Licence Appeal Tribunal File Number: 24-000748/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:
Angelica Avendano Arboleda
Applicant
and
Scottish and York Insurance Co.
Respondent
DECISION
ADJUDICATOR:
Kathleen Wells
APPEARANCES:
For the Applicant:
Kameliya Stancheva, Paralegal
For the Respondent:
Tresa Zacharia, Counsel
HEARD
By way of written submissions
OVERVIEW
1Angelica Avendano Arboleda, the applicant, was involved in an automobile accident on August 5, 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 the respondent, Scottish and York Insurance Co., and applied to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issues in dispute are:
Is the applicant entitled to $3,922.47 for chiropractic services, proposed by Dr. Harjot Grewal, Chiropractor, Integral Health Group, in a treatment plan dated June 7, 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
3I find that:
The applicant is not entitled to $3,922.47 for chiropractic services in the treatment plan dated June 7, 2023.
The applicant is not entitled to an award.
As no payments are owing, no interest is due.
The application is dismissed.
ANALYSIS
Is the applicant entitled to $3,922.47 for chiropractic services in a treatment plan dated June 7, 2023?
4I find that the applicant has not met her onus to prove that the treatment plan dated June 7, 2023 is reasonable and necessary.
5To receive payment for a treatment and assessment plan under s. 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.
6The applicant submits that all treatment plans incurred by the applicant are payable, because she should be removed from the MIG due to chronic pain. The applicant’s MIG eligibility is not set out as an issue in dispute in the CCRO, and the respondent submits that the applicant was removed from the MIG on April 20, 2022, more than a year before the treatment plan was submitted. Therefore, it is not necessary for me to consider the applicant’s MIG eligibility.
7The Case Conference Report and Order (“CCRO”) sets out only one treatment plan in dispute. Although the applicant has not submitted a copy of the treatment plan seeking $3,922.47 for chiropractic services dated June 7, 2023 for my review, or made any submissions specific to the treatment plan, the respondent has provided a copy of the treatment plan. Therefore, I will review the evidence submitted by the applicant and the respondent’s submissions and evidence to consider whether the treatment plan is reasonable and necessary.
8The goals of the treatment plan are: pain reduction, increased range of motion, increase in strength, and a return to activities of normal living, pre-accident functional status and pre-accident work activities.
9The treatment plan sets out services totalling $3,922.47, including a total body assessment, 18 one-hour sessions of manipulation, 18 half-hour sessions of massage therapy, 18 15-minute sessions of laser therapy, and $200.00 for the preparation of the treatment plan.
10The applicant relies on the clinical notes and records (“CNRs”) of the Trillium Health Partners Mississauga Hospital, the CNRs of the applicant’s family doctor, Dr. Bortnick dated August 12, 2021 and the OCF-3 dated August 23, 2021.
11The respondent submits that applicant has not met her onus to prove that the treatment plan is reasonable and necessary. The respondent relies on the July 27, 2023 s.44 insurer examination (“IE”) report of Dr. Neetan Alilkhan, general practitioner, who opined that the applicant had reached maximum medical recovery from her soft tissue injuries, did not meet the criteria for a diagnosis of chronic pain syndrome, and that the treatment plan was not reasonable and necessary.
12I find that the evidence does not establish on a balance of probabilities that the treatment plan is reasonable and necessary. The applicant was taken to Trillium Health Partners emergency department by ambulance immediately after the accident, complaining of head, neck, shoulder, and back pain, She was sent for CT imaging of her head and cervical spine, which returned normal studies, and was discharged without a diagnosis and advised to take over-the-counter pain medication and follow up with her family doctor.
13Dr, Bortnick’s CNRs. dated August 12, 2021, indicate that she diagnosed the applicant with soft tissue injuries to her lumbar and cervical spine, and prescribed pain medication and physiotherapy. The OCF-3 , dated August 3, 2-21 identified sprain and strain injuries to the applicant’s back and shoulders Both the CNRs and the OCF-3 are dated within a month of the accident and pre-date the submission of the treatment plan by 22 months. As such, I find they shed little light on the applicant’s injuries at the time the treatment plan was submitted, and applicant has not directed me to any further medical evidence in support of the treatment plan.
14Further the applicant did not make any submissions with respect to the overall costs of the treatment plan, or provide information about the applicant’s improvement since her previous treatment.
15For these reasons, I find that the applicant has not met her onus to prove on a balance of probabilities that the treatment plan is reasonable and necessary.
16Accordingly, the applicant is not entitled to $3,922.47 for chiropractic services in the treatment plan dated June 7, 2023.
Interest
17Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no payments are owing, no interest is due.
Award
18The 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.
19As the applicant has not made any submissions or led any evidence with respect to an award, I find that the applicant has not met her onus to prove on a balance of probabilities that she is entitled to an award.
ORDER
20I find that:
The applicant is not entitled to $3,922.47 for chiropractic services in the treatment plan dated June 7, 2023.
The applicant is not entitled to an award.
As no payments are owing, no interest is due.
The application is dismissed.
Released: November 19, 2025
Kathleen Wells
Adjudicator