. Dr. Belfon concluded that C.W. suffered sprain and strain soft tissue injuries; that he reached maximum medical recovery and the disputed OCF-18s were not reasonable and necessary.
7The burden remains on C.W. to prove that the disputed OCF-18s are reasonably and necessary on a balance