Licence Appeal Tribunal File Number: 24-001787/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:
Vasantha Vadivel
Applicant
and
Aviva General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Harouna Saley Sidibé
APPEARANCES:
For the Applicant:
John Chui, Paralegal
For the Respondent:
Christina Chiu, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Vasantha Vadivel, the applicant, was involved in an automobile accident on February 4, 2019, 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 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 $1,753.73 for chiropractic services, proposed by Complete Rehab Centre in a treatment plan/OCF-18 (“plan”) dated March 31, 2022?
ii. Is the applicant entitled to $1,302.49 for chiropractic services, proposed by Complete Rehab Centre in a plan dated November 4, 2021?
iii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3For the reasons below, I find that:
The applicant is not entitled to the disputed treatment plans.
The applicant is not entitled to interest or an award.
ANALYSIS
4To receive payment for an OCF-18 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.
Is the applicant entitled to the treatment plans for chiropractic services?
5The applicant requests funding for two chiropractic treatment plans. I find that the applicant has not met the burden of proof to demonstrate that these plans are reasonable and necessary.
6The first treatment plan, dated December 22, 2021, covers chiropractic services valued at $1,302.49. It is signed by chiropractor Rahim Jessa and recommends 12 sessions targeting multiple body sites. The goals include pain relief, increased range of motion, improved strength, cardiovascular fitness, endurance, flexibility, and motor control of the lumbopelvic and cervicothoracic muscles.
7The second treatment plan, dated March 31, 2022, covers chiropractic services amounting to $1,753.73. It is also signed by Mr. Jessa and details 16 sessions with similar goals and modalities as the first plan.
8In support of her claim, the applicant relies on the chronic pain assessment by Dr. Farhan Siddiqui, a chronic pain management specialist, dated February 26, 2020, which diagnosed chronic pain syndrome, and on clinical records from her family physician, Dr. Ravi Murthy, documenting ongoing fatigue, pain, and limited shoulder function. The applicant argues that the treatment goals of pain reduction, improved range of motion, and increased strength are reasonable and achievable.
9The respondent opposes the treatment plans, referencing insurer examinations performed by Dr. Isa Mohammed, a physician, dated January 6, 2022, with addenda dated May 2 and July 11, 2022. Dr. Mohammed observed no objective impairments and a normal range of motion, concluding that the applicant had reached maximum medical improvement. The respondent maintains that the applicant’s subjective reports of improvement do not justify ongoing passive treatment.
10On February 5, 2019, Dr. Murthy diagnosed the applicant with a minor soft tissue injury and noted that a referral for physiotherapy was not necessary.
11On March 19, 2019, Dr. Murthy recorded complaints of pain, fatigue, and low mood. He suggested that the pain had a psychological component and recommended a psychiatric assessment. He also advised that pain medication beyond Advil was unnecessary.
12Subsequent visits to Dr. Murthy involve other health issues, including obesity (March 1, 2023) and depression (December 5, 2022), which are not clearly connected to the accident.
13On August 11, 2022, Dr. Nicola Berman, a rheumatologist and internal medicine specialist, assessed the applicant’s bilateral shoulder and neck pain. He attributed the symptoms to poor sleep posture and postural habits, recommending continued physiotherapy to address these issues. This is not linked to the accident.
14Notably, Dr. Suganthan Kayilasanathan, a family doctor, recorded shoulder pain that dated back 4.5 years before March 30, 2016, indicating that it might be a pre-existing condition.
15Dr. Siddiqui’s report dated February 26, 2020, diagnosed myofascial pain, non-restorative sleep, anxiety consistent with PTSD, cervical and trapezius sprain or strain, and cervicogenic headaches. He noted that the applicant had received appropriate treatment thus far and recommended psychological therapy to improve functionality and coping strategies. He maintained the same diagnoses in his two addenda dated May 2 and July 11, 2022.
16Dr. Mohammed’s insurer examination revealed tenderness in multiple areas but showed no neurological or radicular pathology. He concluded that the applicant sustained uncomplicated soft tissue injuries.
17I assign limited weight to Dr. Siddiqui’s report. While he is a pain specialist and has diagnosed the applicant with chronic pain, his opinion does not explicitly support chiropractic treatment and is not aligned with the broader medical evidence, which indicates soft tissue injuries. Although the report does not reference the American Medical Association Guidelines or other clinical standards, I acknowledge that such references are not strictly necessary for a chronic pain diagnosis. Nonetheless, the absence of these references reduces the report’s persuasive value regarding the specific treatment recommendations at issue.
18Importantly, none of the applicant’s treating practitioners has specifically recommended chiropractic treatment for the accident.
19Based on the evidence, I conclude that the applicant has not proven that the proposed chiropractic plans are reasonable and necessary.
20Accordingly, on a balance of probabilities, I find that the applicant is not entitled to payment for these treatment plans.
Interest
21Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since no benefits are payable, no overdue amounts exist for interest to accrue under s. 51.
Award
22The 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.
23In this case, the respondent relied on prompt insurer examinations conducted by Dr. Isa Mohammed. The assessments were completed within the required timelines and formed the basis of the respondent’s denials. The respondent communicated its decisions via Explanation of Benefits letters, which detailed the rationale for its position. I find that the respondent’s conduct was consistent and procedurally proper throughout the claims process.
24The respondent has not unreasonably withheld or delayed benefits, and therefore, no award is due. There is no evidence before me that the respondent acted in bad faith, failed to investigate the claim adequately, or otherwise delayed payment in a manner that would meet the high threshold required for an award.
25Accordingly, I find that the applicant is not entitled to an award.
ORDER
26For the above reasons, it is ordered that:
i. The applicant is not entitled to the disputed treatment plans.
ii. The applicant is not entitled to interest or an award.
Released: November 12, 2025
Harouna Saley Sidibé
Adjudicator