Licence Appeal Tribunal File Number: 23-015464/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:
Michelle Farinha
Applicant
and
Intact Insurance Company
Respondent
DECISION
ADJUDICATOR: Raymond Selbie
APPEARANCES:
For the Applicant: Dayana Soto Santana, Paralegal
For the Respondent: Robbie Brar, Counsel
HEARD: By way of written submissions
OVERVIEW
1Michelle Farinha, the applicant, was involved in an automobile accident on June 20, 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, Insurer, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the "Tribunal") for resolution of the dispute.
ISSUES
2The issue in dispute are:
i. Are the applicant's injuries predominantly minor as defined in s. 3 of the Schedule and therefore subject to treatment within the $3,500.00 minor injury guidelines (MIG) limit? Note: The parties agree that the MIG limits have not been exhausted, and their submissions shall identify the amounts herein remining.
ii. Is the applicant entitled to $1,420.40 for applicant/aide transportation, proposed by 101 Physio in a treatment plan/OCF-18 ("plan") dated September 14, 2023?
iii. Is the applicant entitled to $2,460.00 for a psychological assessment, proposed by 101 Assessments in a plan dated July 26, 2023?
iv. Is the applicant entitled to $3,790.70 for psychological services, proposed by 101 Assessments in a plan dated November 13, 2023?
v. Is the applicant entitled to the plans proposed by 101 Physio, as follows:
a. $2,591.28 for medical services, in a plan dated June 23, 2023;
b. $2,394.69 for medical services, in a plan dated January 12, 2024; and
c. $2,361.02 for chiropractic services, in a plan dated March 3, 2024?
vi. Is the applicant entitled to interest on any overdue payments or benefits?
MOTION
3After this application was set down for a written hearing, the applicant filed a Motion dated October 15, 2025, which was served upon the respondent pursuant to a Certificate of Service of even date.
4The Motion noted that the respondent has removed the applicant from the MIG following a S. 44 insurer examination and has approved partial payment of issue [2] iii. for a psychological assessment in the amount of $1,496.10 leaving the balance of $963.90 in dispute. The respondent has not responded to the Motion.
5I have allowed the Motion and removed the issue of the MIG as well as amended issue [2] iii to reflect a partial approval as above.
RESULT
6I find that the applicant is not entitled to $1,420.40 for applicant/aide transportation, proposed by 101 Physio in a treatment plan/OCF-18 ("plan") dated September 14, 2023.
7I find that the applicant is entitled to $963.90 ($2,460.00 less $1,496.10 approved), for a psychological assessment, proposed by 101 Assessments in a plan dated July 26, 2023.
8I find that the applicant is entitled to $3,790.70 for psychological services, proposed by 101 Assessments in a plan dated November 13, 2023.
9I find that the applicant is entitled to the plans proposed by 101 Physio, as follows:
10$2,591.28 for medical services, in a plan dated June 23, 2023; and
11$2,394.69 for medical services, in a plan dated January 12, 2024.
12I find that the applicant is not entitled to $2,361.02 for chiropractic services, proposed by 101 Assessments in a plan dated March 3, 2024.
13I find that the applicant is entitled to interest pursuant to s. 51 of the Schedule.
ANALYSIS
Transportation proposed by 101 Physio for $1,420.40 for applicant/aide transportation, proposed by 101 Physio in a treatment plan/OCF-18 ("plan") dated September 14, 2023, is not reasonable and necessary.
14The applicant submitted an OCF-18 ("plan") dated September 14, 2023, for applicant/aide transportation proposed by 101 Physio for $1,420.40.
15The plan is to provide transportation for the applicant/aide as an 'authorized transportation expense' per s. 3(1) of the Schedule.
16Sections 14-15 of the Schedule provide that the insurer shall pay for medical and rehabilitation benefits to or on behalf of the applicant so long as the applicant sustains an impairment as the result of the accident and the expense of the incurred benefit is reasonable and necessary.
17The applicant relies on the OCF-18 dated September 14, 2023. However there does not appear, upon review of the OCF-18 to be a calculation of the distance required for the applicant to attend upon treatment.
18The respondent relies upon the plan not being reasonable or necessary as well as s. 3(1) of the Schedule which defines the expense as being covered only after the first 50 kilometres of the trip 'unless the insured person sustains a catastrophic impairment as a result of the accident'.
19I find that the evidence does not satisfy the onus on the applicant to establish that she is entitled to the amount of the plan as it would require proof that the distance is over 50 kilometres as required in s. 3(1) of the Schedule unless the applicant sustained a catastrophic impairment, which is not the case.
Psychological assessment proposed by 101 Assessments for $963.90 ($2,460.00 less $1,496.10 approved), in a plan dated July 26, 2023, is reasonable and necessary
20The applicant submitted an OCF-18 dated July 26, 2023, for a psychological assessment in the amount of $2,460.00 proposed by 101 Assessments. The respondent subsequently approved $1,496.10 leaving a balance of $963.90.
21The plan was to assess mental health and addictions and document support activity for the claim form to the respondent.
22Sections 14-15 of the Schedule provide that the insurer shall pay for medical and rehabilitation benefits to or on behalf of the applicant so long as the applicant sustains an impairment as the result of the accident and the expense of the incurred benefit is reasonable and necessary.
23The applicant relies on the findings of Dr. Papazoglou who diagnosed the applicant with adjustment disorder and specific (isolated) phobia and noted the prescription of antidepressants by Dr. Sethi for anxiety.
24The respondent initially denied the plan as the applicant had failed to attend an insurer exam and despite a request to reschedule, the applicant has failed to reschedule.
25The respondent partially funded the plan and there appears to be no reason given for non-approval of the full amount of the plan.
26I find that the applicant has fulfilled the onus to demonstrate the need for the plan and that it is reasonable and necessary.
Psychological services proposed by 101 Assessments for $3,790.70 in a plan dated November 13, 2023, is reasonable and necessary
27The applicant submitted an OCF-18 for psychological services dated November 13, 2023, proposed by 101 Assessments.
28The plan is to provide counselling, assessment, documentation and support activity for pain reduction and reduction of depressive symptomatology and improve emotional status.
29Sections 14-15 of the Schedule provide that the insurer shall pay for medical and rehabilitation benefits to or on behalf of the applicant so long as the applicant sustains an impairment as the result of the accident and the expense of the incurred benefit is reasonable and necessary.
30The applicant relies on the findings of Dr. Papazoglou who diagnosed the applicant with adjustment disorder and specific (isolated) phobia and noted the prescription of antidepressants by Dr. Sethi for anxiety.
31The respondent relies on the IE psychological assessment report of Dr. Seon dated February 28, 2024, wherein the applicant denied any significant psychological impairment of her social, occupational, overall level of functioning or sleep patterns. The respondent further relied upon the report from Dr. T. Seon, which opined that the injuries suffered by the applicant could be treated under the MIG. The applicant has subsequently been removed from the MIG as set forth in paragraph [5] above. The respondent submits that the plan is not reasonable and necessary.
32I find that the applicant has fulfilled the onus to demonstrate the need for the plan and that it is reasonable and necessary.
Medical services proposed by 101 Physio for $2,591.28 in a plan dated June 23, 2023, is reasonable and necessary
33The applicant submitted an OCF-18 for medical services proposed by 101 Physio.
34The plan called for physical rehabilitation, therapy acupuncture and goods to reduce the applicant's pain and increase range of motion.
35Sections 14-15 of the Schedule provide that the insurer shall pay for medical and rehabilitation benefits to or on behalf of the applicant so long as the applicant sustains an impairment as the result of the accident and the expense of the incurred benefit is reasonable and necessary.
36The applicant relies on the findings of chronic pain by Dr. Sethi commencing in July 2023, the assessment of Ms. Butt of 101 Assessments in September 2023, the ongoing pain assessed by the Chronic Pain Clinic Rapid Access Clinic in April 2024. The applicant further relies on the findings of Dr. Papazoglou, Psychiatrist in September 2023 which opined on the psychological suffering being experienced by the applicant as the result of pain from the accident.
37The respondent submits that there is no compelling evidence that the applicant's physical injuries fall outside of the MIG. The applicant has subsequently been removed from the MIG as set forth in [5] above.
38I find the applicant has suffered a physical impairment (chronic pain) and that the refusal of the plan by the respondent is based on the applicant's injuries being capable of treatment under the MIG The applicant has been removed from the MIG pursuant to paragraph [5] above.
39I find that the applicant has fulfilled the onus to demonstrate the need for the plan and that it is reasonable and necessary.
Medical services proposed by 101 Physio for $2,394.69 in a plan dated January 12, 2024, is reasonable and necessary
40The plan called for physical therapy to reduce pain, increase strength and increase range of motion for the applicant to return to activities of normal living and return to pre-accident work activities.
41The applicant relies on the findings of chronic pain by Dr. Sethi commencing in July 2023, the assessment of Ms. Butt of 101 Assessments in September 2023, the ongoing pain assessed by the Chronic Pain Clinic Rapid Access Clinic in April 2024. The applicant further relies on the findings of Dr. Papazoglou, Psychiatrist in September 2023, which opined on the psychological suffering being experienced by the applicant as the result of pain from the accident.
42The respondent relies on the IE of Dr. Moolla on June 20, 2023, as well as the subsequent paper review of February 28, 2024, and submits that there is no compelling evidence that the applicant's injuries fall outside of the MIG. The applicant has subsequently been removed from the MIG as set forth in [5] above.
43I find that the applicant has suffered a physical impairment (chronic pain) and fulfilled the onus to demonstrate the need for the plan and that it is reasonable and necessary.
Medical services proposed by 101 Physio for $2,361.02, is not reasonable and necessary
44The applicant submitted an OCF-18 for medical services proposed by 101 Physio.
45The plan called for physical therapy (chiropractic services) to reduce pain, reduce depressive symptomatology, improve emotional status, and for the applicant to return to activities of normal living.
46The applicant relies on the findings of chronic pain by Dr. Sethi commencing in July 2023, the assessment of Ms. Butt of 101 Assessments in September 2023, the ongoing pain assessed by the Chronic Pain Clinic Rapid Access Clinic in April 2024. The applicant further relies on the findings of Dr. Papazoglou, Psychiatrist in September 2023, which opined on the psychological suffering being experienced by the applicant as the result of pain from the accident. The applicant argues that the plan is necessary to treat these physical (chronic pain) impairments.
47The respondent submits that the treatment is not reasonable and necessary and that the failure of the applicant to sign the OCF-18 prevented the respondent from considering approval.
48I have reviewed the respondent's letter to the applicant dated November 3, 2024. The respondent pointed out the failure of the applicant to sign the OCF-18, the respondent's refusal to waive the requirement and the caution to the applicant pursuant to s. 33 of the Schedule. The applicant was made aware of the consequences of failure to sign the OCF-18 and the respondent's right to withhold determination of entitlement for benefits 'for any period before you comply with the Insurer's request'. There is no evidence that the applicant took appropriate measures to correct the default and thus is bound by that decision. Further, the Case Conference Report and Order of Adjudicator Edward Langley dated May 31, 2024, allows the applicant 7 calendar day prior to the hearing to file a reply to the respondent's submissions. The applicant did not file a reply.
49I find that the applicant failed to submit a completed OCF-18, she has not provided a reasonable explanation for this delay, the respondent has not waived this requirement, and I find that this plan is denied.
Interest
50Considering that the treatment plans set forth in paragraphs 2 (ii), (iii), (iv), (v) a, and (v) b, are reasonable and necessary, it follows that the applicant is entitled to interest on any overdue payment of benefits pursuant to s. 51 of the Schedule.
ORDER
51I find that:
i. The applicant is not entitled to $1,420.40 for applicant/aide transportation, proposed by 101 Physio in a plan dated September 14, 2023.
ii. The applicant is entitled to $963.90 ($2,460.00 less $1,496.10 approved), for a psychological assessment, proposed by 101 Assessments in a plan dated July 26, 2023.
iii. The applicant is entitled to $3,790.70 for psychological services proposed by 101 Assessments in a plan dated November 13, 2023.
iv. The applicant is entitled to $2,591.28 for medical services, in a plan proposed by 101 Physio dated June 23, 2023.
v. The applicant is entitled to $2,394.69 for medical services, proposed by 101 Physio in a plan dated January 12, 2024.
vi. I find that the applicant is not entitled to $2,361.02 for chiropractic services, proposed by 101 Physio in a plan dated March 3, 2024.
vii. I find that the applicant is entitled to interest pursuant to s. 51 of the Schedule.
Released: November 14, 2025
Raymond Selbie
Adjudicator