Licence Appeal Tribunal File Number: 24-000774/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:
Rayan Alsafadi
Applicant
and
Primmum Insurance Company
Respondent
DECISION
ADJUDICATOR:
Kathleen Wells
APPEARANCES:
For the Applicant:
Mobina Khan, Counsel
For the Respondent:
Stefan Sistilli-Sguazzin, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Rayan Alsafadi, the applicant, was involved in an automobile accident on March 3, 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, Primmum Insurance Company, and applied to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issues to be decided in the hearing are:
Is the applicant entitled to an income replacement benefit (“IRB”) in the amount of $400.00 per week from May 19, 2023 and ongoing?
Is the applicant entitled to $2,630.00 for an electrophysiological assessment of his arm, proposed by Desai Jamsheed in a treatment plan/OCF-18 (“treatment plan”) dated July 15, 2022?
Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
Is the applicant entitled to interest on any overdue payment of benefits?
3The treatment plan dated July 15, 2022 and listed as issue #2 in the Case Conference Report and Order(CCRO) was set out in the CCRO as “$2,630.00 for other assistive devices/electrophysiological assessment of arm.” However, there is no mention of assistive devices in the treatment plan. Therefore, I have removed the reference to assistive devices.
RESULT
4I find that:
The applicant is not entitled to an IRB.
The applicant is not entitled to $2,630.00 for an electrophysiological assessment in the treatment plan dated July 15, 2022.
As no payments are owing, no interest is due.
The applicant is not entitled to an award.
The application is dismissed.
ANALYSIS
Is the applicant entitled to an IRB?
5I find that the applicant has not established on a balance of probabilities that he is entitled to an IRB.
IRB
Pre-104 Week IRB
6To receive payment for an IRB under s. 5(1) of the Schedule, the applicant must be employed at the time of the accident and, as a result of and within 104 weeks after the accident, suffer a substantial inability to perform the essential tasks of that employment.
7If the applicant was not employed at the time of the accident, the applicant must have been employed for 26 of the previous 52 weeks, or have been receiving unemployment benefits, or have been excused from attending school at the time of the accident, and suffer a substantial inability to perform the essential tasks of the employment in which they were engaged for most of the 52 weeks preceding the accident.
8The applicant must identify the essential tasks of their employment, which tasks they are unable to perform and to what extent they are unable to perform them. The applicant bears the burden of proving, on a balance of probabilities, that they meet the test.
Post-104 Week IRB
9To receive payment for a post-104-week IRB under s. 6 of the Schedule, the applicant must demonstrate on a balance of probabilities that they suffer from a complete inability to engage in any employment or self-employment for which they are reasonably suited by education, training or experience.
10The applicant submits that he is entitled to an IRB of $400.00 per week from May 19, 2023 to ongoing because his accident-related injuries, combined with injuries from a previous accident, have left him unable to work. The respondent submits that the applicant has not met his onus to prove that he is entitled to an IRB.
11In his submissions, the applicant refers to “’the’ OCF-3,” however the evidence reveals that the applicant submitted two OCF-3s. Both were prepared by Dr. Oscar Manias, chiropractor, and dated March 12, 2022 and June 16, 2022.
12Both OCF-3s indicate that the applicant was not working at the time of the accident and had not worked 26 of the previous 52 weeks. In the March 12, 2022 OCF-3, Dr. Manias stated that the applicant was not able to “seek/enrol in any education program” due to his accident-related injuries, however, in the June 16, 2022 OCF-3, he indicated that the applicant had been enrolled in an English as a Second Language program at the time of the accident, but was unable to attend due to his accident-related injuries.
13The applicant has not made any submissions or directed me to any evidence with respect to the applicant’s employment or educational history, or his ability to perform the essential tasks of his employment to establish his entitlement to a pre-104 week IRB. Likewise, he has not made any submissions or directed me to any evidence with respect to his qualifications or the type of employment to which he is suited to establish that he is entitled to a post-104 week IRB.
14As a result, I find that the applicant has not met his onus to prove on a balance of probabilities that he is entitled to a pre-104 week IRB or a post-104 week IRB.
Is the applicant entitled to $2630.00 for an electrophysiological assessment in a treatment plan dated July 15. 2022.
15I find that the applicant is not entitled to the treatment plan dated July 15. 2022.
16To 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.
17The purpose of an assessment is to determine whether a condition exists. For an insured, they bear the onus to demonstrate that there are grounds on which to believe that a condition exists that would warrant further investigation by way of an assessment.
18The treatment plan, dated July 15, 2022, and prepared by Dr Jamsheed Desai, physician, identifies the applicant’s injuries as mononeuropathies of upper limb, carpal tunnel syndrome and pain – unspecified. The goals of the treatment plan are: pain reduction, a return to the activities of normal living, and a return to pre-accident work activities. It seeks funding of $1,500.00 for an electrophysiological assessment of the arm, and documentation and support fees in the amount of $800.00 to complete forms, and $200.00 in additional document support activities, for a total of $2,630, inclusive of $130.00 in taxes.
19The applicant submits that the treatment plan is reasonable and necessary for the applicant’s recovery “by medical best practices and assessments.”
20The respondent argues that the applicant has not met his onus to prove that he is entitled to the treatment plan, because the applicant has not established that the proposed treatment is reasonable and necessary or related to injuries sustained in the accident. The respondent relies on the s.44 insurer’s examination (“IE”) report of Dr. Dr. Nagib Yahmad, neurologist, who opined that the treatment plan was not reasonable and necessary form a neurological perspective.
21The applicant has not explained why an electrophysiological assessment is warranted, and I find that the treatment plan itself is lacking in detail and does not contain any additional comments, or attachments. Further, I find that Dr. Desai’s diagnosis of mononeuropathies in the treatment plan is not corroborated by contemporaneous medical evidence.
22The applicant relies on the CNRs of the Trillium Health Centre from July 2, 2022, which reveal that the applicant attended the emergency department on July 2, 2022, complaining of numbness in his hand, arm and knee, and was discharged with a diagnosis of shoulder pain, and prescribed with pain medication and giveninformation about treatment of sprains and strains. The neurological testing done at the hospital found that the patient’s results were within defined limits. The applicant was encouraged to follow-up with his family doctor or sports medicine, and to pursue physiotherapy, but further neurological investigation was not recommended.
23Finally, the applicant did not make any submissions with respect to the reasonableness of the cost of the assessment, which includes documentation and support fees which exceed the maximum of $2000.00 plus HST set out in s. 25(5) of the Schedule.
24For these reasons, I find that the applicant has not met his onus to prove on a balance of probabilities that the treatment plan for an electrophysiological assessment is reasonable and necessary.
25Accordingly, the applicant is not entitled to $2,630.00 for the treatment plan dated July 15, 2022.
Interest
26Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no payments are owing, no interest is due.
Award
27The 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.
28The applicant has not made submissions or directed me to evidence to support a finding that the respondent’s behaviour has risen to the level of was excessive, imprudent, stubborn, unyielding or immoderate, in withholding or delaying payments. Further, as I have found that the applicant is not entitled to the benefits in dispute, I find that no payments have been unreasonably withheld or denied.
29For these reasons, I find that the applicant is not entitled to an award.
ORDER
30I find that:
The applicant is not entitled to an IRB.
The applicant is not entitled to $2,630.00 for an electrophysiological assessment in the treatment plan dated July 15, 2022.
As no payments are owing, no interest is due.
The applicant is not entitled to an award.
The application is dismissed.
Released: December 12, 2025
Kathleen Wells
Adjudicator