Licence Appeal Tribunal File Number: 24-014268/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:
Ahela Asif
Applicant
and
Definity Insurance Company
Respondent
DECISION
VICE-CHAIR:
Henry Harris
APPEARANCES:
For the Applicant:
Robert Besunder, Counsel
Muhammad Aftab Alam, Counsel
For the Respondent:
Stephen Whibbs, Counsel
Joshua Vickery, Counsel
Court Reporter:
Siriana Taylor
HEARD by Videoconference:
June 23-27 and 30, 2025
OVERVIEW
1Ahela Asif (the "applicant") was involved in an automobile accident on October 12, 2021, 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 Definity Insurance Company (the "respondent") 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. Has the applicant sustained a catastrophic impairment as defined by the Schedule?
ii. Is the applicant entitled to an income replacement benefit ("IRB") in the amount of $400.00 per week from October 19, 2021 to date and ongoing?
iii. Is the applicant entitled to attendant care benefits ("ACB") in the amount of $2,018.04 per month from November 24, 2023 to date and ongoing?
iv. Is the applicant entitled to the medical services proposed by New Hope Physiotherapy Inc., as follows:
a) $1,370.90 for physiotherapy services in a treatment plan/OCF-18 ("plan") dated July 20, 2022;
b) $998.00 for physiotherapy services, in a plan dated May 31, 2023;
c) $1,696.25 for physiotherapy services, in a plan dated August 30, 2023;
d) $1,397.00 for physiotherapy services, in a plan dated January 15, 2024; and
e) $1,397.00 for physiotherapy services, in a plan dated March 8, 2024?
v. Is the applicant entitled to the medical services proposed by Pearson Medical Assessment, as follows:
a) $3,964.51 for psychological services in a plan dated September 12, 2024; and
b) $2,200.00 for a chronic pain assessment in a plan dated March 7, 2022?
vi. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
vii. Is the applicant entitled to interest on any overdue payment of benefits?
3At the start of the hearing, the applicant withdrew issues 4vi, vii and viii, and 5x, xii, xiii, xiv and xv as listed in the case conference report and order dated February 21, 2025 (the "CCRO").
4On the fifth day of the hearing, the applicant withdrew issues 6, 7 and 8 as listed in the CCRO. The withdrawn issues have not been included in the issues in dispute set out above.
5For issue iv(a) above, the CCRO refers to a plan submitted July 22, 2022. However, in reviewing the plan it is dated July 20, 2022 as set out above.
6For issue iv(b) above, the CCRO refers to a plan submitted June 7, 2023. However, in reviewing the plan it is dated May 31, 2023 as set out above.
RESULT
7The applicant has not sustained a catastrophic impairment as defined by the Schedule under Criterion 8.
8The applicant is not entitled to IRB, the plans in dispute, interest or an award.
9The applicant is not entitled to ACB in the amount of $2,018.04 per month from November 24, 2023 to date and ongoing.
10The application is dismissed.
PROCEDURAL ISSUES
Applicant's motion to allow adjuster to be summoned without personal service denied
11At the start of the hearing, the applicant brought a motion to recognize a summons as being validly served on the adjuster. The applicant advised that she had attempted to serve a summons for the adjuster to appear as a witness at the hearing via email of the summons to the respondent's counsel. The applicant indicated that it understood the respondent was taking issue with the applicant not serving the summons personally on the adjuster as is required under the Statutory Powers Procedure Act, RSO 1990, c S.22 (the "SPPA").
12The applicant argued that from a practical perspective the summons had been served in that it was emailed to the respondent on June 13, 2025, providing sufficient time to allow the adjuster to attend. The applicant submitted that the testimony of the adjuster is relevant and necessary to addressing the issue of her claim under s. 10 of Reg 664 ("s. 10 claim"). The applicant further submitted that if personal service was found to be required, she would not be seeking an adjournment in order to comply with the Licence Appeal Tribunal Rules (the "Rules") requirement that the summons be served 10 days before the hearing.
13The respondent objected to the motion, arguing that the summons is not valid as the applicant failed to comply with s.12(3) of the SPPA which require a summons to be served personally. The respondent argued that no effort was made by the applicant to seek out the adjuster's address and that the applicant simply sent the summons to respondent's counsel by email and did not raise this issue prior to the hearing.
14I denied the applicant's motion to recognize the summons as being served on the adjuster. Section 12(3) of the SPPA is clear that a summons shall be served personally on the person summoned. This is also indicated on the Tribunal summons form under the Important Information heading. Rule 8.2 specifies that the approved summons must be served no later than 10 days before the hearing. I find there was no indication that the applicant made any effort to obtain the adjuster's address for personal service, and that the issue had not been raised by the applicant prior to the hearing. I find that any prejudice to the applicant is mitigated by the applicant being able to make submissions on the s. 10 claim and evidence can be presented through the adjusters' log notes.
ANALYSIS
The applicant has not sustained a catastrophic impairment under Criterion 8
15I find the applicant has not established that she has sustained a catastrophic impairment as defined by the Schedule for the reasons that follow.
16The applicant seeks a catastrophic ("CAT") impairment determination under s. 3.1(1)8 of the Schedule, referred to as Criterion 8. The applicant bears the burden of proof.
17In order to meet the threshold for CAT status under Criterion 8, an individual must have sustained at least three marked (class 4) impairments or one extreme (class 5) impairment out of the four spheres of functioning as a result of the accident due to a mental and behavioural disorder. These impairments are assessed under Chapter 14 of the American Medical Association's Guides to the Evaluation of Permanent Impairment, 4th Edition, 1993 (the "Guides").
18Mental and behavioural impairments are rated according to how seriously they affect a person's useful daily functioning. The Guides sets out the four areas or "spheres" of functioning and the relative levels of impairment. The test to determine whether the applicant has sustained a catastrophic impairment is a legal one and not a medical one. See: Liu v. 1226071 Ontario Inc. (Canadian Zhorong Trading Ltd.), 2009 ONCA 571 at paras 29-30.
19The four spheres of functioning, classes of impairment and rating criteria set out in the Guides are outlined in the chart below.
Area or Aspect of Functioning
Class 1: NO Impairment
Class 2: MILD Impairment
Class 3: MODERATE Impairment
Class 4: MARKED Impairment
Class 5: EXTREME Impairment
Activities of Daily Living
No impairment is noted
Impairment levels are compatible with most useful functioning
Impairment levels are compatible with some, but not all useful functioning
Impairment levels significantly impede useful functioning
Impairment levels preclude useful functioning
Social Functioning
Concentration, Persistence and Pace
Adaption (in a work-like setting)
20In this case, the parties' catastrophic assessors gave the following ratings:
Sphere
Applicant
Respondent
Activities of Daily Living
Class 4
Class 4
Social Functioning
Class 4
Class 3
Concentration, Persistence, and Pace
Class 3
Class 3
Adaptation
Class 4
Class 4
21Classes 1, 2, 3 and 5 are defined by a person's level of useful functioning: respectively, all useful functioning, most useful functioning, some useful functioning, and no useful functioning. Class 4, on the other hand, is defined by whether useful functioning is significantly impeded rather than the residual level of useful functioning.
22The parties agree that the applicant suffers from a mental or behavioural disorder due to the accident. Neither party argued that the applicant suffers from a Class 5 extreme impairment. Therefore, the applicant must show that she suffers from a Class 4 marked impairment in three of the four spheres of functioning. The parties' assessors found that the applicant sustained a Class 3 moderate impairment in the sphere of concentration, persistence, and pace, and a Class 4 marked impairment in the spheres of activities of daily living and adaptation. It follows that the applicant must demonstrate that she sustained a Class 4 marked impairment in the sphere of social functioning in order to meet the definition of CAT under Criterion 8.
23In the area of social functioning, the applicant's assessor rated her as Class 4 marked impairment, while the respondent's assessor rated the applicant as Class 3 moderate impairment. The applicant limited her arguments to whether she has sustained a Class 4 marked impairment.
24The applicant has not satisfied me that she meets the CAT threshold under Criterion 8 as I do not find she has a Class 4 marked impairment in the area of social functioning, which I will address now.
Social Functioning
25I find the applicant has not met her onus to establish that she sustained a marked impairment under the domain of social functioning.
26The Guides specify that the factors to consider under the social functioning domain are an individual's capacity to interact appropriately and communicate effectively with other individuals. It includes the ability to get along with others, such as family members, friends, neighbours, grocery clerks, landlords or bus drivers. Impaired social functioning may be demonstrated by a history of altercations, evictions, fear of strangers, avoidance of interpersonal relationships, social isolation, or similar events or characteristics. An individual's ability to initiate social contact with others, communicate clearly with others, and interact and actively participate in group activities are seen as strengths in social functioning.
27The applicant relies on the assessments completed by Dr. Sadiq Hasan, psychiatrist, and Mr. Justin Moy, occupational therapist, who both testified at the hearing. In Dr. Hasan's s. 25 CAT psychiatric examination report dated November 20, 2023, he opined that the applicant had a marked impairment in activities of daily living, social functioning and adaptation, and a moderate impairment in concentration, persistence and pace, as set out above.
28The respondent relies on the assessments completed by Dr. Joel Eisen, psychiatrist, and Mr. Dan Gauthier, occupational therapist, who both testified at the hearing. In Dr. Eisen's IE CAT psychiatric examination report dated September 3, 2024, he opined that the applicant had a marked impairment in activities of daily living and adaptation, and a moderate impairment in social functioning and concentration, persistence and pace, as set out above.
29Both Dr. Hasan and Dr. Eisen found the applicant to have accident-related diagnoses of somatic symptom disorder with predominant pain, major depressive disorder, and post-traumatic stress disorder. Dr. Hasan also diagnosed a specific situational driving phobia. Given the commonality of two of the diagnoses of the applicant and respondent's assessors, there is no dispute that the applicant suffers from a mental or behavioural disorder as a result of the accident.
30The applicant testified that prior to the accident she enjoyed going on picnics with the family, playing badminton with her three children and going to the mosque to pray. She reported to medical assessors that she had not made friends since moving from Pakistan to Canada in 2019 due to COVID and her working. She used to enjoy spending time with her family, attending dinners, socializing, exercising at the gym and walking and hiking for leisure and travelling. Post-accident, she reported that she is no longer attending the mosque and has withdrawn from participating in social activities with family and friends and other mosque members due to pain symptoms which have decreased her interest and motivation.
31Dr. Hasan opined that the applicant has a marked impairment in social functioning. In his report, the doctor notes that the applicant has become socially isolated and does not spend quality time with family or friends due to her preoccupation with pain and fatigue. He notes that her inability to return to work has devastated her previous optimistic outlook toward her future. Dr. Hasan also referred to Mr. Moy's s. 25 CAT occupational therapy in-home and situational assessment report dated October 25, 2023. Mr. Moy notes that the applicant reports that she does not enjoy public places and gets frustrated. She reports that she does not do anything important, and just does her daily prayers, watches TV and lays down in her bed. However, she reports that she has dinner with her children every night, without her husband as he is working.
32Dr. Eisen determined that the applicant has a moderate impairment in social functioning, noting that she continues to maintain a very close relationship with her husband, a close relationship with her children and enjoys spending quiet time with them, and a close relationship with her parents with whom she speaks to on a daily basis. Mr. Gauthier's IE CAT occupational therapy assessment report dated September 3, 2024, notes that the applicant also speaks by phone with her younger brother weekly and her two younger sisters once or twice weekly. She continues to drive to appointments and takes her children to their cricket classes weekly, which is a 10-15 minute drive. Dr. Eisen found that although the applicant has likely experienced a significant decline in functioning in this domain, she retains useful social functioning.
33I find the opinion of Dr. Eisen more closely aligns with the preponderance of evidence of the applicant's social functioning abilities than does the opinion of Dr. Hasan. Therefore, I put significant weight on this report. The applicant has maintained a close relationship with her three children and spouse, and they were expecting a fourth child shortly after the date of the hearing. She continues to drive and pick up her children from school in the afternoons and drives the children to sporting activities on a weekly basis. Video surveillance from October 2023 demonstrates useful social functioning, in which the applicant is seen driving on multiple days, including driving three children, as well as shopping with her husband and having a conversation with a store clerk. The applicant also continued to have a close relationship with her extended family that live outside of Canada, including speaking on the phone with her parents on a daily basis, and her brother and two sisters at least once a week.
34While the applicant reports that she is socially isolated and does not do anything important and lays in bed inactive watching TV, I find this underestimates the meaningful social interactions that she continues to have. Her primary social interactions pre-accident was with her family as she indicated that she had not made friends since moving to Canada. She has maintained such close familial relationships, initiating regular contact with her extended family and participating in daily life activities with her husband and children.
35As well, the evidence presented shows that post-accident the applicant secured new employment on a casual basis as a lunchroom supervisor, and later as an educational assistant at Great Lakes Public School for a period of a year and a half starting a few months after the accident until October 2023, working an aggregate of over 200 hours. The existence and scope of such employment was not clearly communicated to the assessors, with Dr. Eisen noting that the applicant said she did not return to work following the accident, while Dr. Hasan reported that the applicant worked for a few weeks. In any case, I find that the assessors did not have a clear picture of the scope of her post-accident employment. Dr. Evans testified that this employment information would have been relevant to his assessment, as it is an example of useful functioning.
36I find that the applicant's ability to secure and maintain her employment at the school for 18 months demonstrates useful social functioning. She was responsible for the safety of children, and her continuing to serve in that role for an extended period of time demonstrates an ability and capacity to interact appropriately and communicate effectively with other individuals, including children, teachers and work supervisors. Such capacity to interact appropriately and communicate effectively with other individuals are seen as strengths in social functioning in the Guides.
37Accordingly, for the above-noted reasons, I find the applicant has not met her onus to establish that she sustained a marked impairment under the domain of social functioning.
CAT Criterion 8 Conclusion
38As the applicant has not established that she has a marked impairment in the area of social functioning, the applicant cannot meet the requirement of having sustained at least three marked impairments in order to be designated catastrophically impaired. Although I acknowledge that the applicant sustained impairments as a result of the accident which have had a negative impact on her life, this alone does not satisfy the thresholder under Criterion 8.
39Accordingly, for the reasons set out above, I find that the applicant has not proven on a balance of probabilities that she sustained a catastrophic impairment under Criterion 8 in accordance with the Schedule as a result of the accident.
The applicant is not entitled to IRB
40I find the applicant has not established entitlement to IRB.
41To receive payment for an IRB under s. 5(1) of the Schedule, the applicant must be employed at the time of the accident and, as a result of and within 104 weeks after the accident, suffer a substantial inability to perform the essential tasks of that employment. The applicant must identify the essential tasks of their employment, which tasks they are unable to perform and to what extent they are unable to perform them. The applicant bears the burden of proving on a balance of probabilities that they meet the test.
42To receive payment for a post-104 week IRB under s. 6 of the Schedule, the applicant must demonstrate on a balance of probabilities that they suffer from a complete inability to engage in any employment or self-employment for which they are reasonably suited by education, training or experience.
43I will first consider the applicant's entitlement to pre-104 IRB.
44The applicant submitted that at the time of the accident, she was working on a part-time basis as a cashier at a grocery store, Iqbal Foods. The applicant testified that she interacted with customers, scanned items for them at checkout and put purchased items in the shopping cart for customers. The position involved standing. The applicant worked in this position for six weeks. Prior to that, the applicant worked as a part-time cashier at Dollarama for approximately two weeks.
45Dr. Hasan and Mr. Moy found the applicant's pre-accident duties as a cashier to include managing transactions at the checkout, organizing stock, scanning items, standing for sustained periods, reaching, lifting and carrying. Occasional sitting was also found to be required.
46Based on the applicant's testimony and Mr. Moy's report, I find that the essential tasks of the applicant's employment as a cashier to be standing for sustained periods, managing an area at checkout, interacting with customers, reaching, lifting and scanning grocery items.
47The applicant testified that she was unable to continue working as a cashier after the accident. She said the job required her to stand and lift items, which she cannot do now due to pain. She also testified that the position involves dealing with people, and that when she sees many people at once she gets nervous.
48In her testimony, the applicant indicated that she did not remember whether she tried to return to work at Iqbal after the accident, and if she did return, she did not remember whether she had any difficulties working there.
49As the applicant bears the onus to establish which of the essential tasks of her employment she is unable to perform, I find it is not helpful to her case that she cannot recall whether she attempted to return to work as a cashier after the accident.
50In Dr. Hasan's s. 25 CAT psychiatric examination report, he was of the opinion that the applicant suffers a substantial inability to perform the essential tasks of her pre-accident employment as a cashier. Dr. Hasan found that the physical and psychological limitations prevent her from completing her essential duties. He cites diagnoses of somatic symptom disorder, major depressive disorder and post-traumatic stress disorder as impacting her cognitive functioning, affective stability and coping skills.
51Dr. Hasan indicated in his report that the applicant worked as a lunchroom supervisor at a school for a few weeks, working two hours per week, but was unable to complete her job duties as a result of ongoing sequalae from the subject accident. However, in cross-examination, Dr. Hasan acknowledged he was unaware that the applicant had worked at the school for 18 months and that she progressed from a lunchroom supervisor to an educational assistant. He acknowledged that this information about the applicant's post-accident employment, including the length of employment and responsibilities, would have been relevant to his assessment and findings.
52I give no weight to Dr. Hassan's opinion on the applicant's inability to perform pre-accident employment tasks because at the time of his assessment in October 2023, he was not made aware that she had been working with children at a school for the past 18 months.
53In addition, the applicant entered as evidence a letter dated March 18, 2025 from Dr. Jagtaran Dhaliwal, psychiatrist, who states that the applicant tried to return to work but could not due to ongoing pain in her body. The applicant also entered an April 1, 2025 letter from the family doctor, Dr. Ihsan Waraich, stating that physical and psychological problems have made it increasingly difficult for the applicant to work. I am not persuaded by these letters made proximate to the hearing as the applicant did not substantiate how these brief references alone would establish entitlement to pre-104 IRB.
54The respondent relies on the multidisciplinary assessment reports dated September 28, 2022 of Dr. Esmat Dessouki, orthopaedic surgeon, Dr. Janet Clewes, psychologist, and Dr. Philip Dimakis, chiropractor. Dr. Dessouki conducted a physical assessment of the applicant and found that there was no objective evidence of residual musculoskeletal impairment attributable to the injuries sustained in the subject accident. He testified that there was a discrepancy between the formal examination finding and his casual observations. For example, her range of motion presented was far greater when he observed her outside of the formal testing. Dr. Dessouki opined that the applicant does not suffer a substantial inability to complete the essential tasks of her pre-accident employment.
55Dr. Clewes previously conducted an in-person assessment of the applicant and prepared a report dated August 5, 2022, prior to completing her file review report dated September 28, 2022. While Dr. Clewes diagnosed the applicant with psychological conditions of specific driving phobia and adjustment disorder with mixed anxiety and depression, the doctor found that the applicant does not suffer a substantial inability to engage in her pre-accident employment activities.
56I find the reports of Dr. Dessouki and Dr. Clewes to be persuasive, as the doctors conducted independent examinations and testing of the applicant as well as documentary review of her medical history in reaching their opinions on the applicant's ability to perform essential tasks of pre-accident employment. I prefer these reports over the report of Dr. Hasan, which I have given no weight because Dr. Hasan recognized that the applicant had not advised the doctor of the length and scope of her post-accident employment, which he acknowledges would be relevant information for his assessment and findings.
57For these reasons, I find the applicant has not established entitlement to pre-104 IRB. With this finding of not satisfying the "substantial inability" standard, it follows that I find the applicant has not established an ongoing entitlement to the benefit of post-104 week IRB under the higher standard of "complete inability".
58Accordingly, I find on a balance of probabilities that the applicant has not established that she is entitled to pre or post-104 IRB.
The applicant is not entitled to ACB in the amount of $2,018.04 per month from November 24, 2023 to date and ongoing
59I find the applicant has not established entitlement to ACB in the amount of $2,018.04 per month from November 24, 2023 to date and ongoing.
60Section 19 of the Schedule states that an insurer shall pay for all reasonable and necessary expenses incurred by or on behalf of an insured person as a result of an accident for ACBs provided by an aide or attendant. Section 42(1) of the Schedule provides that an application for ACBs must be in the form of, and contain the information required to be provided in, the version of the document entitled Assessment of Attendant Care Needs ("Form-1").
61Section 42(3) states that an insurer has 10 business days after the submission of the Form-1 to provide notice of the ACBs it agrees to pay, refuses to pay and the medical and other reasons for the denial. Alternatively, it can provide notice requesting an IE.
62The maximum payable for ACB under the Schedule is $3,000.00 per month for a non-catastrophically impaired insured person.
63Section 3(7)(e) provides that to meet the definition of incurred the following three criteria must be satisfied:
i. The applicant received the service to which the expense relates;
ii. The applicant paid the expense or promised to pay the expense or is legally obligated to pay the expense; and
iii. The person who provided the service:
a) did so in the course of his or her employment, occupation, or profession in which he or she would ordinarily have been engaged, but for the accident; or
b) sustained an economic loss as a result of providing the goods or services to the insured person.
64The applicant relies on the Form-1 completed by Mr. Justin Moy, occupational therapist, dated October 16, 2023 which assessed monthly ACB of $2,018.04 (the "applicant's Form-1"), and Mr. Moy's s. 25 CAT occupational therapy in-home and situational assessment report dated October 25, 2023. It is the applicant's position that all recommended attendant care is reasonable and necessary. The applicant submitted that there is no question of entitlement as the respondent has continued to pay a monthly ACB of $1,580.30. Rather, the issue is quantum of ACB for the period November 24, 2023 to date and ongoing.
65The respondent's position is that the quantum of attendant care recommended in the applicant's Form-1 is not reasonable and necessary. The respondent relies on Mr. Gauthier's IE occupational therapy attendant care benefits assessment report dated August 26, 2024 and accompanying Form-1 dated July 29, 2024 completed by Mr. Gauthier which assessed monthly ACB of $1,580.30 (the "respondent's Form-1"). The respondent also relies on a paper review report of Mr. Gauthier dated March 10, 2025. The respondent submitted that the applicant is not entitled to ACB as there is no evidence to show any incurred, unpaid amounts owing by the respondent to the applicant for ACB.
66I find the applicant is not entitled to ACB of $2,018.04 per month from November 24, 2023 to date and ongoing because she did not direct me to evidence that the ACB expenses in the applicant's Form-1 have been incurred pursuant to s. 3(7)(e) of the Schedule. The applicant did not direct me to the test for ACB or her position on how she qualifies for the benefit in dispute.
67In addition, I am not persuaded by Mr. Moy's s. 25 CAT in-home and situational assessment report dated June 14, 2023. Despite the report being titled as an in-home assessment, the actual assessment took place at an office. While Mr. Moy testified that this was due to the applicant not being comfortable conducting the assessment at home with a male, he acknowledged that it would have been better to do the assessment at the applicant's home in order to observe how she functions in her environment. As an example, the office lacked the appliances and utensils needed for a kitchen assessment. For observing meal prep, he was limited to asking her to make a cup of tea. The assessment was conducted over three hours, and done without an interpreter as Mr. Moy felt her English was fluent and that there was no issue understanding her. In contrast, Mr. Gauthier's IE ACB assessment was done at the applicant's home over the course of two days and utilized an interpreter, as was the case for all other assessments referred to at the hearing. As such, I prefer Mr. Gauthier's report.
68Accordingly, I find on a balance of probabilities that the applicant has not met her onus of demonstrating entitlement to ACB of $2,018.04 per month from November 24, 2023 to date and ongoing.
69To receive payment for a 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. 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 is not entitled to the plans for physiotherapy services
70I find the applicant has not proven on a balance of probabilities that any of the plans for physiotherapy services proposed by New Hope Physiotherapy Inc. are reasonable and necessary.
71The plan dated July 20, 2022 was prepared by Anchal Budhiraja, physiotherapist, and sought funding of $1,370.90 for 8 - 1 hour physiotherapy sessions and 6 - 1 hour massage therapy sessions.
72The plan dated May 31, 2023 was prepared by Gurdeep Kaur, physiotherapist, and sought funding of $998.00 for 8 - 1 hour physiotherapy sessions.
73The plan dated August 30, 2023 was prepared by Gurdeep Kaur, physiotherapist, and sought funding of $1,696.25 for 15 - 1 hour physiotherapy sessions.
74The plan dated January 15, 2024 was prepared by Anchal Budhiraja, physiotherapist, and sought funding of $1,397.00 for 12 - 1 hour physiotherapy sessions.
75The plan dated March 8, 2024 was prepared by Anchal Budhiraja, physiotherapist, and sought funding of $1,397.00 for 12 - 1 hour physiotherapy sessions.
76A treatment plan in and of itself is insufficient to establish entitlement to a benefit. The applicant did not provide any submissions or direct me to any evidence to support entitlement to the plans in dispute, other than having the plans entered as exhibits.
77Accordingly, I find on a balance of probabilities that the applicant has not met her onus of demonstrating that the plans for physiotherapy services are reasonable and necessary.
The applicant is not entitled to $2,200.00 for a chronic pain assessment
78I find the applicant has not proven on a balance of probabilities that the plan for a chronic pain assessment is reasonable and necessary.
79The plan dated March 7, 2022 was prepared by Inderneet Arora, occupational therapist, and sought funding of $2,200.00 for a chronic pain assessment, inclusive of $200.00 for documentation support.
80A treatment plan in and of itself is insufficient to establish entitlement to a benefit. The applicant did not provide any submissions or direct me to any evidence to support entitlement to the plan in dispute, other than having the plan entered as an exhibit.
81Accordingly, I find on a balance of probabilities that the applicant has not met her onus of demonstrating that the plan for a chronic pain assessment is reasonable and necessary.
The applicant is not entitled to $3,964.51 for psychological services
82I find the applicant has not proven on a balance of probabilities that the plan for psychological services is reasonable and necessary.
83The plan dated September 12, 2024 was prepared by Dr. Tony Toneatto, psychologist, and sought funding of $3,964.51 for 12 – 1 hour psychological sessions, inclusive of $1,172.47 for documentation support and $99.00 for brokerage services.
84The applicant relies on progress reports dated April 11, 2024 and September 17, 2024 of Dr. Toneatto, and directed me to the sections of the report on recommendations and goals of continuing treatment. As Dr. Toneatto prepared the plan and is the treatment provider, I do not find his progress reports alone to be persuasive in the absence of other contemporaneous medical evidence to corroborate the necessity of the additional 12 sessions proposed in the plan.
85Accordingly, I find on a balance of probabilities that the applicant has not met her onus of demonstrating that the plan for psychological services is reasonable and necessary.
Interest
86Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since no benefits are owing, interest does not apply.
Award
87The 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.
88As the respondent did not unreasonably withhold or delay the payment of benefits, no award is payable.
ORDER
89For the reasons outlined above, I find that:
i. The applicant has not sustained a catastrophic impairment as defined by the Schedule under Criterion 8;
ii. The applicant is not entitled to IRB, the plans in dispute, interest or an award;
iii. The applicant is not entitled to ACB in the amount of $2,018.04 from November 24, 2023 to date and ongoing; and
iv. The application is dismissed.
Released: October 10, 2025
__________________________
Henry Harris
Vice-Chair