Licence Appeal Tribunal File Number: 24-001421/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:
Shayne Goodman
Applicant
and
Northbridge General Insurance Company
Respondent
DECISION
ADJUDICATOR: Harouna Saley Sidibé
APPEARANCES:
For the Applicant: Eric Findlay, Counsel
For the Respondent: Jonathan Heeney, Counsel
HEARD: By way of written submissions
OVERVIEW
1Shayne Goodman, the applicant, was involved in an automobile accident on March 12, 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, Northbridge General Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issue in dispute is:
i. Is the applicant entitled to $8,000.49 ($9,850.48 less $1,849.99 approved) for other assistive devices, proposed by Function Ability Rehabilitation Services in a treatment plan/OCF-18 (“plan”) submitted June 6, 2023, and partially denied August 1, 2023?
RESULT
3For the reasons below, I find that:
- The applicant is not entitled to the outstanding amount of the disputed treatment plan.
ANALYSIS
Is the applicant entitled to the outstanding amount of the disputed treatment plan?
4I find that the applicant is not entitled to the outstanding amount of the treatment plan.
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.
6Section 16(3)(i) provides for funding of “home modifications and home devices […], to accommodate the needs of the insured person,” where such items are reasonable and necessary to support the insured’s recovery.
7The applicant is requesting funding for a plan dated June 6, 2023, amounting to $9,850.48, prepared and signed by occupational therapist Alicia Kralt. The goals of the plan are to reduce sleep disturbances and support a return to normal activities. The plan includes various items: documentation and support activity fees, a memory-foam mattress, a waterproof mattress protector, bamboo sheets, an adjustable bed, a platform bed, a five-drawer chest, and delivery and setup costs.
8The applicant argues that these items are reasonable and necessary home devices, stating that they encourage restful sleep, correct biomechanical positioning, and provide psychological comfort, factors that aid in his physical and emotional recovery after a traumatic amputation.
9In support of the claim, the applicant relies on an Occupational Therapy In-Home Functional Assessment Report dated June 5, 2023, authored by Ms. Alicia Kralt. The report recommends sleep-system upgrades to reduce sleep disturbances and facilitate transfers.
10The applicant also cites case law recognizing pain relief and improved sleep quality as legitimate rehabilitation goals, even in the absence of full physical recovery, including Amoa-Williams v. Allstate Insurance Co. of Canada, 2000 ONFSCDR 596; F.J. v. Intact Insurance Co., 2020 CanLII 34495 (ON LAT); and Tobin v. Cayuga Mutual Insurance Co, 2022 CanLII 106459 (ON LAT).
11The respondent partially approved the proposed plan on June 15, 2023, following an insurer’s examination conducted by occupational therapist Ms. Himadri Kaul. In her in-home assessment dated July 31, 2023, Ms. Kaul determined that only the memory foam mattress, the documentation fee, and delivery costs were reasonable and necessary. She advised against funding the adjustable bed, platform, dresser, bamboo sheets, and waterproof protector, citing a lack of medical justification. Based on this assessment, the respondent approved $1,849.99 and denied the remaining amount for the plan.
12The respondent contends that the applicant has not satisfied the burden of proof. It highlights that Ms. Kralt’s assessment primarily relied on information from the applicant’s mother rather than a direct assessment of the applicant. Conversely, the respondent’s assessor carried out a comprehensive in-person evaluation and determined that most of the proposed items were not medically necessary. The respondent further asserts that the plan does not clearly specify how each item would directly assist in reducing sleep disturbance or supporting normal living. It bases its argument on the Barabash v. Pembridge, 2023 CanLII 42570 (ON LAT) and the general LAT test for reasonableness and necessity.
13The Disability Certificate (OCF-3) dated March 22, 2023, confirms the applicant's lower limb amputation from an accident. Occupational therapist Ms. Kralt assessed the applicant on May 18 and 26, 2023, to evaluate his care needs and daily functioning, and to recommend equipment and services. Although she couldn't observe bed transfers directly due to the applicant’s low mood and lack of consent, she relied on the applicant’s mother’s reports. She noted that the applicant could mobilize in bed and transfer from a wheelchair or standing with a walker.
14In contrast, the respondent’s occupational therapist, Ms. Kaul, conducted an in-home assessment on July 31, 2023. She concluded that only the memory foam mattress, the documentation fee, and delivery costs were reasonable and necessary. She found that the applicant’s existing bedframe could accommodate the new mattress, the bedroom space was limited for additional furniture, and that the applicant was capable of safe transfers. Ms. Kaul also noted that the applicant’s use of a wheelchair was expected to be temporary and that there was insufficient objective evidence linking the requested items to functional improvement. A follow-up paper review dated August 25, 2023, reaffirmed her initial conclusions.
15The applicant disputes the respondent’s assessment, arguing that it failed to adequately consider his phantom limb pain and the psychological impact of disrupted sleep. In support, the applicant relies on an email dated August 1st, 2023, from his treating occupational therapist, Ms. Laura Zuliani. Ms. Zuliani criticized the respondent’s report for inaccurately assessing the applicant’s physical condition and for recommending pillows instead of an adjustable bed to address comfort needs. She emphasized that phantom limb pain and psychological distress were significant and ongoing concerns, and that the applicant’s need for a wheelchair was likely permanent due to fatigue and other limitations associated with lower limb amputation. Ms. Zuliani also expressed concern that the respondent’s assessor did not seek clarification regarding the therapeutic rationale for the remaining items on the plan.
16Having considered the totality of the evidence, I find that the applicant has not met the burden of proof to establish, on a balance of probabilities, that the disputed items are reasonable and necessary under the Schedule.
17I accept the conclusions of Ms. Kaul’s comprehensive in-home and follow-up assessments, which were based on direct observation of the applicant’s functional abilities and living environment. Her findings provide a more reliable foundation than Ms. Kralt's assessment, which did not reflect the applicant’s full engagement in the process.
18I am satisfied that the applicant can safely perform transfers using his current bedframe and that the proposed adjustable and platform beds would not lead to significant improvements in function or safety. There is no evidence suggesting that the current bed setup hinders mobility or independence. Likewise, the proposed five-drawer chest and accessories, including bamboo sheets and a waterproof mattress protector, are not supported by medical evidence connecting them to rehabilitation or reintegration goals. Comfort does not satisfy the statutory criteria of reasonableness and necessity.
19Although I acknowledge the applicant’s challenges with sleep disturbance and phantom limb pain, there is insufficient medical evidence to establish that lacking an adjustable bed or specialty bedding contributes to these symptoms. The respondent’s approval of a high-quality memory-foam mattress reasonably addresses these concerns.
20I distinguish Tobin, where the claimants demonstrated that adjustable beds directly alleviated pain or facilitated transfers. In this case, the applicant remains independently mobile and capable of safe bed transfers.
21Accordingly, on a balance of probabilities, I find that the applicant is not entitled to the outstanding amount of the treatment plan.
ORDER
22For the above reasons, it is ordered that:
i. The applicant is not entitled to the outstanding amount of the disputed treatment plan.
Released: November 21, 2025
Harouna Saley Sidibé
Adjudicator