Licence Appeal Tribunal File Number: 24-002319/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:
Fang Li
Applicant
and
Security National Insurance Company
Respondent
DECISION
ADJUDICATOR: Harouna Saley Sidibé
APPEARANCES:
For the Applicant: Rakesh Sharma, Counsel
For the Respondent: Kateryna Borodenko, Counsel
HEARD: By way of written submissions
OVERVIEW
1Fang Li, the applicant, was involved in an automobile accident on June 18, 2022, 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, Security National 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 $1,463.52 for physiotherapy services, proposed by Easy Health Care in a treatment plan/OCF-18 (“plan”) dated June 13, 2023?
ii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
iii. 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 plan.
The applicant is not entitled to interest or an award.
ANALYSIS
Is the applicant entitled to the disputed treatment plan?
4I find that the applicant is not entitled to the disputed 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.
6Under the Schedule, section 38(3) requires an insured person to submit a completed treatment and assessment plan (Form OCF-18) to the insurer before incurring expenses for medical or rehabilitation benefits, unless otherwise permitted. Section 38(8) imposes a strict timeline on insurers, requiring them to respond within 10 business days after receiving the plan: either approve it or deny it in whole or in part. If there is any form of denial, the insurer may also require an insurer’s examination. Failure to comply with section 38(8) results, in accordance with section 38(11), in the insurer being liable for the proposed goods and services and being prohibited from relying on the Minor Injury Guideline for that plan.
7The treatment plan dated June 12, 2023, for physiotherapy services, for $1,463.25, is signed by Sreejith Jayanth, a physiotherapist. The goals are pain reduction, increased range of motion, improved strength, return to normal daily activities, and resumption of pre-accident work. It outlines a support activity, eight sessions of physical rehabilitation, and eight sessions of acupuncture at multiple body sites.
Section 38 of the Schedule
8The applicant states the treatment plan was submitted adequately under s. 38(3) and is deemed reasonable unless denied validly. He cites s. 38(8) and argues the respondent’s denial letters lack adequate medical reasons, making them deficient.
9In support of his position, the applicant relies on Hedley v. Aviva Insurance Company, 2019 ONSC 5318, which held that denial reasons must be “meaningful and specific” to allow an insured person to understand and challenge the denial. He also cites LAT decisions (R.K. v. RBC General Insurance, 2018 CanLII 2309; Flauta v. Aviva General Insurance, 2023 CanLII 4445), which support the proposition that a treatment plan compliant with s. 38(3) is prima facie evidence of necessity when the insurer’s denial lacks substantive justification.
10The respondent argues that the applicant mischaracterized the June 23, 2023, denial letter, which references Dr. Chris Aldridge’s insurer examination on October 17, 2022, that diagnosed soft tissue injuries (the report was not submitted by the parties as evidence). The letter considers the injury mechanism, the date of loss, and the treatment received, warranting a second opinion. The applicant overlooked the full content, which included medical and other reasons.
11Upon review, I find that the respondent complied with s. 38(8). The June 23, 2023, denial provided medical reasons, referencing Dr. Chris Aldridge’s October 17, 2022, insurer examination, and classified the injuries as musculoskeletal under the Minor Injury Guideline (“MIG”). It addressed the injury mechanism, date of loss, and prior treatment, noting that a second opinion was needed to assess the reasonableness of the treatment. The September 27, 2023, denial included findings from Dr. Ahmad Belfon’s September 9, 2023, family physician examination, concluding that no objective musculoskeletal findings warranted further therapy. Both notices informed the applicant of their dispute rights, satisfying the Schedule’s requirement. There is no evidence of delay or deficiency.
12The applicant’s claim that a treatment plan under s. 38(3) is “deemed” reasonable and necessary, which misinterprets the law. Section 38 sets procedural rules and response presumptions, but funding entitlement ultimately relies on the substantive reasonableness and necessity test under the Schedule.
Reasonableness and Necessity
13The applicant submits that Dr. Belfon’s insurer examination report dated September 25, 2023, is statutorily deficient because it concluded with a diagnosis of the injuries as minor and did not address whether the applicant had achieved maximal recovery. The applicant argues that this omission is significant, as determining maximal recovery is necessary to assess whether the proposed OCF-18 treatment plan was required for rehabilitation.
14The applicant maintains that he was removed from the MIG following Dr. Moshiri's assessment on October 17, 2022 (which was not submitted as evidence), claiming that subsequent treatment falls outside MIG limits. He argues that the legal test is whether the treatment is necessary for rehabilitation and achieving maximum recovery, rather than whether the injuries are minor.
15The respondent maintains that the applicant has not met the burden of proof to establish, on a balance of probabilities, that the disputed treatment plan is reasonable and necessary within the meaning of the Schedule.
16The respondent cites insurer reports from Dr. Aldridge (October 17, 2022) and Dr. Belfon (September 25, 2023). The respondent notes that Dr. Aldridge stated the applicant's soft-tissue injuries were uncomplicated and expected to reach maximum recovery within the MIG. Dr. Belfon found no tear, fracture, or neurological deficit and observed that shoulder and hip pain had resolved, with only intermittent neck and lower back discomfort remaining.
17The respondent submits that continued facility-based therapy for more than one year post-accident is not medically supported and is inconsistent with the applicant’s demonstrated recovery and functional status.
18Additionally, the respondent argues that the applicant has not provided independent medical evidence or contemporaneous clinical records from treating providers to support the need for further therapy to achieve additional improvement.
19The applicant’s visit to his family physician, Dr. Nayef Shubair, on June 20, 2022, resulted in a recommendation for pain medication. A follow-up on June 24, 2022, noted unremarkable medical findings.
20Dr. Belfon’s report dated September 25, 2023, diagnosed the applicant with uncomplicated sprain/strain injuries to the cervical spine, thoracolumbar spine, and right shoulder. He noted that the right shoulder pain had resolved, and that only intermittent neck and low back pain remained.
21Progress reports from Somatic Assessments & Treatment Clinic Inc., covering August 2023 to January 2024, indicated that the applicant appeared well and was performing most of his prescribed exercises.
22I accept that the applicant was removed from the MIG by the respondent’s own determination in October 2022, following the psychological insurer examination. However, removal from the MIG does not automatically render subsequent treatment plans reasonable and necessary. The applicant must still establish that the disputed plan satisfies the statutory test under ss. 15 or 16 of the Schedule.
23Dr. Belfon’s insurer examination was conducted approximately 15 months after the accident and included a comprehensive physical assessment. He found normal range of motion in the cervical and lumbar spine, full strength, intact neurological findings, and resolution of most accident-related symptoms. He concluded that further facility-based therapy was not reasonable or necessary in the absence of ongoing objective impairment.
24Although Dr. Belfon did not explicitly use the term “maximal recovery,” his findings support a clinical conclusion that the applicant’s injuries had substantially resolved. This supports a determination that additional in-clinic therapy would not materially improve function.
25In this case, the applicant has not submitted current clinical notes or treatment records to support the need for ongoing therapy. The only independent medical opinion available is from Dr. Belfon, who found no ongoing impairment requiring further treatment.
26Accordingly, I find that the applicant has not established, on a balance of probabilities, that the OCF-18 dated June 12, 2023, is reasonable and necessary.
Interest
27Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since no benefit is owed, interest does not apply.
Award
28The 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.
29The applicant submits that the respondent’s denial of the treatment plan was unreasonable and therefore seeks an award pursuant to s. 10 of O. Reg. 664.
30The respondent claims that an award is only valid if the insurer unreasonably withholds or delays benefits. It argues that it acted reasonably by reviewing medical documents and conducting an insurer examination. Based on Dr. Belfon's findings, the respondent concluded that the disputed treatment was not necessary. The respondent also states that the applicant has not demonstrated egregious conduct or provided sufficient proof of the necessity of the treatment. Therefore, it contends that their actions do not meet the criteria for an award.
31I accept the respondent’s submissions. There are no benefits that were unreasonably withheld or delayed. The evidence shows that it did not act in a high-handed, malicious, or egregiously improper manner. It relied on insurer exams and provided timely, supported denial letters. There’s no indication that the respondent ignored relevant medical information or acted in bad faith.
32Therefore, I find that the applicant has not met the burden of proving that the respondent unreasonably withheld or delayed payment of benefits. As a result, the respondent is not liable for an award.
ORDER
33For the above reasons, it is ordered that:
i. The applicant is not entitled to the disputed treatment plan.
ii. The applicant is not entitled to interest or an award.
Released: December 1, 2025
Harouna Saley Sidibé
Adjudicator