Licence Appeal Tribunal File Number: 24-000746/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:
Dwight Dolius
Applicant
and
Aviva General Insurance
Respondent
DECISION
ADJUDICATOR: Kathleen Wells
APPEARANCES:
For the Applicant: Kameliya Stancheva, Paralegal
For the Respondent: Hilary Doyle, Counsel
HEARD: By way of written submissions
OVERVIEW
1Dwight Dolius, the applicant, was involved in an automobile accident on April 17, 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, Aviva General Insurance, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issues in dispute are:
Is the applicant entitled to $1,841.00 ($3,641.00 less $1,800.00 approved) for psychological services, proposed by Prime Healthcare in a treatment plan/OCF-18 (“treatment plan”) submitted January 4, 2023?
Is the applicant entitled to $2,023.03 for chiropractic services, proposed by Mackenzie Medical Rehabilitation Centre in a treatment plan submitted September 23, 2022?
Is the applicant entitled to $200.00 ($1,300.00 less $1,100.00 approved) for chiropractic services, proposed by Mackenzie Medical Rehabilitation Centre in a treatment plan submitted August 3, 2022?
Is the applicant entitled to $2,200.00 for an orthopedic assessment, proposed by Prime Healthcare in a treatment plan submitted July 21, 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 which sought $1,841.00 for psychological services was set out as issue #1 in the Case Conference Report and Order with a date of January 4, 2024, and a denial date of January 17, 2024. However, in its submissions, the respondent referred to the treatment plan as having a date of January 4, 2023, and submitted an Explanation of Benefits (“EOB”), for the same amounts set out in the treatment plan, dated January 17, 2023. Therefore, I have referred to the date of January 4, 2023 with respect to issue number #1.
RESULT
4I find that:
The applicant is not entitled to the remaining balance of $1,841.00 for psychological services in a treatment plan dated January 4, 2023.
The applicant is not entitled to $2,023.03 for chiropractic services in a treatment plan dated September 23, 2022.
The applicant is not entitled to the remaining balance of $200.00 in a treatment plan for chiropractic services in a treatment plan dated August 3, 2022.
The applicant is not entitled to $2,200.00 for an orthopaedic assessment in a treatment plan dated July 21, 2022.
As no payments are owing, no interest is due.
The applicant is not entitled to an award.
The application is dismissed.
ANALYSIS
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.
Is the applicant entitled to the remaining balance of $1,841.00 for psychological services in a treatment plan dated January 4, 2023?
6I find that the applicant has not established on a balance of probabilities that the remaining balance of $1,841.00 ($3,641.00 less $1,800 approved) for psychological services in the January 4, 2023 treatment plan, is reasonable and necessary.
7The applicant submits that he is entitled to the balance of the treatment plan for psychological services, because the services were recommended in a s.25 psychological assessment report. Neither party submitted the treatment plan into evidence. The s. 25 report, dated December 15, 2022, was prepared by Sandra Ramnaraine, registered psychotherapist, under the supervision of Dr. Jacqueline Brunshaw, psychologist, and recommended 14 sessions of psychotherapy as well as a reassessment near the completion of the sessions to determine whether future treatment is required.
8The respondent submits that the applicant has not met his onus to prove that the balance of the treatment plan is reasonable and necessary, because the applicant has not made any submissions or led any evidence to explain that the costs of the plan are reasonable. The respondent relies on its EOB dated January 17, 2023, in which it informed the applicant that it had approved $1,800.00, which included $1,400.00 for psychotherapy at a rate of $100.00 per hour and a progress report, in addition to the $200.00 fee for completion of the OCF-18.
9The respondent submits that the $1,841.00 in dispute represents $1047.34 in preparation and brokerage fees, which were not approved by the respondent, and the difference of $49.61 per hour, (for a total of $794.74) between the hourly rate for a psychologist as set out in the Professional Services Guideline Number 03/14 (“Guideline”), published by Financial Services Commission of Ontario sought by the applicant, and the lower amount that the respondent agreed to pay for the psychotherapist identified in the treatment plan as the service provider.
10I agree with the respondent that the applicant has not provided submissions or pointed me to evidence in support of whether the remaining balance is reasonable and necessary. The applicant has not explained what the preparation and brokerage fees encompass or why they are reasonable and necessary. The applicant also has not provided submissions on who will be providing the proposed treatment, and what their hourly rate should be. As a result, on a balance of probabilities, I find that the remaining portion of this treatment plan is not reasonable and necessary.
11Accordingly, the applicant is not entitled to the remaining balance of $1,841.00 in the treatment plan for psychological services dated January 4, 2023.
Is the applicant entitled to $2,023.03 for chiropractic services in a treatment plan dated September 23, 2022?
12I find that the applicant has not established on a balance of probabilities that he is entitled to $2,023.03 for chiropractic services in the September 23, 2022 treatment plan.
13The applicant submits that the treatment plan should be approved, and relies on the clinical notes and records (CNRs) of the Humber River Hospital, dated April 19, 2022 and the April 22, 2022 Disability Certificate (OCF-3) of Dr. Khshayar Khoshmashrab, chiropractor, of MacKenzie Rehabilitation Centre.
14The respondent submits that the applicant has not met his onus to prove that the treatment plan is reasonable and necessary because he has not submitted medical evidence in support of the plan.
15I agree with the respondent. I assign limited weight to the OCF-3, which identified multiple soft tissue injuries to the applicant’s spine, hip, and leg, as it is not corroborated by the CNRs of the Humber River Hospital. The CNRs, which were dated 3 days earlier, identified the applicant’s only complaint as leg pain. No back pain was identified on examination, no x-ray or other imaging was done, and the applicant was discharged with a recommendation of Tylenol and Advil for pain. Further, in the OCF-3, Dr. Khoshmashrab estimates the applicant’s recovery time as 9-12 weeks, and the treatment plan was submitted more than 12 weeks after the accident.
16While I agree with the case law cited by the applicant, that pain relief is a legitimate goal of treatment, the applicant has not directed me to any contemporaneous medical or other evidence to indicate that the applicant is experiencing pain as a result of his accident-related injuries. The applicant has not submitted into evidence any records from his family doctor or treating physician, to establish accident-related impairments, or pain reports beyond the initial few days post-accident.
17Further the applicant has not made any submissions with respect to the goals of the treatment plan or how they would be met, or to the overall cost of the treatment plan.
18For these reasons, I find that the applicant has not met his onus to prove that the treatment plan is reasonable and necessary. Accordingly, the applicant is not entitled to $2,023.03 for chiropractic services in the treatment plan dated September 23, 2022.
Is the applicant entitled to the remaining balance of $200.00 for chiropractic services in a treatment plan dated August 3, 2022?
19I find that the applicant has not established on a balance of probabilities that he is entitled to the remaining balance of $200.00 ($1,300 less $1,100 approved) for chiropractic services in the treatment plan dated August 3, 2022.
20The applicant submits that the treatment plan should be approved, and relies on the clinical notes and records (CNRs) of the Humber River Hospital, dated April 19, 2022 and the April 22, 2022 Disability Certificate (OCF-3) of Dr. Khshayar Khoshmashrab, chiropractor, of MacKenzie Rehabilitation Centre.
21The respondent submits that the remaining $200.00 was initially denied because the applicant had reached the $3,500.00 MIG limit. It argues that the applicant has not met his onus to prove that the balance of the treatment plan is reasonable and necessary, because he has not submitted any contemporaneous evidence to establish that the balance of the treatment plan is reasonable and necessary.
22I agree with the respondent. Further, the applicant has not made submissions with respect to whether the remaining $200.00 balance of the treatment plan is reasonable.
23As such, I find that the applicant has not met his onus to prove on a balance of probabilities that the remaining balance of $200.00 for chiropractic services in the treatment plan dated September 23, 2022 is reasonable and necessary.
Is the applicant entitled to $2,200.00 for an orthopaedic assessment in a treatment plan dated July 21, 2022.
24I find that the applicant has not met his onus to establish on a balance of probabilities that the applicant is entitled to $2,200.00 for an orthopaedic assessment.
25The 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.
26The applicant submits that the orthopaedic assessment should be approved, and relies on the April 22, 2022 OCF-3, in which Dr. Khoshmashrab recommends an orthopaedic assessment.
27The respondent submits that the applicant has not submitted the treatment plan, and has not made any submissions or led any evidence to corroborate the OCF-3.
28I agree with the respondent. The applicant has not made any submissions to explain why an orthopaedic assessment is warranted. As discussed above, the April 22, 2022 OCF-3 is inconsistent with the April 19, 2022 CNRs of Humber River Hospital, which is the only other medical evidence submitted by the applicant.
29As a result, I find that the applicant has not met his onus to prove on a balance of probabilities that there is reason to believe that a condition exists to warrant further examination.
30Accordingly, the applicant is not entitled to $2,200.00 for an orthopaedic assessment in the treatment plan dated July 21, 2022.
Interest
31Interest 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
32The 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.
33As the applicant has not made any submissions or led any evidence with respect to an award, and no benefits were unreasonably withheld or delayed, I find that the applicant is not entitled to an award.
ORDER
34I find that:
The applicant is not entitled to the remaining balance of $1,841.00 for psychological services in a treatment plan dated January 4, 2023.
The applicant is not entitled to $2,023.03 for chiropractic services in a treatment plan dated September 23, 2022.
The applicant is not entitled to the remaining balance of $200.00 in a treatment plan for chiropractic services in a treatment plan dated August 3, 2022.
The applicant is not entitled to $2,200.00 for an orthopaedic assessment in a treatment plan dated July 21, 2022.
As no payments are owing, no interest is due.
The applicant is not entitled to an award.
The application is dismissed.
Released: December 16, 2025
Kathleen Wells
Adjudicator