RECONSIDERATION DECISION
Before:
Craig Mazerolle, Vice-Chair
Licence Appeal Tribunal File Number:
23-011932/AABS
Case Name:
Stephanie Neves v. CUMIS General Insurance Company
Written Submissions by:
For the Applicant:
Justin Mariani, Paralegal
For the Respondent:
Hooman Zadegan, Counsel
OVERVIEW
1On October 6, 2025, the applicant requested reconsideration of the Tribunal’s decision released September 15, 2025.
2Stemming from an accident on July 9, 2022 and a request for benefits made pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”), the parties participated in a written hearing. In the decision, the Tribunal found the applicant was entitled to a treatment plan for occupational services, along with interest on any overdue payment of benefits. It denied the remaining four treatment plans, as well as a request for payment of a Disability Certificate (“OCF-3”). The Tribunal also denied claims for an attendant care benefit and an award. The award was denied based on the applicant’s lack of submissions with respect to this part of her claim.
3The grounds for a request for reconsideration are found in Rule 18.2 of the Licence Appeal Tribunal Rules, 2023 (“Rules”). To grant a request for reconsideration, the Tribunal must be satisfied that one or more of the following criteria are met:
a) The Tribunal acted outside its jurisdiction or committed a material breach of procedural fairness;
b) The Tribunal made an error of law or fact such that the Tribunal would likely have reached a different result had the error not been made; or
c) There is evidence that was not before the Tribunal when rendering its decision, could not have been obtained previously by the party now seeking to introduce it, and would likely have affected the result.
4The applicant selected all three criteria under Rule 18.2 on her Request for Reconsideration form. Her supporting reconsideration submissions only reference Rule 18.2(a) and Rule 18.2(b). Considering no documents are attached to the request, I find the applicant erroneously marked Rule 18.2(c) on her Request for Reconsideration form.
5I also note that, following the submission of the reconsideration request, an amended version of the decision was released on October 9, 2025 (“decision”). This amended decision is the version I have considered in this reconsideration decision.
6The applicant is seeking an order to vary the decision to find she is entitled to three of the four denied treatment plans, i.e., assistive devices treatment plan (dated July 21, 2023); neuro-ocular therapy treatment plan (dated December 15, 2023); and the treatment plan for a chronic pain assessment (dated December 15, 2022). In the alternative, she is asking for a rehearing.
7The applicant included a request for payment of the OCF-3 in her initial submissions, but she later stated in reply that this issue was included in error.
8The respondent is seeking a determination that the applicant is not entitled to any of the disputed benefits.
RESULT
9The applicant’s request for reconsideration is granted, in part.
10I am varying the decision, pursuant to Rule 18.4, to find the applicant has shown that the denial of the assistive devices treatment plan was not compliant with s. 38(8) of the Schedule.
ANALYSIS
11The test for reconsideration under Rule 18.2 involves a high threshold, and the requesting party must show how or why the decision falls into one of the categories in Rule 18.2. The reconsideration process is not an opportunity for a party to re-litigate its position where it disagrees with the Tribunal’s decision, or with the weight assigned to the evidence.
Rule 18.2 – Assistive Devices Treatment Plan
12The applicant claims the Tribunal materially breached her right to procedural fairness when it did not address her argument about s. 38(8) as it relates to the assistive devices treatment plan. Specifically, she argues the Tribunal “appears to have conflated two of [her] arguments”, namely, her argument that the denial itself was deficient, as well as her assertion that the related insurer’s examination (“IE”) was “predicated upon this deficient rationale”. According to the applicant, only the latter argument was explicitly addressed in the decision.
13The applicant also challenges the Tribunal’s reliance on the lack of evidence that the plan had been incurred to dismiss this part of her submissions. According to the applicant, this chain of reasoning is incorrect, because the Divisional Court has ruled that an insurer can only cure a deficient denial notice prior to the hearing: see Aviva Insurance Company of Canada v. Danay Suarez, 2021 ONSC 6200 (“Suarez”). As such, the question of whether the plan had been incurred should not have acted as a bar to whether the Tribunal determined the respondent’s compliance with s. 38(8) of the Schedule.
14After laying out a summary of the notice requirements under s. 38(8) and s. 38(11), the Tribunal provided its analysis of the assistive devices plan at paragraphs 24 – 26 of the decision:
The applicant has not made any submissions with respect to whether the treatment plan is reasonable and necessary, instead arguing that the treatment plan is payable under s. 38(11), because the denial letter dated August 3, 2023 does not contain sufficient medical reasons, rendering Ms. Kanji’s September 26, 2023 s.44 report inadmissible, and the treatment plan payable.
I am not persuaded by the applicant’s argument that the treatment plan is payable based on the sufficiency of reasons in the August 3, 2023 denial notice. I found above that the respondent issued a NOE for the September 8, 2023 s.44 examination; however, the applicant did not make any submissions with respect to the sufficiency, or provide a copy, of the NOE or any subsequent denial notice. Further the applicant has not directed me to any evidence of any costs incurred under the treatment plan.
Because the applicant has not provided sufficient evidence for me to determine whether or when a compliant notice was issued, or whether any costs were incurred, I find that the applicant has not met her onus to prove on a balance of probabilities that the treatment plan is payable under s.38(11).
15As noted by the Supreme Court of Canada at paragraph 79 in Canada (Minister of Citizenship and Immigration) v. Vavilov, 2019 SCC 65 (“Vavilov”), reasons ensure the fairness and legitimacy of administrative decision-making (citations removed):
Reasons explain how and why a decision was made. They help to show affected parties that their arguments have been considered and demonstrate that the decision was made in a fair and lawful manner. Reasons shield against arbitrariness as well as the perception of arbitrariness in the exercise of public power.
16Further, the Supreme Court stated at paragraph 39 of Baker v. Canada (Minister of Citizenship and Immigration), 1999 CanLII 699 (SCC), that reasons allow decisions to be questioned: “Reasons are invaluable if a decision is to be appealed, questioned, or considered on judicial review”.
17With these observations in mind, I do not find the Tribunal adequately explained why it dismissed the applicant’s s. 38 argument for the assistive devices plan. Though it laid out the framework for how to assess payment of a plan based on s. 38(11), I do not find the Tribunal then went on to provide sufficient reasons to explain why it found this argument was not persuasive. Most notably, I cannot differentiate between the Tribunal’s handling of the applicant’s arguments concerning the initial denial, and those involving the IE report. Without this level of clarity, I find the applicant has shown that the reasons provided in this part of the decision are insufficient. In turn, she has established a material breach of procedural fairness.
18I further accept her position that the question of whether the applicant had incurred the plan is not a barrier to granting a remedy under s. 38(11). Established in Suarez, there is no requirement for an insured person to incur a plan prior to contesting compliance with s. 38(8). An insurer is also disallowed from following up a finding of non-compliance with a further, compliant denial. Both potential situations would violate the consumer protection mandate of the Schedule: see paragraphs 32 – 36 of Suarez. Therefore, while the Tribunal was entitled to find there was no evidence that the plan had been incurred, this finding did not then mean that there was no need to rule on the respondent’s compliance with s. 38(8).
19The respondent disputes the applicant’s position in several ways, but I do not find these arguments challenge my conclusions. Highlighting how the s. 38(8) argument was recognized by the Tribunal, it claims there is no obligation on the part of a decision-maker to “exhaustively state every piece of rationale”. According to the respondent, this point is particularly key to my present review, as the applicant had the (emphasis in original) “onus to prove both substantive entitlement and any alleged procedural shortcoming”, and yet her arguments were only based on s. 38.
20Aside from the clear wording in the Schedule that establishes there is no need to prove substantive entitlement once s. 38(8) has been breached, I do not find the applicant is seeking to have the Tribunal exhaust “every piece of rationale”. It is well-settled that decision-makers are not required to mention every argument presented at a hearing, nor is it necessary for their reasons to go into granular detail about every single step of their analytical process. For instance, the Supreme Court in Vavilov made it clear that reviewing judges should not engage in a “line-by-line treasure hunt for error” when assessing the reasonableness of administrative decision-making: see paragraph 102. However, in the case at hand, I am satisfied that the applicant has highlighted a section of the decision where a clear chain of reasoning is not present. As such, the applicant is not seeking a granular level of “exhaustive” detail. Rather, she is seeking to understand how this key part of her case was dismissed.
21I also note that the respondent takes issue with how the applicant is citing cases that were not presented during the written hearing. Generally, parties are not permitted to present new arguments on reconsideration, and I accept that Suarez was not included in the applicant’s initial written submissions. However, this case is binding on the Tribunal’s handling of s. 38(11). As such, I see no issue with considering this binding jurisprudence at this stage of the proceeding.
22Taken together, the applicant has established a material breach of procedural fairness, pursuant to Rule 18.2(a), as it relates to the assistive devices plan.
Rule 18.2 – Neuro-ocular Therapy Treatment Plan
23Like the arguments made above, the applicant submits that her s. 38 submissions were also overlooked for the neuro-ocular therapy treatment plan. In contrast with my findings about the assistive devices plan, I do not find the applicant has shown the Tribunal overlooked a similar set of submissions for this plan.
24The applicant highlights paragraph 46 of her initial written submissions to support this part of her reconsideration request:
The Applicant further takes the position that the initial denial, indicating that it was “unclear” whether the submission was reasonable and necessary does not constitute effective/compliant notice. Accordingly, as described above, the IE that was secured based upon said denial was not secured in accordance with the Schedule, hence the IE must be excluded from the evidentiary record. (see paragraphs 37-39 above)
25Aside from the brief reference to paragraphs 37 – 39 (which includes her s. 38 argument about the assistive devices plan), the applicant did not provide any other submissions that stated she was entitled to payment of the neuro-ocular therapy treatment plan based on s. 38(11). Rather, the focus was on her assertion that the IE “secured based upon said denial” should be excluded.
26This focus is then further cemented by the applicant’s reply at paragraph 14:
At paragraphs 25- 26, the Respondent references the Medical Benefit of $2,620.00 for Neuro-Ocular Therapy. The Applicant has described at paragraphs 45- 46 both why the IE assessor’s report at best must be afforded little weight, and more importantly why said IE must be struck from the evidentiary record, which the Respondent again did not rebut in submissions.
27There is no reference to s. 38(8), nor is there any argument about how she is entitled to payment of the plan by way of a deficient denial. Rather, the applicant is focused on her assertion that the IE report for this plan should not be admitted.
28Once again, adjudicators are not expected to address every comment made during a hearing. Instead, they have an obligation to show they have responded to all the key arguments presented by the parties. Decision-makers are also discouraged from piecing together loose and disparate threads in a party’s case to see if there is an argument that could have been made to support their position. Though the applicant may now claim that she was presenting an argument for payment based on s. 38(11), her written hearing submissions show that her focus on this denial had nothing to do with payment. She was challenging the admission of the IE report.
29Parties are expected to put their best foot forward during the hearing, as reconsideration is not a venue for presenting new arguments that could have been reasonably raised at an earlier stage. I see no reason why an argument for payment based on s. 38(11) could not have been raised during the hearing, especially since this same argument had been clearly articulated for the assistive devices plan. In sum, I am satisfied that the Tribunal did not err, nor did it materially breach the applicant’s right to procedural fairness, by choosing not to address s. 38(11) as a possible means for allowing payment of this plan.
30The applicant also submits that the Tribunal erred when it assessed the reasonable and necessary nature of this plan. Specifically, the applicant claims it misinterpreted the recommendations from Dr. Behzad Mansouri, neurologist and neuro-psychologist, in his report (dated March 20, 2024), and it incorrectly found she made no submissions about how the goals of this treatment plan will be met.
31At paragraph 48 of the decision, the Tribunal made several findings about Dr. Mansouri’s report—a key piece of evidence put forward by the applicant in support of this treatment plan. In particular, the Tribunal contrasted Dr. Mansouri’s recommendations against those made by Dr. Manbir Randhawa, optometrist and author of the neuro-ocular therapy treatment plan:
Dr. Mansouri conducted a neuro-ophthalmological examination and diagnosed the applicant with Dysfunctional Tear (Dry Eye) Syndrome, and “Occipital neuralgia, Concussion and Post-concussion syndrome that has caused convergence insufficiency, vestibulopathy and migraine headaches.” He recommended home treatment for her eyes and headaches including using a humidifier, vitamin and Omega 3 supplementation, improving posture, tear drops, warm eye compress, and blinking exercises. While Dr. Mansouri did recommend that the applicant continue with vestibular physiotherapy, he did not recommend the facility-based neuro-ocular therapy outlined in Dr. Randhawa’s report [dated December 8, 2023] or treatment plan.
32The applicant disagrees with this interpretation, claiming that the reference to vestibular physiotherapy in Dr. Mansouri’s report “must be read in conjunction” with another statement he makes about her treatment regiment. To trigger Rule 18.2(b), the requesting party must demonstrate a legal or factual error. It is not sufficient for a party to merely disagree with an adjudicator’s factual finding, which is what it appears the applicant is doing with this part of her request.
33Turning to the assertion that the Tribunal overlooked her submissions about how the plan’s goals will be met, I again do not find this error meets the standard of Rule 18.2(b). Even though it was likely missed by the Tribunal due to a formatting error (i.e., this part of her submissions was erroneously included as part of a quotation from an expert report), I can accept that there is a brief argument about how the goals of the plan will be met. Specifically, at paragraph 26 of her initial submissions, the applicant writes that she “references and relies upon” the treatment regiment endorsed by Dr. Randhawa in the December 8, 2023 report.
34However, even if this argument had been incorporated into the Tribunal’s assessment of the plan, I find the applicant has not shown how correcting this error would likely have changed the outcome. The bulk of the Tribunal’s analysis involves the inconsistencies it found between the recommendations made by Drs. Mansouri and Randhawa. Therefore, even if it had taken stock of the applicant’s brief submissions at paragraph 26, I find the Tribunal would likely have still denied the plan based on these inconsistencies.
Rule 18.2 – Treatment Plan for a Chronic Pain Assessment
35Finally, despite acknowledging that “the Schedule does not specifically mention this obligation”, the applicant claims Tribunal case law has found that insurers have a duty to revisit treatment plans “that were denied only based on the MIG following the Applicant’s removal from the MIG.” Specifically, the applicant takes issue with the finding at paragraph 33 of the decision: “While the respondent may have a duty of good faith to reassess a treatment plan once the applicant is removed from the MIG, there is no requirement to do so in the Schedule.”
36To this end, the applicant cites several cases where the Tribunal found this obligation existed: M.J. v. Dufferin Mutual Insurance Company, 2020 CanLII 87976 (ON LAT) (“Dufferin”); 16-000872 v. Certas Home and Auto Insurance Company, 2017 CanLII 39689 (ON LAT) (“Certas”); Yang v. Dominion of Canada General Insurance Company (Travelers), 2022 CanLII 23412 (ON LAT); and, most recently, Bygrave v. Co-operators General Insurance Company, 2025 CanLII 31135 (ON LAT). The applicant argues there is a need for consistency in the Tribunal’s case law, especially in light of the consumer protection mandate.
37I do not accept this argument. As the applicant concedes, the Schedule does not have any explicit provision that requires insurers to revisit past denials once an insured person is removed from the MIG. While the Tribunal may occasionally be called upon to address ambiguities and gaps in the Schedule—instances of statutory interpretation that will be guided by the consumer protection mandate—the Tribunal cannot create new rights based on otherwise unambiguous wording. Without some basis for this requirement in the wording of the Schedule, I find the applicant has not shown any error in the Tribunal’s approach at paragraph 33.
38Further, aside from the fact that Tribunal case law is not binding, I find the cases the applicant has cited do not alter my conclusions. In these cases, the Tribunal found a general requirement to revisit denied plans based on “the spirit of the overall benefit scheme”: see Certas at paragraph 16. While I accept that this practice might help demonstrate good faith on the part of an insurer (see, for example, the assessment of the award claim in Dufferin), the Tribunal is still left with a lack of explicit wording in the Schedule to support this requirement.
39I see no error in the Tribunal’s assessment of this proposed obligation in paragraph 33 of the decision.
Rule 18.4 – Varying the Decision
40Considering the applicant was only successful on one of the grounds for reconsideration, I find the most appropriate remedy under Rule 18.4 is to reconsider the parties’ s. 38 arguments for the assistive devices treatment plan. I further find that this analysis can be done within the confines of this reconsideration decision, and I see no prejudice that would face either party from conducting the review based on their original submissions and evidence.
41For the following reasons, I am varying the decision to find the applicant has shown that the denial of the assistive devices treatment plan was not compliant with s. 38(8) of the Schedule.
42Section 38(8) requires an insurer to inform an insured person, within ten business days after it receives a treatment plan, of which goods, services, assessments, and/or examinations it agrees to pay for, and which it does not, as well as the “medical reasons and all of the other reasons” why it considered any of the goods and services to not be reasonable and necessary.
43If an insurer does not comply, the following remedy under s. 38(11) is triggered:
The insurer is prohibited from taking the position that the insured person has an impairment to which the MIG applies.
The insurer shall pay for all goods, services, assessments, and examinations described in the treatment and assessment plan that relate to the period starting on the 11th business day after the day the insurer received the application and ending on the day the insurer gives a notice described in subsection (8).
44The applicant argues that the denial letter (dated August 3, 2023) for the assistive devices plan “does not remotely satisfy the requirements” under s. 38(8), as it only states that the proposed devices are not reasonable and necessary.
45The respondent did not address this part of the applicant’s argument in its responding submissions. Rather, it focuses on the substantive merits of the plan.
46After providing a list of the expenses included in the plan (e.g., Blue Light Filter, shower chair, shoehorn, etc.), the respondent’s denial letter provided the following information under the header, “Medical and All Other Reasons for Denied Expenses”:
We do not agree that requested medical devices are reasonable and necessary based on your accident related impairments, approximately 1 year after your accident. We have also arranged this opinion to further clarify and understand how your functional complaints affect your ability to perform personal care tasks and the need for these devices.
47In the oft-cited case of 16-003316/AABS v. Peel Mutual Insurance Company, 2018 CanLII 39373 (ON LAT), the Tribunal provided helpful guidance for assessing the adequacy of “medical reasons and all of the other reasons” under s. 38(8). Briefly, reasons for denial should “engage the specific details about the insured’s condition”, with a level of adequacy that will “allow an unsophisticated person to understand them and make an informed decision in response”: see paragraph 21.
48I find the applicant has shown the reasons provided in the respondent’s denial are not compliant with s. 38(8). Aside from the fact that there is no indication of what impairments the respondent is referring to when discussing “your accident related impairments”, there is no breakdown to show how its understanding of the applicant’s condition applies to the different items being proposed in the plan. This latter point is especially important, as the applicant is requesting a number of different assistive devices that will presumably assist with a variety of impairments, be they physical limitations, cognitive issues, etc.
49By not drawing a connection between the applicant’s specific impairments and the various items being proposed in the plan, I find the respondent’s denial would not allow an unsophisticated person to “make an informed decision in response”.
50Further, once a breach of s. 38(8) has been established, the remedy under s. 38(11) is triggered. Therefore, while the respondent may argue that the applicant has not established the reasonable and necessary nature of this plan, I find this argument has little bearing on s. 38 of the Schedule.
51Taken together, I am varying the decision, pursuant to Rule 18.4, to find the applicant has shown that the denial of the assistive devices treatment plan was not compliant with s. 38(8) of the Schedule.
52The applicant is entitled to payment of the assistive devices treatment plan, pending proof she has incurred the plan in accordance with s. 38(11).
53The applicant is also entitled to interest on any outstanding payments in accordance with s. 51 of the Schedule.
CONCLUSION & ORDER
54The applicant’s request for reconsideration is granted, in part.
55Pursuant to Rule 18.4, the amended version of the decision is varied at paragraph 63(1) to find the applicant has shown that the August 3, 2023 denial of the assistive devices treatment plan (dated July 21, 2023) was not compliant with s. 38(8) of the Schedule.
56Paragraph 63(1) is further varied to find the applicant is entitled to payment of the assistive devices treatment plan, pending proof she has incurred the plan in accordance with s. 38(11) of the Schedule.
57The remaining forms of relief sought in the applicant’s reconsideration request are dismissed.
Craig Mazerolle
Vice-Chair
Released: December 11, 2025