Licence Appeal Tribunal File Number: 22-006538/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:
Muhammed Siddiqui
Applicant
and
Aviva General Insurance
Respondent
DECISION
ADJUDICATOR:
Margaret Sims
APPEARANCES:
For the Applicant:
Kelisa Reyes, Paralegal
For the Respondent:
Daniel MacDonald, Counsel
HEARD:
By way of written submissions
OVERVIEW
BACKGROUND
1Muhammed Siddiqui, the applicant, was involved in an automobile accident on June 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, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the "Tribunal") for resolution of the dispute.
ISSUES IN DISPUTE
2The issues to be decided in the hearing are:
- Is the applicant entitled to $3,246.14 for chiropractic services, proposed by E-Clinic United Hearing in a treatment plan/OCF-18 ("plan") submitted on June 3, 2022, and denied on June 13, 2022?
- Is the applicant entitled to $3,739.23 for psychological services, proposed by E-Clinic United Hearing in a plan submitted on June 3, 2022, and denied on June 13, 2022?
- Is the applicant entitled to $2,460.00 for a chronic pain assessment, proposed by HAL Disability Management Inc. in a plan submitted on May 10, 2022, and denied on June 13, 2022?
- Is the respondent liable to pay an award under s. 10 of O. Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
- Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant is entitled to:
i. $3,246.14 for chiropractic services, proposed by E-Clinic United Hearing in a plan submitted on June 3, 2022; ii. $3,739.23 for psychological services, proposed by E-Clinic United Hearing in a plan submitted on June 3, 2022; iii. $2,460.00 for a chronic pain assessment, proposed by HAL Disability Management Inc. in a plan submitted on May 10, 2022; iv. $2,500.00 in respect of an award under s. 10 of O. Reg. 664; and v. interest pursuant to s.51 of the Schedule.
ANALYSIS
4I find that the treatment plans at issue are reasonable and necessary as a result of the accident.
5To be entitled to a treatment plan under sections 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. In considering whether the treatment is reasonable and necessary, I have considered whether (i) the treatment goals are reasonable, (ii) the goals are being met to a reasonable degree and (iii) the overall costs of achieving the goals is reasonable.
Chiropractic Services Plan submitted on June 3, 2022
6I find that the chiropractic services plan in the amount of $3,246.14 submitted on June 3, 2022 is reasonable and necessary as a result of the accident.
7The applicant submits that, as a result of the subject accident and as set out in the Clinical Notes and Records of Dr. Sithamparanathan dated June 29, 2017, he suffered from neck pain, thoracic pain, lumbar pain, sacroiliac joint pain, anxiety, dizziness, nervousness, sleep disturbances, and headaches. The applicant further submits that his pre-existing pain from a prior right-hand fracture and surgically repaired ankle injury were exacerbated by the subject motor vehicle accident.
8The applicant notes that he was only removed from the minor injury guideline ("MIG") on September 17, 2021 (4.5 years after the accident) when a prior application under file no. 20-009861/AABS was settled on the basis that the applicant was removed from the MIG and incurred treatment plans were paid, and, as a result, he experienced a significant delay in approval and payment of treatment essential for medical recovery and abstained from receiving necessary treatment for an extended period due to the recurring issues of non-approval and non-payment of incurred expenses. In addition, the applicant submits that he experienced barriers in obtaining treatment during the COVID-19 pandemic.
9The applicant submits that, as set out in the plan completed by chiropractor Nabavi Mir-Reza, the goals of the OCF-18 include: (1) pain reduction, (2) increase in strength, (3) increased range of motion, (4) to provide the tools to foster patient self-management, (5) implement a rehabilitation program (exercises