Citation: Lomiyev v. Certas Home and Auto Insurance Company, 2025 ONLAT 23-014428/AABS

Licence Appeal Tribunal File Number: 23-014428/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 Y Lomiyev

Applicant

and

Certas Home and Auto Insurance Company

Respondent

DECISION

ADJUDICATOR:

Ulana Pahuta

APPEARANCES:

For the Applicant:

Mariya Verkhovets, Counsel

For the Respondent:

Rebecca Pepper, Counsel

HEARD:

By way of written submissions

OVERVIEW

1Muhammed Lomiyev, the applicant, was involved in an automobile accident on December 3, 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, Certas Home and Auto Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

PRELIMINARY ISSUES

2The preliminary issue to be decided is:

For the following benefits, is the applicant barred from proceeding to a hearing because the applicant failed to dispute their denial within the 2-year limitation period?

i. Substantive issue 1 (i. – viii.)

ii. Substantive issue 2 (i. and ii.)

iii. Substantive issue 3 (i. – iv.)

SUBSTANTIVE ISSUES

3The substantive issues in dispute are:

1 The treatment plans/OCF-18s (“plans”) for chiropractic services proposed by Polyclinic Rehabilitation Institute Inc., as follows:

i. $142.73 ($1,283.68 less $1,140.95 approved) in a plan dated March 13, 2019;

ii. $2,502.32 in a plan dated May 22, 2019;

iii. $1,026.86 in a plan dated August 9, 2019;

iv. $1,528.08 in a plan dated November 21, 2019;

v. $2,528.10 in a plan dated January 24, 2020;

vi. $2,502.32 in a plan dated December 22, 2020;

vii. $2,502.32 in a plan dated February 23, 2021; and

viii. $4,532.96 in a plan dated August 17, 2021.

2 The treatment plans for psychological services proposed by Polyclinic Rehabilitation Institute Inc., as follows:

i. $897.66 ($3,141.81 less $2,244.15 approved) in a plan dated January 24, 2020; and

ii. $299.22 ($2,244.15 less $1,944.15 approved) in a plan dated September 8, 2020.

3 The treatment plans for cost of examinations proposed by Polyclinic Rehabilitation Institute Inc., as follows:

i. $4,650.00 ($14,842.00 less $10,192.00 approved) for a catastrophic assessment, in a plan dated April 13, 2021;

ii. $2,200.00 for a psychological assessment in a plan dated January 24, 2020;

iii. $2,486.00 for a medical/surgical assessment in a plan dated March 18, 2021; and

iv. $2,486.00 for a neurological assessment in a plan dated March 18, 2021?

4Has the applicant sustained a catastrophic impairment as defined by the Schedule?

5Is the applicant entitled to the treatment plans for chiropractic services proposed by Polyclinic Rehabilitation Institute Inc., as follows:

i. $1,351.16 in a plan dated October 13, 2022;

ii. $1,351.16 in a plan dated December 15, 2022;

iii. $1,351.16 in a plan dated March 20, 2023;

iv. $3, 653.48 in a plan dated June 29, 2023;

v. $2,502.32 in a plan dated October 6, 2023; and

vi. $2,502.32 in a plan dated October 5, 2023.

6Is the applicant entitled to $2,593.80 for the treatment plan for psychological services proposed by Polyclinic Rehabilitation Institute Inc. in a plan dated November 20, 2023?

7Is the applicant entitled to the treatment plans for the cost of examinations proposed by Polyclinic Rehabilitation Institute Inc., as follows:

i. $2,200.00 for a dental assessment (TMJ), in a plan dated October 17, 2022; and

ii. $3,051.00 ($11,104.50 less $8,053.50 approved) for an orthopaedic and neurological assessment in a plan dated March 7, 2023?

8Is the applicant entitled to $5,548.00 for other goods and services (hearing aids), proposed by Polyclinic Rehabilitation Institute Inc. in a treatment plan dated March 23, 2023?

9Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?

10Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

4On the preliminary issue, I find that the applicant is barred from proceeding to a hearing with respect to the fourteen treatment plans listed in paragraph 2 above, because the applicant failed to dispute their denial within the 2-year limitation period.

5On the substantive issues I find that:

i. The applicant has not sustained a catastrophic impairment;

ii. The applicant is not entitled to the treatment plans in dispute or interest;

iii. The respondent is not liable to pay an award.

preliminary issue

Did the applicant fail to dispute the denials within the 2-year limitation period?

6I find that the applicant is statute-barred pursuant to s. 56 of the Schedule from proceeding with the fourteen treatment plans listed as substantive issues 1, 2 and 3, as he failed to dispute the denials within the two-year limitation period.

7Section 56 of the Schedule provides that an application to dispute a denial of a benefit shall be commenced within two years of the insurer’s refusal to pay.

8The applicant does not dispute that his application was brought well outside the two-year limitation period to dispute the denial of the fourteen treatment plans. Further, from my review of the denial letters, all of the treatment plans were denied between March 2019 and August 2021. However, the application was filed on November 28, 2023, after the expiration of the two-year limitation period.

9The onus is on the applicant to establish reasonable grounds for an extension under s. 7 of the Licence Appeal Tribunal Act, 1999 (“LAT Act”). Section 7 allows the Tribunal to extend a limitation period for filing an appeal. In considering whether to exercise its discretion to extend the limitation period, the Tribunal must consider the following four factors set out in Manuel v. Registrar, 2012 ONSC 1492, to determine if the justice of the case requires the extension:

1. The existence of a bona fide intention to appeal within the limitation period;

2. The length of delay;

3. Prejudice to the other party; and

4. Merits of the appeal.

10The applicant has provided limited submissions on the grounds for an extension. His sole submission on this point, is that his claim was prejudiced because of delay on the part of his previous representatives. The applicant requests that these fourteen treatment plans be permitted to proceed, and that the Tribunal direct the parties to make submissions pertaining to these issues at a later date.

11The respondent submits that a s. 7 extension should not be granted. It argues that Courts and Tribunals have long held that ignorance of the law or reliance on representation does not absolve a party of the duty to comply with statutory deadlines. It further submits that the applicant has not met his burden of proof to establish grounds for the discretionary relief.

12I find that the applicant has not established that the limitation period should be extended under s. 7. The applicant has not provided specific submissions on the four factors stipulated in Manuel. Rather, he makes the general submission that any delay was due to his previous representatives. However, no details or evidence have been led in support of this submission. It is well-settled that submissions alone are not evidence. Rather, evidence must be led in support of the applicant’s argument.

13No particulars have been provided of any undue delay by his representatives, nor has the applicant led any evidence of a bona fide intention to dispute the denial within the limitation period. I agree with the respondent that the delay has been significant, and that by including the additional fourteen treatment plans as issues in dispute, the total issues in dispute have now numbered over 20, leaving limited room to address multiple issues. The applicant has not provided submissions on these treatment plans but rather requests that he be permitted to make submissions on them at “a later date” selected by the Tribunal. As such, he has not provided any submissions on the final Manuel factor, being the merits of the treatment plans. Without any supporting evidence or specific submissions on the grounds for an extension, I find that the applicant has not established that the limitation period should be extended under s. 7.

14As such, I find that the applicant is statute-barred pursuant to s. 56 of the Schedule from proceeding with the fourteen treatment plans listed as substantive issues 1, 2 and 3.

SUBSTANTIVE ISSUES

CATASTROPHIC IMPAIRMENT

15I find that the applicant has not sustained a catastrophic (“CAT”) impairment as a result of the accident.

16The applicant submitted two Applications for Catastrophic Determination (“OCF-19s”). The first OCF-19 dated July 8, 2021, sought a CAT determination under paragraph 8 of s. 3.1(1) of the Schedule, referred to as Criterion 8. The subsequent OCF-19 dated December 20, 2023 cited Criteria 7 and 8. Accordingly, I will first discuss whether the applicant sustained a CAT impairment pursuant to Criterion 7.

The applicant does not meet the CAT threshold under Criterion 7

17In order to qualify for CAT status under Criterion 7, the applicant must prove that he has a combination of physical and psychological impairment ratings from medical professionals that meet the 55% whole person impairment (“WPI”) threshold as outlined in Chapter 4 of the American Medical Association’s Guides to the Evaluation of Permanent Impairment (the “Guides”).

18The applicant submits that he has an overall WPI of 72%. He relies on the executive summary report of Dr. Vladimir Levitin, chiropractor, dated December 19, 2023; the psychiatric catastrophic determination assessment report dated September 21, 2021 of Dr. Yaroshevsky, psychiatrist; the orthopaedic catastrophic determination assessment report of Dr. Getahun, dated September 15, 2023; the independent neurological examination report of Dr. Neilank Jha dated October 17, 2023; the catastrophic temporomandibular assessment report of Dr. Marc Altman, dentist, dated June 25, 2023; and an audiological evaluation report by Dr. Ian Castor, dated September 8, 2022. Dr. Yaroshevsky found that the applicant had a mental and behavioural rating of 30% WPI. The applicant’s physical and neurology assessors further found that the applicant had a physical impairment rating of 60%, resulting in an overall 72% WPI.

19The respondent argues that the applicant’s combined WPI is 15%, far below the 55% threshold. It relies on the executive summary report of Dr. Bruce Paitich, orthopaedic surgeon, dated August 13, 2024; the catastrophic orthopaedic assessment report of Dr. Paitich dated August 13, 2024; the catastrophic neurology assessment of Dr. Gary Moddel, neurologist, conducted on June 17, 2024; the catastrophic psychiatry assessment of Dr. Velan Sivasubramanian on June 25, 2024; the catastrophic occupational therapy assessments of Delize Roberts on May 28, 2024; and the catastrophic dental assessment of Dr. Earl Magder on June 10, 2024. The respondent’s assessors found that the applicant’s combined WPI was 15%.

20The parties’ assessors assigned the WPI% ratings in the following manner:

AMA Guides 4th Ed.	Applicant’s CAT Summary	Respondent’s CAT Summary
Physical Impairments
Cervical Spine Impairment	5% (per applicant’s orthopaedic assessor) updated to 10% (per applicant’s neurology assessor)	0%
Lumbar Spine Impairment	5% (per applicant’s orthopaedic assessor) updated to 10% (per applicant’s neurology assessor)	0%
Thoracic Spine Impairment	5%	0%
Temporomandibular Joint Impairment	20%	0%
Emotional and Behavioural Disturbances	15%	0%
Hearing Loss	11%	0%
Headaches	10%	0%
Sleep/arousal disorder	3%	0%
Medication	3%	0%
Total Physical WPI Combined Values Chart:	60%	0%
Mental/behavioural Impairments
Mental/Behavioural WPI	30%	15%
TOTAL CRITERION 7 COMBINED RATING
Total WPI Criterion 7 Combined Values Chart:	72%	15%

Cervical/Lumbar/Thoracic Spine Impairment, Cervicogenic Headaches and Medication Adjustment

21I find that the applicant has sustained a 15% WPI for his cervical, lumbar and thoracic spine, 3% WPI for the medication adjustment, and 10% WPI for cervicogenic headaches.

22I do not accept the respondent’s assessor’s 0% WPI calculation. Dr. Paitich found that the applicant had sustained only myofascial strain of the cervicothoracic and lumbosacral spine, but that given the time that had elapsed, it was unlikely that his stated symptoms were causally related to the accident. Rather, Dr. Paitich found the symptoms were likely due to axial skeletal pain and unrelated to the accident.

23I agree with the applicant that the medical record, particularly the clinical notes and records (“CNRs”) of his family physician, provide consistent examples of back and neck pain reports that were causally linked to the accident. The applicant reported to Dr. Sheffield in May 2019 that 2 weeks after the accident he developed back pain. He was prescribed Baclofen and was recommended to do physiotherapy. These reports continued in the years post-accident.

24I accept the applicant’s orthopaedic assessor Dr. Getahun’s finding that the applicant’s injuries to the cervical, thoracic and lumbar spine each warrant a DRE II rating of 5% for a combined 15% spinal impairment rating. And given the chronicity of his complaints and the persistent use of medication, this would warrant an additional 3% adjustment rating. The applicant’s neurologist, Dr. Jha, also assigned a 10% WPI for cervicogenic headaches, which I accept.

25However, I do not accept the additional WPI rating assigned by Dr. Jha for radiculopathy. He had assigned 10% WPI for cervicothoracic radiculopathy and 10% for lumbosacral radiculopathy, but he noted that further investigation with an MRI was recommended. I agree with the respondent that the applicant has not established that any of the reported numbness or tingling symptoms were related to the accident, particularly given that they were initially reported more than a year after the accident. Moreover, the applicant does not direct me to objective testing that supports a finding of radiculopathy or neuropathy.

26In August 2021, the applicant had a neurology consult at Mackenzie Health hospital and EMG testing. Nerve conduction tests were unremarkable and found no evidence of neuropathy or radiculopathy. Subsequent MRIs also found no cause for the applicant’s reported symptoms. Accordingly, I do not accept the additional WPI ratings assigned by the applicant’s neurology assessor for radiculopathy.

Temporomandibular Joint Impairment

27I do not accept the 20% WPI assigned by Dr. Altman for a temporomandibular joint (“TMJ”) impairment.

28I find that the applicant has not established that his TMJ complaints were causally linked to the accident. The applicant had a pre-existing history of jaw clicking complaints, as noted in an orthodontics CNR entry dated June 2017. Dr. Sheffield also noted the applicant’s pre-existing history of TMJ syndrome. Post-accident, TMJ complaints were first noted by the applicant’s treating physiotherapy clinic in June 2023, and it was stated that they had only begun six months earlier, more than four years after the accident. Although the applicant frequently attended his family physician’s office for his neck and back complaints, he does not direct me to similar reports of TMJ complaints in the years post-accident. I agree with the respondent that the applicant has not established that the accident caused or worsened his TMJ issues.

Emotional/Behavioural disturbances and Sleep Disorder

29I do not accept the 15% and 3% WPI assigned by the applicant‘s neurologist, Dr. Jha, for emotional/behavioural disturbances and sleep disorder.

30Dr. Jha found that it was “possible” that the applicant had sustained a mild traumatic brain injury (“TBI”) as a result of the accident which may have exacerbated a prior TBI. However, my review of the medical record, particularly the CNRs of the applicant’s family physician, does not support an accident-related TBI. Accordingly, I do not find that the applicant’s emotional/behavioural disturbances or sleep issues would be linked to a neurological impairment. The Guides would only permit an impairment rating to be applied to emotional or sleep issues when they are attributed to neurologic impairment of brain function.

31Accordingly, I agree with the respondent’s neurology assessor Dr. Garry Moddel’s finding that there was no evidence of an accident-related neurological impairment.

Hearing Loss

32I do not accept the 11% WPI assigned by Dr. Jha and Dr. Levitin for hearing loss.

33Dr. Jha, the applicant’s neurologist had initially assigned 3% WPI for hearing loss. In the catastrophic impairment executive summary, Dr. Levitin found that hearing loss should be rated at 8% WPI and added an additional 2.5% for tinnitus. Dr. Jha referred to a September 8, 2022 audiological evaluation which found mild/moderate hearing loss in the right ear, and moderately/severe hearing loss in the left ear. The evaluator further noted a history of a major concussion in high school and a “car accident in 2018 that damaged nerves in neck and back. Since then, hearing has deteriorated and onset of tinnitus in the left ear.”

34I agree with the respondent that the medical evidence does not establish that the applicant’s hearing loss or tinnitus were causally linked to the accident. The applicant had reported hearing loss pre-accident, in January 2016. Although the 2022 audiology report noted the applicant’s reports that the accident had “damaged nerves in the neck and back”, there is no medical evidence of such accident-related nerve damage. Further, the applicant did not appear to report issues with hearing to his family physician until 2022, more than three years after the accident.

Mental/Behavioural Impairments

35I find that the applicant has sustained a 15% WPI for mental and behavioural impairments. I accept the rating assigned by the respondent’s assessor Dr. Sivasubramanian.

36To establish a catastrophic impairment, the applicant relies on the psychiatric catastrophic assessment by Dr. Yaroshevsky dated September 21, 2021 and his rebuttal report dated August 2, 2022. The respondent relies on the psychiatric catastrophic IE of Dr. Sivasubramanian dated August 13, 2024.

37The applicant’s psychiatric assessor Dr. Yaroshevsky diagnosed the applicant in September 2021 with post-concussional disorder, generalized anxiety disorder and panic disorder with agoraphobia and assigned a 30% WPI. With respect to the Global Assessment of Functioning Scale (GAF), Dr. Yaroshevsky found that the applicant scored 31-40 (20% WPI), on the Psychiatric Impairment Rating Scale (PIRS) the applicant scored 7 (30% WPI) and on the Brief Psychiatric Rating Scale (BPRS) the applicant scored 59 (30%), with the median score being 30%.

38The respondent’s psychiatric assessor, Dr. Sivasubramanian, diagnosed the applicant with somatic symptom disorder with predominant pain and adjustment disorder with anxious and depressed mood. He assigned a 15% WPI rating for the applicant’s mental and behavioural disorders. When considering Dr. Yaroshevsky’s findings, Dr. Sivasubramanian disagreed with the diagnoses and 30% WPI rating, noting that the applicant’s mental health may have significantly improved in the three years since Dr. Yaroshevsky’s assessment.

39When comparing the psychiatric assessment reports, I prefer the 15% WPI assigned by Dr. Sivasubramanian. The applicant’s psychiatric assessor Dr. Yaroshevsky had diagnosed the applicant in September 2021 with panic disorder with agoraphobia, and described the applicant’s inability to maintain activity or leave the house for long periods of time. However, this diagnosis does not appear to be accurate at the time of the present application.

40The applicant has submitted progress reports from his psychotherapy sessions from 2020 to 2023. The April 26, 2023 progress report noted that the applicant had made moderate improvement with his third session block of treatment. He reported only intermittent feelings of depressed mood and irritability, that he had “some” driving anxiety while driving next to big trucks, and no passenger anxiety, that his social activity had increased, and he was meeting with friends twice per week. The respondent has also submitted surveillance evidence that the applicant was attending the gym multiple times a week and going for regular walks. In my view, this evidence aligns more with Dr. Sivasubramanian’s diagnoses of adjustment disorder with anxious and depressed mood and somatic symptom disorder, rather than Dr. Yaroshevsky’s diagnoses of generalized anxiety disorder and panic disorder with agoraphobia.

41Accordingly, I find Dr. Sivasubramanian’s assessment of the applicant’s mental and behavioural impairments to be more persuasive and I accept Dr. Sivasubramanian’s 15% WPI rating.

42Therefore, I accept the following WPI% ratings: 15% WPI for cervical, lumbar and thoracic spine impairments, 3% WPI for medication adjustment, 10% WPI for cervicogenic headaches, and 15% WPI for mental and behavioural impairments. When these WPI% ratings are added up in accordance with the Combined Values Chart in the Guides, they do not meet the 55% WPI threshold under Criterion 7.

The applicant does not meet the CAT threshold under Criterion 8

43To qualify as CAT under Criterion 8, an individual must sustain a Class 4 (“Marked Impairment”) as a result of the accident in three out of the four spheres of functioning or a Class 5 impairment (“Extreme Impairment”) in one or more areas of function, outlined in Chapter 14 of the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993 (“Guides”), due to a mental or behavioural disorder.

44The Guides set out that mental and behavioural impairments are rated according to how seriously they affect a person’s useful daily functioning. The following chart sets out the four spheres of functioning and the levels of impairment.

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
Adaptation (Deterioration in a work-like setting)

45The applicant relies on the psychiatric catastrophic assessment report dated September 21, 2021 of Dr. Yaroshevsky, who had diagnosed the applicant with post-concussional disorder, generalized anxiety disorder and panic disorder with agoraphobia. Dr. Yaroshevsky found that the applicant had sustained a Class 3 (Moderate) Impairment in the sphere of Activities of Daily Living, and Class 4 (Marked) Impairments in the spheres of Social Functioning, Concentration, Persistence and Pace, and Adaptation.

46The respondent relies on the psychiatric catastrophic assessment report dated August 13, 2024 of Dr. Sivasubramanian, who diagnosed the applicant with somatic symptom disorder with predominant pain and adjustment disorder with anxious and depressed mood. He found that the applicant had sustained a Class 3 (Moderate) Impairment in the spheres of Activities of Daily Living, Concentration, Persistence and Pace and Adaptation and a Class 2 (Mild) Impairment in the area Social Functioning.

47Both parties agree that the applicant did not sustain a marked impairment in the sphere of Activities of Daily Living. On the remaining domains, I do not find that the applicant sustained a marked impairment under three spheres of functioning. The applicant did not provide submissions on the spheres of functioning, but rather, directs me to Dr. Yaroshevsky’s report. However, as previously noted, I have found that the diagnoses in the September 2021 CAT report of Dr. Yaroshevsky do not appear to be reflective of the applicant’s mental health status three years later.

48With respect to the sphere of Social Functioning, Dr. Yaroshevsky found a marked (Class 4) impairment, noting that the applicant’s relationships with family members, friends and community members was significantly restricted. He found that the applicant had become reclusive, isolative and avoidant of social and familial interactions. However, in his psychological progress report dated April 26, 2023, the applicant reported increasing his social activity and that he had been meeting with friends twice a week. Surveillance evidence also established that the applicant was attending the gym multiple times a week and going for walks, which was inconsistent with Dr. Yaroshevsky’s description of the applicant as reclusive and isolative. Accordingly, I agree with Dr. Sivasubramanian’s assessment of a mild impairment in this domain.

49With respect to Concentration, Persistence and Pace, the Guides define this sphere as having the ability to sustain focused attention long enough for the timely completion of tasks commonly found in work settings. Deficiencies in concentration, persistence and pace are best noted from previous work attempts or from observations in work-like settings. In activities of daily living, this may be reflected in terms of the ability to complete everyday tasks. Dr. Yaroshevsky found that the applicant demonstrated decreased memory, attention and concentration function and was moderately-severely limited in understanding, remembering and carrying out detailed instructions and planning and organizing task completion. He was also severely limited in his task initiation and completion.

50I am persuaded by the report of Dr. Sivasubramanian who found that during the interview with the applicant there was no evidence of gross thought disorder, and no word finding difficulties. Dr. Sivasubramanian noted that the applicant still maintained control of his medications, finances and scheduling, and that he still drove independently. I note that the applicant’s independent driving was confirmed in his psychotherapy progress reports. I also note the respondent’s submissions that while the applicant argues that he was unable to complete his college program due to post-accident concentration difficulties, he did not provide his academic records as ordered in the Case Conference Report and Order, which would have confirmed his academic progress or decline. I agree that supportive evidence of the applicant’s academic history pre and post accident would have been persuasive on the issue of his ability to sustain focus. As such, I find that the applicant has not met his evidentiary onus to prove a marked impairment in the sphere of Concentration, Persistence and Pace.

51Having found that the applicant has sustained moderate impairments in the spheres of Social Functioning and Concentration, Persistence and Pace, and noting the applicant’s submissions that he sustained a moderate impairment in the sphere of Activities of Daily Living, I find that the applicant has not demonstrated marked impairments in at least three of the four domains. I further note that no extreme impairment was argued in any of the domains. Accordingly, the applicant has not established that he is catastrophically impaired under Criterion 8.

52To receive payment for a treatment and assessment plan under s. 15 and 16 of the Schedule, the applicant must 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.

OCF-18s for chiropractic treatment and psychological services

53I find that the applicant has not established entitlement to the treatment plans for physical and psychological treatment. The applicant has not provided any specific submissions on the seven treatment plans for physical treatment or psychological services, but rather, makes the general submission that all of them remain reasonable and necessary. The applicant further has not identified the proposed treatment or stated goals, identified how the goals are being met, or included copies of the OCF-18s to allow me to assess the plans. Finally, the applicant has not referred me to specific evidence in support of the reasonableness and necessity of the treatment or assessments. Rather he directs me to the totality of medical evidence, including all clinical notes and records and assessments.

54The Tribunal cannot connect the dots and make the applicant’s case. Doing so inappropriately places the Tribunal in the role of advocate. It is up to the applicant to make specific citations with reference to the evidence and explain why it supports entitlement to a specific benefit. Without any specific submissions on the treatment plans, I find that the applicant has not established, on a balance of probabilities, that the treatment plans in dispute are reasonable and necessary.

OCF-18 for hearing aids in the amount of $5,548.00

55The applicant submits that the hearing aids are reasonable and necessary as a result of the accident. He argues that Dr. Hua, his treating otolaryngologist, recommended on November 23, 2023 that the applicant obtain hearing aids and stated that the accident may have been the cause of his hearing loss. The applicant also relies on the neurological catastrophic assessment report of Dr. Jha, and the audiological evaluation of Dr. Castor dated September 8, 2022.

56I find that the applicant has not met his onus to prove that the treatment plan for hearing aids is reasonable and necessary. As previously noted, I have found that the applicant has not established that his hearing loss was caused by the accident. The applicant refers to Dr. Hua’s November 23, 2023 report where he states that the hearing loss was “possibly due to a labyrinthine concussion from his MVC in 2018”. However, I do not find that Dr. Hua’s statement that the hearing loss was “possibly” caused by an accident-related concussion, causally links the hearing impairment to the accident, particularly given that I have found that the applicant has not established an accident-related concussion.

57Accordingly, I find that the applicant has not established entitlement to the treatment plan for hearing aids.

OCF-18s for dental (TMJ), orthopaedic and neurological assessments

58I find that the applicant has not met his onus to prove, on a balance of probabilities, that the proposed assessments are reasonable and necessary.

59With respect to the OCF-18 for a dental assessment, as previously noted, I have found that the applicant has not established that the accident caused or worsened his TMJ issues.

60Further, with respect to the OCF-18s for orthopaedic and neurological assessments, the CCRO identifies these treatment plans as being partially approved in the amount of $8,053.50. What is in dispute appears to be the denied portion of $3,051.00. However, the applicant has not provided submissions on what the denied portion of the plan relates to and how it is reasonable and necessary. Without any submissions on the denied portions of the treatment plans, I find that the applicant has not established that the outstanding balance is reasonable and necessary.

Interest

61Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no benefits are overdue, the applicant is not entitled to interest.

Award

62The 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. Given that no benefits were unreasonably withheld or delayed, the applicant has not established that an award is warranted.

ORDER

63On the preliminary issue, I find that the applicant is barred from proceeding to a hearing with respect to the fourteen treatment plans listed in paragraph 2 above, because the applicant failed to dispute their denial within the 2-year limitation period.

64On the substantive issues I find that:

i. The applicant has not sustained a catastrophic impairment;

ii. The applicant is not entitled to the treatment plans in dispute or interest;

iii. The respondent is not liable to pay an award.

Released: October 24, 2025

__________________________

Ulana Pahuta

Adjudicator