Licence Appeal Tribunal File Number: 24-001165/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:
Mohammed Alsafadi
Applicant
and
TD General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Rebecca Hines
APPEARANCES:
For the Applicant:
Georgiana Masgras, Counsel
For the Respondent:
Alanna Pink, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Mohammed Alsafadi, the applicant, was involved in an automobile accident on December 20, 2022, 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, TD General Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issues to be decided in the hearing are:
Is the applicant entitled to an income replacement benefit (“IRB”) in the amount of $400.00 per week from August 22, 2023, to date and ongoing?
Is the applicant entitled to $1,266.40 (2,681.60 less $1,215.20 approved) for physiotherapy services, proposed by Oscar Manias in a treatment plan (“OCF-18”) submitted on October 27, 2023?
Is the respondent liable to pay an award under s. 10 of 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 not entitled to the benefits claimed, interest or an award.
ANALYSIS
The applicant has not established that he is entitled to the quantum of IRBs in the amount of $400.00 per week from August 22, 2023 to date and ongoing.
4Section 5(1)1 of the Schedule provides that an insurer shall pay an IRB to an insured person who sustains an impairment as a result of an accident if they were employed at the time of the accident and, as a result of and within 104 weeks after the accident, suffers a substantial inability to perform the essential tasks of that employment. At the post-104 mark, the applicant must prove he has a complete inability to engage in any employment for which she is suited by education, training, or experience. It is the applicant’s onus to prove entitlement to the benefit.
5The applicant’s submissions did not address what his pre-accident occupation was and did not articulate the relevance of most of the evidence in his document brief. However, he argues that his physical and cognitive impairments have resulted in a substantial inability to carry out the essential tasks of his employment. Further, he asserts that he is entitled to an IRB in the amount of $400.00 per week for the disputed time-period.
6The respondent does not dispute the applicant’s entitlement to an IRB. It maintains that the applicant’s entitlement to an IRB is no longer in dispute because it issued a lump sum payment in the amount of $18,814.78 for past IRBs on January 9, 2025. It also submits that it has been paying the applicant an IRB in the amount of $240.61 per week on an ongoing basis as per the accounting report of Pricewaterhouse Coopers (“PWC”).
7The applicant’s submissions did not acknowledge receiving any payment for past IRBs from the respondent. Moreover, he chose not to file reply submissions to address the respondent’s position that it has paid the IRBs for the disputed time period. Nor did the applicant’s submissions address the quantum of the IRB or direct me to any evidence to support his position that he is entitled to $400.00 per week.
8I conclude that the applicant has not proven on a balance of probabilities that he is entitled to the quantum of IRBs in the amount of $400.00 per week.
The applicant is not entitled to the OCF-18 in the amount $1,266.40.
9Section 14 and 15 of the Schedule provides 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 onus of proving on a balance of probabilities that any claimed medical expenses are reasonable and necessary. 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 Tribunal has also determined that treatment is reasonable and necessary if it results in the temporary relief of pain.
10The applicant argues that he is entitled to the balance of the OCF-18 in the amount of $1,266.40 because he was removed from the Minor Injury Guideline and he requires treatment for his impairments.
11The respondent submits that this issue is no longer in dispute because on February 13, 2025, it approved the balance of the OCF-18. It relies on an Explanation of Benefits from the same date where it advised the applicant that it was approving the full OCF-18 for physiotherapy in the amount of $2,681.60.
12Again, the applicant chose not to file reply submissions to challenge the respondent’s position that it approved this OCF-18. Further, I find that the respondent’s EOB supports that it approved the OCF-18. Consequently, I find that the issue is no longer in dispute and find it unnecessary to address further.
The applicant is not entitled to interest.
13Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. I find the applicant is not entitled to interest because I have not found that any benefits are overdue.
The applicant is not entitled to an award.
14The applicant sought an award under s. 10 of Reg. 664. Under s. 10, the Tribunal may grant an award of up to 50 per cent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits.
15The applicant’s submissions did not address the award claim at all. Therefore, I find that he has not met his onus in proving that an award is payable.
ORDER
16The applicant is not entitled to the benefits claimed, interest or an award. The application is dismissed.
Released: October 7, 2025
Rebecca Hines
Adjudicator