Licence Appeal Tribunal File Number: 21-002415/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:
Vinoshan Pancharajah
Applicant
and
Aviva General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Anita Goela
APPEARANCES:
For the Applicant:
Agal Lankeswaran, Paralegal
For the Respondent:
Sophia Chaudri, Counsel
HEARD:
By way of written submissions
OVERVIEW
1The applicant was involved in an automobile accident on January 6, 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.
2According to the Case Conference Order, the issues in this dispute were narrowed at the June 20, 2022 Case Conference. The minor injury guideline (“MIG”) and the non-earner benefit (“NEB”) issues were withdrawn by the applicant on consent. However, the applicant’s written submissions address MIG and NEB rather than the outstanding issues that remain in dispute.
ISSUES
3The issues in dispute are:
i. Is the applicant entitled to $3,523.22 for physiotherapy services proposed by Alexmuir Wellness Centre in a treatment plan/OCF-18 (“plan”) dated October 29, 2019 and denied on November 13, 2019?
ii. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
4The applicant is not entitled to the disputed treatment plan or interest.
ANALYSIS
The applicant’s application is dismissed
5I find that the applicant has not met his onus, on a balance of probabilities, that the treatment plan is reasonable and necessary as a result of his accident-related injuries and impairments.
6Sections 14 and 15 of the Schedule provide that an insurer is only liable to pay for medical expenses that are reasonable and necessary as a result of the accident. The applicant bears the burden of proving entitlement to a disputed treatment plan on a balance of probabilities.
7As stated above, the applicant’s initial and reply submissions do not address the disputed treatment plan or provide submissions to support why it is reasonable and necessary.
8I found there were several issues with the applicant’s submissions. The applicant’s initial submissions were 18 pages long and not double-spaced. This is contrary to the Case Conference Order. The applicant does not explain the reason for non-compliance with the Order in his initial and reply submissions. Additionally, a proper reply is meant to address issues raised by the respondent that were not addressed by the applicant as they could not have been reasonably foreseen by the applicant when making his initial submissions. Instead, the applicant’s reply reiterated his entitlement to be removed from the MIG and did not address the arguments raised by the respondent, including the withdrawal of the MIG and NEB issues during the case conference, the missing disputed treatment plan and reasons supporting his entitlement to the disputed plan on the requisite reasonable and necessary standard. To be clear, even if I were to decide that the applicant should be removed from the MIG (and I do not make any such ruling here as it is not before me), the mere fact that an insured person is removed from the MIG does not automatically prove that the disputed treatment plan is reasonable and necessary.
9As it is the applicant’s burden to demonstrate entitlement to the benefits in dispute, and where the Tribunal was not presented with evidence from the applicant in support of his application, it follows that the applicant cannot be successful with his claim. I find that the applicant is not entitled to the benefit claimed.
ORDER
10The applicant is not entitled to the benefit in dispute. As no benefits are overdue, it follows that no interest is payable.
11The application is dismissed.
Released: September 12, 2023
Anita Goela
Adjudicator