Licence Appeal Tribunal File Number: 24-001500/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:
Karoline Allalouf
Applicant
and
Wawanesa Mutual Insurance Company
Respondent
DECISION
ADJUDICATOR:
Aric Bhargava
APPEARANCES:
For the Applicant:
Bretton Dugan, Counsel
For the Respondent:
Eric Boate, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Karoline Allalouf, the applicant, was involved in an automobile accident on July 22, 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, Wawanesa Mutual Insurance Company, and applied to the Licence Appeal Tribunal — Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
2On July 10, 2024, a case conference took place for this matter and the Case Conference Report and Order (“CCRO”) dated July 16, 2024, set a 5-day videoconference hearing scheduled for February 24 – 28, 2025.
3On February 5, 2025, the applicant filed a Notice of Motion requesting that the Tribunal grant a motion order to convert the videoconference hearing to a written hearing and the issue of catastrophic impairment was withdrawn. The respondent consented to the motion.
4The motion order dated February 6, 2025, granted the motion and a notice for this written hearing was issued on March 13, 2025.
ISSUES
5The issues in dispute are:
i. Is the applicant entitled to $2,120.78 for physiotherapy services proposed by Iscope Concussion and Pain Centres in a treatment plan/OCF-18 (“plan”) dated December 6, 2021?
ii. Is the applicant entitled to $1,902.00 for physiotherapy services proposed by Top Rehab in a plan dated March 22, 2022?
iii. Is the applicant entitled to $3,622.73 for chiropractic services proposed by Mackenzie Medical Rehabilitation Centre in a plan dated June 20, 2022?
iv. Is the applicant entitled to $3,266.97 for psychological services proposed by Alliance Diagnostics and Treatments Inc. in a plan dated January 4, 2023?
v. Is the applicant entitled to $3,107.00 for physiotherapy services proposed by Om Sai Physiotherapy Clinic (Mississauga) Inc. in a plan dated February 24, 2023?
6In her submissions the applicant withdrew issue iv) and v) listed in the CCRO. As such, I will not address the issue of a psychological assessment in the amount of $2,175.91, and the issue of an orthopaedic assessment in the amount of $2,485.00.
RESULT
7I find the applicant is not entitled to $2,120.78 for physiotherapy services.
8I find the applicant is not entitled to $1,902.00 for physiotherapy services.
9I find the applicant is not entitled to $3,622.73 for chiropractic services.
10I find the applicant is not entitled to $3,266.97 for psychological services.
11I find the applicant is not entitled to $3,107.00 for physiotherapy services.
PROCEDURAL ISSUES
12The respondent submits that the applicant failed to produce relevant records in accordance with the CCRO and an adverse inference should be drawn from this. The respondent submits this is prejudicial for two reasons; first the applicant’s failure deprives the respondent of its ability to review relevant medical records as it relates to the disputed medical rehabilitation benefits, and second it has deprived the respondent of its ability to order a section 44 examination based on the requested records.
13The applicant does not deny the Tribunal Order was breached and argues that the prejudice to the respondent is minimized because these records are not cited in her submission.
14I find that the issue is moot because the applicant does not rely on these records and no prejudice is caused to the respondent.
ANALYSIS
15To receive payment for a treatment plan 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 the 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 plan in the amount of $2,120.78 for physiotherapy services?
16I find the applicant has not demonstrated the physiotherapy services treatment plan is reasonable and necessary.
17The physiotherapy treatment plan dated December 6, 2021, prepared by Mr. Farhankhan Pathan, physiotherapist, from Iscope Concussion and Pain Centres is meant to address the applicant’s injuries including post-concussional syndrome, migraine, sleep and mood disorders. The provider proposed physical rehabilitation. The goals for this plan are pain reduction, increased range of motion, return to activities of normal living, and return to pre-work activities. The treatment plan includes 12 sessions of physical rehabilitation, and four counts of documentation, planning, and preparation, over a period of 12 weeks. Progress will be evaluated through subjective measures.
18The applicant states the treatment plan is for long-term management of symptoms for her pre-existing fragilities. The applicant is relying on part of the section 44 physician report prepared by Dr. Eric Silver, physician, dated September 29, 2020, and part of the section 44 physiatrist report prepared by Dr. Julian Mathoo, physiatrist, dated December 14, 2023.
19The respondent submits the applicant has not met her onus to demonstrate the treatment plan is reasonable and necessary and the applicant has reached maximal medical recovery. The respondent relies on the section 44 physician report prepared by Dr. Silver, dated September 29, 2020, and the section 44 psychological assessment report prepared by Dr. Karen Spivak, psychologist, dated June 2, 2021.
20Dr. Silver’s section 44 report notes he found no “objective evidence of an ongoing accident-related musculoskeletal pathology,” and the applicant has reached maximum medical recovery. Dr. Mathoo’s section 44 report notes “no objective findings of radiculopathy or myelopathy” as a result of the accident.
21I find the applicant has not directed me to contemporaneous medical evidence or any recommendation in support of the treatment plan for her accident-related injuries, beyond that of the treating provider. A treatment plan by itself is not evidence in support of the need for treatment.
22I find, on a balance of probabilities, the applicant has not met her onus to establish entitlement to the physiotherapy services treatment plan.
Is the applicant entitled to the treatment plan in the amount of $1,902.00 for physiotherapy services; $3,622.73 for chiropractic services; and $3,107.00 for physiotherapy services?
23I find on a balance of probabilities the applicant has not demonstrated the physiotherapy treatment plans and chiropractic treatment plan are reasonable and necessary.
24The applicant submits she is entitled to the treatment plans because the treatment is reasonable and necessary. The applicant relies on the section 44 reports prepared by Dr. Silver and Dr. Spivak.
25While Dr. Silver’s and Dr. Spivak’s section 44 reports provide a summary of the applicant’s self-reported complaints, Dr. Silver notes the applicant “has reached maximum medical recovery from the musculoskeletal injuries she sustained in the subject accident and further facility-based therapy is therefore not medically required.” In my view, the section 44 reports do not support the applicant’s position that the physiotherapy and chiropractic services are reasonable and necessary.
26I apply the same line of reasoning noted above with respect to the physiotherapy treatment plan. The applicant has not provided contemporaneous medical evidence in support of the treatment plan. The treatment plan itself is not evidence in support of the need for treatment.
27I find, on a balance of probabilities, the applicant has not met her onus to establish entitlement to the physiotherapy and chiropractic treatment plans.
Is the applicant entitled to the treatment plan in the amount of $3,266.97 for psychological services?
28I find on a balance of probabilities that the applicant is not entitled to the psychological services treatment plan.
29The psychological services treatment plan submitted by Elena Vinogradova, speech-language pathologist, intends to address the applicant’s injuries including adjustment and anxiety disorders, specific phobias, and persistent somatoform pain disorder. The provider proposes 12 sessions of therapy, 12 sessions for planning, and three counts of documentation, and one count for assessment, over a period of 12 weeks. The goals for this plan are to decrease psychological impairment and return to activities of normal living. The provider notes progress will be evaluated through clinical observation and self-reporting.
30The applicant submits she suffers from anxiety and PTSD and the treatment plan is reasonable and necessary because the respondent previously approved a more extensive psychological treatment plan of the same nature.
31The respondent submits the applicant has not met her onus to demonstrate the plan is reasonable and necessary and the treatment plan for psychological services is a duplication of services. The respondent’s denial letter states the treatment is not reasonable and necessary because the applicant’s impairments are not directly related to the accident.
32I find this plan is duplicative because the respondent previously approved a treatment plan for 12 one-hour treatment sessions from the same provider, including documentation and documentation support activity based on the report prepared by Dr. Spivak.
33However, if I am wrong, it is well established a treatment plan in itself is not persuasive evidence that it is reasonable and necessary. The applicant has not submitted evidence in support of her claim and not directed me to any third-party professional recommendation in support of the treatment plan.
34I find on a balance of probabilities that the applicant has not met her onus to establish entitlement to the psychological services treatment plan.
ORDER
35For the reasons outlined above, I find the applicant is not entitled to the treatment plans in dispute.
36The application is dismissed.
Released: November 27, 2025
Aric Bhargava
Adjudicator