Licence Appeal Tribunal File Number: 24-000459/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:
Leima El Ferra
Applicant
and
Security National Insurance Company
Respondent
DECISION
ADJUDICATOR: Melanie Malach
APPEARANCES:
For the Applicant: Mobina Khan, Counsel
For the Respondent: Ashley Dunkley, Counsel
HEARD: By way of written submissions
OVERVIEW
1Leima El Ferra, the applicant, was involved in an automobile accident on January 9, 2023, 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, Security National Insurance Company, 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. Is the applicant entitled to $5,690.00 for chiropractic services, proposed by Jamal Alaloul and Cindy Jesse, in a treatment plan, dated January 3, 2024?
ii. Is the applicant entitled to $1,248.65 in respect of an invoice for an Annual Individual Everything Membership from Oxford Spine Center, dated March 13, 2024?
iii. Is the applicant entitled to $45.00 in respect of an invoice for ambulance service, dated July 10, 2024?
iv. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
v. Is the applicant entitled to interest on any overdue payment of benefits?
3The Case Conference Report and Order (“CCRO”), dated July 5, 2024, lists issue 1 as, “Is the applicant entitled to an income replacement benefit in the amount of $80.00 per week ($400.00 per week less $320.00 per week approved) from January 12, 2024 to January 1, 2025?” The respondent in its submissions confirms that the applicant received an IRB of $400.00 per week from January 12, 2024 to January 1, 2025, and therefore this issue is not in dispute. Therefore, I have not listed it as an issue in dispute.
4The CCRO lists issue 5 as, “Is the respondent entitled to a repayment of $4,326.86 as assessed as of January 12, 2024 relating to its payment of income replacement benefits?” The respondent in its submissions confirms this issue is not in dispute as any IRB repayment has been fully repaid. Therefore, I have not listed it as an issue in dispute.
RESULT
5I find that the applicant is not entitled to the treatment plan for chiropractic services, the invoice for a gym membership, the invoice for ambulance service, interest or an award.
PROCEDURAL ISSUES
Paragraph submissions are not numbered and the document brief is not properly numbered
6The respondent submits that the applicant’s submissions are in non-compliance with the CCRO, because she failed to consecutively number the paragraphs of her submissions, and she failed to index, bookmark and consecutively number the pages of her documents. The respondent refers to Rule 9.4.5 of the Licence Appeal Tribunal Rules 2023, which states that when filing written submissions, the “written hearing briefs must be filed with the Tribunal as an indexed, tabbed and consecutively page numbered PDF…”
7I agree with the respondent that the applicant has failed to number the paragraphs of her submissions. In addition, with respect to her document brief, while she provided an index with tab numbers and page numbers, the page numbers listed do not correspond with the documents as stated in the index and the documents are not bookmarked. I found it difficult to locate the documents set out in the index, without being bookmarked and without proper corresponding page numbers. However, I find that the respondent has failed to establish how these factors violate procedural fairness. I find that striking the entirety of the applicant’s submissions as a result of her non-compliance with Rule 9.4.5, would make it impossible for the applicant to meet her onus, which would be excessively prejudicial.
8I find that the applicant’s full submissions and book of documents will be admitted into the hearing record.
ANALYSIS
Entitlement to Medical and Rehabilitation Benefits
9To receive payment for medical and rehabilitation benefits under sections 15 and 16 of the Schedule, the applicant has the onus of proving 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 the overall costs of achieving them are reasonable.
The applicant is not entitled to the treatment plan for chiropractic services
10The applicant claims entitlement to $5,690.00 for chiropractic services, proposed by Jamal Alaloul and Cindy Jesse, in the treatment plan, dated January 3, 2024.
11The applicant submits that the respondent’s denial of the treatment plan on January 9, 2024, does not fully acknowledge the severity and the persistence of the applicant’s chiropractic impairments and overlooks the clinical evidence supporting the necessity of continued chiropractic intervention, as well as the professional recommendations provided. The applicant submits that the recommended treatment is reasonable and necessary for her recovery. She argues that given the sustained impact on her emotional well-being and ability to function, approval of the proposed treatment is essential.
12The respondent submits that the applicant’s submissions fail to clearly mark any evidence as to why the treatment plan in dispute is reasonable and necessary. It submits that the applicant’s submissions are not evidence, and she has failed to meet her burden of establishing that the treatment plan in dispute is reasonable and necessary. The respondent further submits that the treatment plan in dispute was denied on January 9, 2024, because there was no objective medical evidence received to support the treatment being sought. It refers to the Insurer Examination (“IE”) report of Dr. Seung-Jun Lee, general practitioner, dated April 18, 2024, where the applicant reported a 50% improvement since the accident. Dr. Lee determined that there were no identifiable and ongoing accident-related musculoskeletal impairments that would necessitate the need for chiropractic therapy. Dr. Lee further found that after the physical examination, there were no valid indicators to support ongoing accident-related musculoskeletal injury or impairment.
13I find that the applicant has not proven on a balance of probabilities that the treatment plan in dispute is reasonable and necessary for the following reasons.
14I find that despite the applicant’s submission that that the treatment is necessary and essential for her recovery, she has not directed the Tribunal to any specific medical evidence in support of her submission. I find that while the applicant has provided a summary of various clinical notes and records (“CNR”) and reports at the end of her submissions, she has not tied these records to her submissions with respect to her entitlement to this specific treatment plan. In my view, it is not the Tribunal’s role to sort through the applicant’s medical evidence, or to search for support for the applicant’s position in the reports provided: see Dooman v. TD Insurance Co. 2025 ONSC 184 at para. 50.
15Despite not pointing the Tribunal to the specific medical evidence that supports her entitlement to the treatment plan in dispute, I have reviewed the CNRs summarized by the applicant at the conclusion of her submissions. I find that the CNR of London Health Sciences Centre, prepared by Dr. Dickson Wong, dated June 10, 2023, notes that the applicant, “has significant back pain and cannot perform her regular duties. She is to stay off work for 2-4 weeks, and return to work with light duties to start, increasing to full duties as tolerated.” Upon review of the CNRs from West London Family Health Clinic, prepared by Dr. Fatemeh Sargolzaei, the applicant was seen on July 12, 2023, and was referred for physiotherapy due to her concussion and back pain. I do not find that these records support the treatment plan in dispute. The records are not contemporaneous to the submitted treatment plan and there are no recommendations within the CNRs for chiropractic treatment. In addition, the applicant has not provided any records indicating that she received physiotherapy treatment in compliance with the recommendations made above.
16I further find that the applicant has not addressed the goals of the treatment plan or how the goals of the treatment would be met if she received the treatment, which is essential to meeting the test that the treatment is reasonable and necessary.
17I give weight to the report of Dr. Lee, dated April 18, 2024, relied upon by the respondent, which found that the applicant’s musculoskeletal injuries suffered in the accident are predominantly minor injuries. Dr. Lee concluded that there were no valid indicators to support ongoing accident-related musculoskeletal injury or impairment. Based on the evidence submitted, I find that Dr. Lee’s opinion is not rebutted by any other medical opinion.
18For the reasons set out above, I find that the applicant has not met her onus of demonstrating on a balance of probabilities that the treatment plan for chiropractic services, dated January 3, 2024 is reasonable and necessary.
The applicant is not entitled to the invoice for a gym membership
19The applicant claims entitlement to $1,248.65 in respect of an invoice for an Annual Individual Everything Membership from Oxford Spine Centre, dated March 13, 2023. The invoice was submitted to the respondent on January 5, 2024, and denied on January 9, 2024.
20The applicant submits that the respondent’s denial of the invoice on January 9, 2024, does not fully acknowledge the severity and the persistence of the applicant’s impairments and overlooks the clinical evidence supporting the necessity of continued chiropractic intervention, as well as the professional recommendations provided. The applicant submits that the recommended treatment is reasonable and necessary for her recovery. She argues that given the sustained impact on her emotional well-being and ability to function, approval of the proposed treatment is essential.
21The respondent submits that the applicant has not provided any medical evidence to support that a gym membership is reasonable and necessary. The respondent submits that on January 9, 2024, it wrote to the applicant confirming receipt of the quote for the gym membership and denying same. The denial was based on a lack of objective medical evidence to substantiate the quote. The respondent further submits that as the applicant failed to submit the gym membership on a treatment plan, she is not entitled to payment of the gym membership invoice pursuant to s. 38(2)(c)(ii) of the Schedule.
22Pursuant to s. 38(2)(c) of the Schedule, an insurer is not liable to pay an expense in respect to a medical benefit that was incurred before the insured person submits a completed treatment and assessment plan unless the expense is reasonable and necessary as a result of the impairment sustained by the insured person for (i) drugs prescribed by a regulated health profession, or (ii) goods referred to in clauses 15(1)(d) to (f) and 16(3)(h) to (j) with a cost of $250.00 or less per item.
23I find that the applicant has not proven that the invoice for a gym membership is reasonable and necessary. In addition, she has not addressed the reasons why a gym membership was required for her recovery.
24I further find that the applicant did not address s. 38(2) of the Schedule in her initial submissions and that she provided no reply submissions to the respondent’s submissions. I agree with the respondent that pursuant to s. 38(2)(c)(ii), the applicant was required to submit a treatment plan rather than an invoice to the respondent for the gym membership. As the applicant did not make any submissions whether the exceptions listed in s. 38(2) apply, I find that the invoice is not payable pursuant to s. 38(2) of the Schedule.
25For the reasons set out above, I find that the applicant has not met her onus of demonstrating on a balance of probabilities that the invoice for the gym membership is reasonable and necessary.
The applicant is not entitled to the invoice for an ambulance service
26The applicant submits that she is entitled to $45.00 in respect of an invoice for ambulance service, dated July 10, 2023. She submits that an incurred ambulance fee of $45.00 is a direct and necessary expense arising from the accident.
27The respondent submits that on July 10, 2023, upon receipt of the Ambulance Call invoice, the respondent advised the applicant that the expense cannot be considered until it is first provided to the applicant’s extended health coverage, and a benefit statement is provided. The respondent submits that it is clear in the Schedule, that the accident benefits insurer is a secondary insurer, and that the applicant has failed in her obligations to submit the invoice to her extended coverage for determination first.
28Section 47(2) of the Schedule provides that payment of any medical, rehabilitation or attendant care benefit or a benefit under Part IV is not required for that portion of an expense for which payment is reasonably available to the insured person under any insurance plan or law or under any other plan or law.
29I find that pursuant to s. 47(2) of the Schedule, the applicant is required to submit the ambulance fee invoice first to her extended coverage for determination. She is then required to provide a copy of the benefit statement to the respondent.
30I find that the applicant has not made any submissions as to whether she had extended health coverage at the time of the accident. I therefore find that the applicant is required to submit the ambulance fee expense to her extended health carrier and provide the respondent with a copy of the benefit statement. I find that no amount is payable by the respondent for the ambulance fee until such time as this is provided to the respondent.
31For the reasons stated above, I find that the applicant has not met her onus of demonstrating on a balance of probabilities that the ambulance fee invoice is payable.
Interest
32Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As there are no benefits owing, the applicant is not entitled to interest.
Award
33The applicant sought an award under s. 10 of Reg. 664. Under s. 10, the Tribunal may grant an award of up to 50 percent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits. As I have found that the respondent did not unreasonably withhold or delay payment of any benefit, no award is warranted.
ORDER
34For the reasons outlined above, I find that the applicant is not entitled to the treatment plan for chiropractic services, the invoice for a gym membership or the invoice for ambulance service, interest or an award. The application is dismissed.
Released: November 5, 2025
Melanie Malach
Adjudicator