Subinski v. Co-operators General Insurance Company, 2025 ONLAT 24-003244/AABS
Licence Appeal Tribunal File Number: 24-003244/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:
Melynda Subinski
Applicant
and
Co-operators General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Harouna Saley Sidibé
APPEARANCES:
For the Applicant:
Victoria Edwards, Counsel
For the Respondent:
Emily Schatzker, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Melynda Subinski, the applicant, was involved in an automobile accident on April 26, 2021, 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, Co-operators General 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 $4,235.00 for chiropractic services, proposed by Dr. Erin White in a treatment plan/OCF-18 (“plan”) dated March 27, 2023?
ii. Is the applicant entitled to $7,453.09 ($9,116.00 less $1,662.91 approved) for social rehab counselling, proposed by Jamie McIntyre in a plan dated March 6, 2023?
iii. Is the applicant entitled to $1,293.59 ($5,216.61 less $3,923.02 approved) for occupational therapy services, proposed by Beth Dyck in a plan dated March 10, 2023?
iv. Is the applicant entitled to $7,173.77 for occupational therapy services, proposed by Beth Dyck in a plan dated October 10, 2023?
v. Is the applicant entitled to $2,910.14 for occupational therapy services, proposed by Beth Dyck in a plan dated October 13, 2023?
vi. Is the applicant entitled to $3,398.42 for Audiometric, speech language, proposed by Jessica Chrapko in a plan dated September 27, 2023?
vii. Is the applicant entitled to $6,334.23 ($8,180.00 less $1,845.77 approved) for social rehab counselling, proposed by Michelle Dzialakiewicz in a plan dated November 15, 2023?
viii. Is the applicant entitled to $1,925.00 for chiropractic services, proposed by Dr. Erin White in a plan dated March 26, 2024?
ix. Is the applicant entitled to $6,150.00 for vision treatment services, proposed by London Vision in a plan dated April 3, 2024?
x. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
xi. Is the applicant entitled to interest on any overdue payment of benefits?
3In her Reply Submissions, the applicant explicitly withdrew the physiotherapy treatment plan dated April 3, 2024, for $2,349.04.
RESULT
4For the reasons below, I find that:
The applicant is entitled to reimbursement for the mattress at the discounted cost incurred (treatment plan dated October 13, 2023), plus interest.
The applicant is not entitled to the treatment plans for chiropractic services, the remaining services of the treatment plan for occupational therapy dated October 13, 2023, the other occupational therapy treatment plans, social rehab counselling treatment plans, speech-language pathology treatment plans, and vision services treatment plans.
The applicant is not entitled to an award.
ANALYSIS
Is the applicant entitled to the disputed treatment plans?
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.
Chiropractic Services
6I find that the applicant is not entitled to the chiropractic treatment plans.
7The applicant seeks funding for two chiropractic treatment plans dated March 26 and March 27, 2023, totalling $1,925.00 and $4,235.00, respectively. Both plans, signed by Erin White, chiropractor, share similar objectives: pain reduction, restoration of normal activities, and return to pre-accident work tasks. They propose multiple sessions of physical rehabilitation, mobilization and manipulation of various body regions, exercise therapy, diagnostic interventions, and documentation of support activities.
8The applicant submits that ongoing neck, upper back, and headache symptoms limit her function. She asserts that chiropractic care has previously provided meaningful pain relief and improved her ability to perform daily activities. She relies on her providers’ advice and maintains that pain reduction alone is a valid therapeutic goal.
9The respondent opposes funding for both plans, noting that 118 chiropractic sessions with Dr. White have already been approved and that a section 44 assessment was requested following these sessions. The respondent relies on insurer examination reports from Dr. Mohamed Khaled, a physiatrist, who concluded that further chiropractic care is neither reasonable nor necessary because passive treatments offer limited functional benefit. The respondent also argues that the applicant’s reported activity level contradicts the need for additional therapy.
10The clinical evidence includes:
i. On February 28, 2023, Jenna Skayman, Nurse Practitioner, noted upper arm weakness and referred the applicant back to her chiropractor.
ii. On July 5, 2023, Dr. Elizabeth Lounsbury, a Neurologist, supported chiropractic care due to a lack of physiotherapy coverage but advised against neck manipulation, recommending conservative therapies.
iii. October 2, 2024: Dr. Dinesh Kumbhare, Physiatrist, reported ongoing chiropractic care along with social work and other medical services.
iv. On May 16, 2023 & November 24, 2023, Dr. Abdalhakim Mustafa, Neurologist, diagnosed concussion/post-concussion syndrome and chronic headaches, concluding the proposed plans were not reasonable or necessary.
v. On May 16, 2023, November 24, 2023 & December 7, 2023, Dr. Mohamed Khaled diagnosed grade 2 whiplash and right shoulder strain, also finding the plans not reasonable or necessary.
11While the applicant asserts that pain reduction alone is a valid therapeutic goal (see para. 8), she has not explained why additional treatment beyond the 118 chiropractic sessions already approved is necessary to achieve that outcome. Further, the proposed plans do not identify specific, measurable objectives or demonstrate how the recommended interventions would provide incremental benefit beyond prior care. Nor has the applicant addressed whether the significant costs associated with these plans are proportionate to the anticipated results.
12Accordingly, based on a balance of probabilities, I find that the March 26, 2023, and March 27, 2023, chiropractic treatment plans are not reasonable or necessary.
Occupational Therapy Services
Outstanding Amount – Plan dated March 10, 2023
13The applicant seeks entitlement for the remaining balance of $1,293.59 from an OT treatment plan dated March 10, 2023, signed by Ms. Beth Dyck, following partial approval of $3,923.02. The disputed items include an ergonomic mat, a two-handled dog leash, a long-handled tub scrubber, and mileage. The plan’s goals were pain relief, an increase in strength, participation in activities of daily living, and a return to normal living and work activities.
14The applicant submits that these items are essential for maintaining independence and safety in daily activities. Ms. Dyck documented difficulties with tasks such as washing dishes, cleaning the bathroom, and walking the dog. In her October 13, 2023, report, she noted ongoing impairments in meal preparation, housekeeping, outdoor work, and anxiety, recommending continued OT to improve sleep, daily activity engagement, cognitive memory, and pain management.
15The respondent argues that these items are unnecessary because the applicant lives independently and performs daily activities without assistive devices. It relies on Ms. Patricia Morand’s OT report (June 2, 2023), which found most devices reasonable but questioned the need for the ergonomic mat, two-handled dog leash, and long-handled tub scrubber, citing uncertainty about the causation of back and shoulder pain. The respondent also points to surveillance footage showing the applicant raking, bending, lifting a 10 lb bag of onions, sweeping, and walking dogs—often on separate leashes with one hand—contradicting her claim that these devices are required. Regarding mileage, the respondent maintains that no evidence was provided to justify travel costs beyond what was already approved.
16I accept that OT services and equipment can be reasonable and necessary when they address functional limitations caused by the accident. However, the applicant bears the onus of proving that the disputed items are necessary to achieve the plan’s goals and that the associated costs are reasonable.
17The evidence does not establish that the ergonomic mat, two-handled dog leash, or long-handled tub scrubber is necessary to restore or maintain function. Surveillance and assessment reports (see Dr. Mustafa’s report dated February 17, 2022, and Ms. Morand’s assessment dated June 2, 2023) indicate that the applicant can perform household and outdoor tasks independently, including bending, cleaning, and walking dogs without assistive devices. These observations undercut the claimed need for ergonomic equipment to reduce pain or improve safety. As for mileage, the applicant has not explained why additional travel costs were incurred or how they relate to achieving measurable functional improvement.
18Accordingly, on a balance of probabilities, I find that the outstanding amount of $1,293.59 from the March 10, 2023, plan—including the ergonomic equipment and mileage—is not reasonable or necessary.
Plan dated October 10, 2023, for $7,173.77
19The applicant requests funding for an OT treatment plan dated October 10, 2023, amounting to $7,173.77. The plan suggests ongoing OT services to address fatigue, cognitive load, and difficulties with multi-step tasks. It includes motor and daily living skills training, provider travel and mileage, service preparation, health education, and equipment such as a computer and related devices, a desk, an office chair, an adaptive lawn mower, and a lightweight lawn trimmer.
20The applicant submits that fatigue, headaches, and reduced cognitive endurance continue to impact her functioning. OT progress notes document ongoing impairments, including difficulties with concentration, increased overwhelm, and fluctuating activity tolerance. She argues that the proposed equipment and strategies are necessary to support engagement in meaningful activities and daily tasks.
21The respondent denied the plan in full, relying on Dr. Mustafa’s neurologic examination, which found no neurological injury, and Dr. Khaled’s opinion that further OT is not reasonable or necessary. Surveillance evidence shows the applicant engaging in physical activities, running errands, and moving house without visible impairment or the use of assistive devices.
22The respondent also notes that the applicant purchased the proposed mower and weed trimmer on May 14, 2023, and the computer, desk, and office chair on July 8, 2023—months before submitting the treatment plan. Section 38(2) of the Schedule prohibits payment for goods or services incurred prior to submission of the plan.
23While the applicant reports ongoing symptoms, the evidence does not demonstrate that the disputed items are necessary to restore or maintain function. Most of the proposed equipment was purchased before the plan was submitted to the respondent, contrary to section 38(2). Surveillance and assessment reports indicate that she performs household and outdoor tasks independently. The proposed items appear to address convenience rather than medical necessity.
24Accordingly, on a balance of probabilities, I find that the October 10, 2023, plan is not reasonable or necessary.
Plan dated October 13, 2023, for $2,910.14
25The applicant seeks funding for an OT treatment plan dated October 13, 2023, in the amount of $2,910.14. The plan focuses on education, planning, and functional skill-building, and includes a mattress, pillow, and support activity documentation.
26The respondent argues that even if the mattress were found necessary, only the discounted incurred cost is reasonable. It maintains that the remaining items are not reasonable or necessary.
27In her reply submissions, the applicant accepts entitlement for the mattress at the discounted cost incurred. The remaining issues concern the pillow and support activity documentation.
28Ms. Dyck recommended a mattress to provide proper spinal alignment during sleep and address neck pain and poor sleep quality. She also recommended replacing the applicant’s pillow to support side-sleeping and reduce neck pain.
29I accept that improving sleep quality can contribute to recovery and functional restoration. However, the applicant has already purchased the mattress at a reduced price, and the entitlement should reflect the amount paid. As to the pillow and support activity documentation, the clinical evidence does not establish that these items would result in measurable functional improvement. There is no indication that replacing the pillow would provide benefits beyond those achieved with the new mattress, nor does the documentation demonstrate how recording support activities would materially advance the applicant’s rehabilitation goals.
30Accordingly, on a balance of probabilities, I find that entitlement for the mattress at the incurred cost is reasonable. The remaining items—the pillow and support activity documentation—are not reasonable and necessary.
Social Rehab Counselling
31I find that the applicant is not entitled to the treatment plans for social rehab counselling.
Outstanding Amount - Plan dated March 6, 2023
32The applicant seeks funding for a social rehabilitation counselling plan dated March 6, 2023, in the amount of $7,453.09 ($9,116.00 less $ 1,662.91 approved). The plan’s goals include counselling support to facilitate recovery, reduce severe anxiety, and address avoidance of driving-related activities. Proposed services include 12 planning sessions, 12 mental health and addictions counselling sessions, provider travel and mileage, and support activity documentation.
33The applicant submits that she continues to experience emotional distress, cognitive fatigue, reduced endurance, and functional limitations in community activities. She argues that social counselling is necessary to rebuild community participation, coping strategies, and structured daily functioning.
34The respondent partially approved the plan based on Dr. Jennifer Out’s psychological assessment, which diagnosed somatic symptom disorder, major depressive disorder, and PTSD. Dr. Out concluded that counselling was partially reasonable and necessary, recommending one-hour virtual sessions and rejecting mileage and travel time because the applicant was satisfied with virtual delivery.
35The respondent approved one-hour virtual sessions at $91.43 per hour, consistent with the Professional Services Guideline, which does not recognize social workers as regulated health professionals and therefore does not apply higher rates. Dr. Out’s May 30, 2023, report confirmed Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) diagnoses and supported limited counselling as reasonable and necessary.
36The applicant did not address the issue of hourly rate or session length in her submissions. Therefore, I accept that the rate set out in the Professional Services Guideline is applicable.
37I accept that counselling can be reasonable and necessary when it addresses psychological impairments caused by the accident. However, the applicant bears the onus of proving that the proposed services and costs are reasonable. While the evidence supports the need for counselling, Dr. Out’s opinion is persuasive because it is grounded in her psychological assessment and aligns with the applicant’s demonstrated tolerance for virtual sessions. Dr. Out specifically recommended one-hour virtual sessions as sufficient and rejected mileage and travel time as unnecessary. Her reasoning reflects both clinical judgment and practical considerations, making her opinion more compelling than the applicant’s proposal for extended sessions and travel-related costs.
38Accordingly, on a balance of probabilities, I find that the disputed portions of the March 6, 2023, plan—planning time, extended session length, and travel-related costs—are not reasonable and necessary.
Outstanding Amount - Plan dated November 15, 2023
39The applicant seeks funding for a second social rehabilitation counselling plan dated November 15, 2023, in the amount of $6,334.23 ($8,180.00 less $1,845.77). The plan’s goals include emotional regulation, coping skills, community engagement, and fatigue management. Proposed services include 12 planning sessions, 12 counselling sessions, provider travel time, and support activity documentation.
40The applicant submits that her functional presentation continues to fluctuate and that she benefits from structured psychosocial support. She argues that in-person sessions are appropriate.
41The respondent partially approved virtual sessions at $91.43 per hour, consistent with Dr. Mark Watson's section 44 assessment as a clinical psychologist and neuropsychologist, and denied the balance, including travel time and higher rates. The respondent also argues that the applicant has not justified in-person sessions with a provider from out of town when local options were available and notes that she previously reported virtual sessions were effective.
42Dr. Watson diagnosed adjustment disorder and somatic symptom disorder. He concluded that 12 further one-hour counselling sessions were reasonable, virtually, at $91.43 per hour.
43The respondent further notes that the applicant had concurrent free counselling with a local psychologist during the first plan without disclosure and took no steps to find a local social worker despite having access to local counselling.
44I accept that counselling remains reasonable and necessary to address ongoing psychological symptoms. However, the applicant has not demonstrated that in-person sessions with a provider from out of town are necessary or that travel costs are reasonable. Virtual sessions have been practical, and local options were available. The applicant did not provide submissions on the hourly rate or justify two-hour sessions.
45Accordingly, on a balance of probabilities, I find that the disputed portions of the November 15, 2023, plan—travel time, mileage, and extended session length—are not reasonable and necessary.
Speech Language Pathology (SLP/Audiometric)
46I find that the applicant is not entitled to the speech-language pathology treatment plan.
47The applicant seeks funding for a speech-language pathology treatment plan dated September 27, 2023, in the amount of $3,398.42. The plan, signed by Jessica Chrapko, Speech-Language Pathologist, identifies goals of providing education, strategies, and training to compensate for and remediate cognitive-communication difficulties allegedly related to the motor vehicle accident. It aims to support the applicant’s return to normal living activities and assist in resuming pre-collision roles or engaging in new, meaningful activities. The plan includes 15 communication training sessions, provider travel time, and documentation of support activities.
48The applicant submits that she continues to experience word-finding difficulties, memory lapses, slowed processing speed, and fatigue during conversations. These concerns are consistent with observations documented by occupational therapist Beth Dyck and nurse practitioner Jenna Skayman. Ms. Jessica Chrapko, a speech-language pathologist, recommended structured intervention, pacing strategies, and communication techniques to address these deficits.
49Ms. Dyck’s report noted difficulties with memory, problem-solving, planning, speech, and concentration, and recommended cognitive testing by a speech-language pathologist. Ms. Chrapko’s October 4, 2023, report further recommended functional interventions focused on social and vocational rehabilitation, the development of augmentative strategies, participation in a comprehensive audiology evaluation, and coordination of care with other providers.
50The respondent opposes funding, arguing that the applicant demonstrated appropriate communication during the hearing and in statements to the insurer. It relies on the neuropsychological assessment examination by Dr. Watson, who concluded that no cognitive treatment was required. Dr. Watson’s January 24, 2024, report indicated that, with the passage of time and expected recovery, and noting that not a single score was in the impaired range, the applicant does not qualify for a neurocognitive diagnosis related to concussion or mTBI. He opined that ongoing neurocognitive deficits would not be expected at this stage, even if a concussion had occurred.
51I accept that speech-language pathology services can be reasonable and necessary when they address functional communication deficits caused by the accident. However, the applicant bears the onus of proving that the proposed services are required to achieve measurable goals and that the associated costs are reasonable.
52The applicant reports subjective difficulties with word-finding and memory, which were noted by OT Dyck. However, Dr. Watson’s neuropsychological assessment provides objective evidence that the applicant does not exhibit cognitive impairment requiring treatment. His opinion is persuasive and consistent with the expected recovery trajectory. The respondent’s observation of appropriate communication during proceedings further supports this conclusion.
53While Ms. Chrapko recommended intervention, her report does not include objective testing results demonstrating impairment. The proposed plan also includes travel time and documentation costs, which are not justified given the lack of evidence of significant functional deficits.
54Accordingly, on a balance of probabilities, I find that the September 27, 2023, speech-language pathology plan is not reasonable or necessary.
Vision Treatment Services
55I find that the applicant is not entitled to the vision services treatment plan.
56The applicant seeks funding for a vision therapy treatment plan dated April 3, 2024, in the amount of $6,150.00. The plan, signed by Dr. Riyad Khamis, an optometrist, identifies goals of reducing pain and vision-related post-concussion symptoms, and supporting the applicant’s return to normal living and pre-accident work activities. The proposed services include 16 neurovisual rehabilitation sessions, a progress evaluation, planning services, documentation of support activities, a report of findings, a home therapy kit, therapeutic spectacles, and syntonic light therapy.
57The applicant submits that she experiences visual fatigue, headaches, and difficulty sustaining visual tasks, which interfere with reading, cognitive functioning, and daily routines. She argues that vision therapy is supported by specialists at London Vision and referenced by Dr. Jonathan Micieli, a neurologist.
58On February 15, 2022, Dr. Kaitlyn Sinclair, an optometrist, noted that the applicant was in the early stages of presbyopia, an age-related condition that can be accelerated by concussion. Her ocular health was otherwise normal.
59In his January 3, 2024, report, Dr. Khamis diagnosed post-concussion syndrome, specifically post-traumatic vision syndrome. He identified fusional vergence dysfunction, oculomotor dysfunction, and visual information processing deficits, which he opined were causing headaches, eye strain, and difficulty concentrating during near work. He explained that these conditions are common in post-concussion syndrome and may persist without treatment.
60The respondent disputes the need for vision therapy, relying on Dr. Mustafa’s insurer examination, which found no neurological deficits. It argues that visual complaints are subjective and unsupported by objective findings.
61Dr. Micieli, ophthalmologist, reported on July 5, 2024, that there were no objective abnormalities in ophthalmology or neuro-ophthalmology related to the accident.
62I accept that vision therapy can be reasonable and necessary when it addresses functional impairments caused by the accident. However, the applicant bears the onus of proving that the proposed services are required to achieve measurable goals and that the associated costs are reasonable.
63The applicant reports ongoing visual symptoms, and Dr. Khamis provided a detailed explanation of post-traumatic vision syndrome and its effect on function. However, his opinion mainly relies on subjective complaints and clinical observations rather than objective diagnostic tests. Conversely, Dr. Micieli’s neuro-ophthalmology assessment found no objective abnormalities, and Dr. Mustafa’s insurer examination concluded there were no neurological deficits. Dr. Sinclair observed that the applicant has presbyopia, an age-related condition, and did not clearly connect it to the accident. These opinions are persuasive and align with the expected recovery process.
64The proposed plan includes high-cost items such as therapeutic spectacles and syntonic light therapy, which lack sufficient evidence of necessity in this case. The applicant has not demonstrated that these interventions will achieve the stated goals to a reasonable degree.
65Accordingly, on a balance of probabilities, I find that the April 3, 2024, vision therapy plan is not reasonable or necessary.
Interest
66Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Interest is payable on any benefit due.
Award
67The applicant seeks an award under section 10 of Regulation 664. Under section 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. The Tribunal has determined that an award is justified where the delay or withholding of benefits by the insurer is unreasonable conduct, meaning “behaviour which is excessive, imprudent, stubborn, inflexible, unyielding or immoderate.” [ See, for e.g., 17-006757 v. Aviva Insurance Canada, 2018 CanLII 81949 (ON LAT); and S.M. v. Unica Insurance Inc., 2020 CanLII 61460 (ON LAT Reconsideration]. The onus is on the applicant to prove, on a balance of probabilities, that the respondent’s conduct meets this threshold.
68The applicant argues that the insurer relied heavily on generalized statements from Dr. Khaled’s insurer examinations, failed to address recommendations from her treatment providers, mischaracterized her submissions, and used her efforts to remain active as a basis for denying benefits. She submits that these actions amount to unreasonable claims handling.
69The respondent denies any unreasonable conduct. It argues that it relied on competent insurer examination evidence and exercised medical judgment in assessing the applicant’s entitlement.
70I do not find that the respondent’s conduct meets the threshold of being unreasonable under section 10.
71While the applicant disagrees with the insurer’s reliance on insurer examination reports, the evidence shows that the respondent obtained multiple assessments from qualified professionals and based its decisions on those opinions. The respondent provided partial approvals for some treatment plans and explained its reasons for denial in writing. There is no evidence of excessive delay, refusal to consider new information, or conduct that was stubborn or inflexible. Disagreement with the insurer’s conclusions does not, on its own, establish unreasonable behaviour.
72Consequently, I find that the respondent acted within its rights under the Schedule and that its conduct does not warrant an award. Accordingly, the applicant’s request for an award is denied.
ORDER
73For the above reasons, it is ordered that:
i. The applicant is entitled to reimbursement for the mattress at the discounted cost incurred (treatment plan dated October 13, 2023), plus interest.
ii. The applicant is not entitled to the treatment plans for chiropractic services, the remaining services of the treatment plan for occupational therapy dated October 13, 2023, the other occupational therapy treatment plans, social rehab counselling treatment plans, speech-language pathology treatment plans, and vision services treatment plans.
iii. The applicant is not entitled to an award.
Released: December 10, 2025
__________________________
Harouna Saley Sidibé
Adjudicator