Licence Appeal Tribunal
Citation: Kanatathipillai v. Pembridge Insurance Company, 2025 CanLII 125941 Licence Appeal Tribunal File Number: 24-003805/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:
Jayasegaran Kanatathipillai Applicant
and
Pembridge Insurance Company Respondent
DECISION
ADJUDICATOR: Harouna Saley Sidibé
APPEARANCES:
For the Applicant: Thomas Zwiebel, Counsel For the Respondent: Karina Dziuba, Counsel
HEARD: By way of written submissions
OVERVIEW
1Jayasegaran Kanatathipillai, the applicant, was involved in an automobile accident on November 3, 2020, 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, Pembridge 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 $3,638.00 for chiropractic services, proposed by Dr. Sasha Kabinski in a treatment plan/OCF-18 ("plan") dated March 24, 2022?
ii. Is the applicant entitled to interest on any overdue payment of benefits?
3The applicant requests that the Tribunal determine that he falls outside the Minor Injury Guideline ("MIG"). The respondent clarified that the MIG is not contested since the applicant was removed at the Case Conference. According to the Case Conference Report and Order ("CCRO") dated August 21, 2024, the MIG is not mentioned as an issue. Consequently, I do not have jurisdiction over the MIG claim.
RESULT
4For the reasons below, I find that:
- The applicant is not entitled to the disputed treatment plan or interest.
ANALYSIS
Is the applicant entitled to the disputed treatment plan?
5I find that the applicant is not entitled to the disputed treatment plan.
6To 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.
7The disputed plan, dated March 24, 2022, seeks $3,638.00 for chiropractic services. It is signed by Sasha Kobrossi, chiropractor, and proposes:
i. 25 sessions of multi-site chiropractic therapy; ii. 10 acupuncture sessions; iii. 10 soft tissue interventions for the head and neck; and iv. Support activity documentation.
8The stated goals are pain reduction, improved range of motion, increased strength, and return to activities of daily living.
9The applicant submits that the plan is reasonable and necessary because the accident caused injuries to his left shoulder, neck, thoracic spine, and ribs. He argues that his shoulder was vulnerable due to a prior workplace injury and multiple surgeries. He disputes the insurer's orthopedic Insurer's Examination (IE) findings, asserting that the collision impact was more severe than described and that the IE assessor did not review all relevant treatment records.
10The applicant also relies on his treating chiropractor's opinion that the proposed chiropractic and acupuncture sessions will improve range of motion, function, and pain.
11The respondent argues that the applicant has not met the burden of proof. It relies on the multidisciplinary IE conducted in October 2021 by orthopedic surgeon Dr. Gianni Maistrelli, who concluded that the applicant sustained only minor, uncomplicated soft tissue injuries (WAD I–II) expected to resolve within six to twelve weeks. Dr. Maistrelli noted symptom magnification and found no objective evidence of ongoing impairment requiring treatment sixteen months post-accident.
12The respondent also notes that the applicant did not submit clinical notes or records from his family doctor or orthopedic surgeon, even though he referenced them. The chiropractor's letter and the treatment plan do not establish that the proposed treatment would have a therapeutic effect related to the accident.
13The respondent further raises causation concerns, citing the applicant's significant pre-existing workplace injury, which remained unresolved at the time of the accident.
14After reviewing the evidence, I find that the applicant has not proven that the proposed treatment plan is reasonable and necessary. My reasons follow.
Lack of Objective, Contemporaneous Medical Evidence
15The applicant referenced clinical notes and records ("CNRs") from his family physician and orthopaedic surgeon, but did not submit them into evidence. The only supporting documentation consists of the disputed plan, a chiropractic letter dated April 23, 2025, and the s.44 IE reports.
16The absence of treating physician records undermines the applicant's ability to establish a causal link between the accident and the impairments allegedly requiring treatment in March 2022—more than 16 months after the accident.
Insurer Examination Evidence is More Persuasive
17I prefer the opinion of Dr. Maistrelli, the insurer's orthopedic assessor. His report is detailed, consistent with the mechanism of injury, and provides a medically reasoned explanation of expected recovery timelines for uncomplicated soft tissue injuries.
18While the applicant criticizes the IE report for omitting certain records, he did not submit those records for this hearing. In the absence of conflicting objective evidence, the IE conclusions remain unchallenged.
19Dr. Maistrelli's findings of symptom magnification and classification of injuries as minor soft tissue strains are consistent with the applicant's documented pre-existing injuries and chronic pain.
Causation Concerns
20The applicant sustained a serious workplace injury in December 2017 affecting the same anatomical areas, including multiple clavicle fractures, surgeries, chronic shoulder problems, psychiatric issues, and ongoing WSIB disability. He acknowledged that these injuries had not fully healed at the time of the accident, creating uncertainty about the cause of his persistent symptoms.
21The chiropractor's letter does not adequately explain why treatment 16 months after the accident would result in improvement specifically attributable to the accident.
Insufficient Clinical Justification for the Plan
22The March 2022 treatment plan proposes extensive therapy sessions, but does not explain:
i. The applicant's functional status leading up to March 2022; ii. Why prior treatment was insufficient; iii. What specific accident-related impairments persist; or iv. How the proposed treatment would meaningfully alter functional outcomes.
23A treatment plan alone is insufficient to establish the reasonableness or necessity of the treatment. Without supporting objective medical evidence, the OCF-18 does not meet the required evidentiary standard.
24For these reasons, I find, on a balance of probabilities, that the applicant has not proven that the treatment plan dated March 24, 2022, is reasonable and necessary.
25Accordingly, the applicant is not entitled to the disputed treatment plan.
Interest
26Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since I have determined that no benefit is payable, there is no overdue amount on which interest can accrue.
ORDER
27For the above reasons, it is ordered that:
i. The applicant is not entitled to the disputed treatment plan or interest.
Released: December 2, 2025
Harouna Saley Sidibé Adjudicator