Licence Appeal Tribunal File Number: 23-005592/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:
Xu Zhou
Applicant
and
Security National Insurance Company
Respondent
DECISION
ADJUDICATOR:
Lisa Holland
APPEARANCES:
For the Applicant:
Anil Hampole, Counsel
For the Respondent:
Rocky Wang, Counsel
HEARD:
By Way of Written Submissions
OVERVIEW
1Xu Zhou, the applicant, was involved in an automobile accident on August 4, 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, Security National 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 $4,008.42 for physiotherapy services, proposed by Goodhealth Wellness Centre in a treatment plan/OCF-18 (“plan”) dated January 7, 2022?
ii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
iii. Is the applicant entitled to interest on any overdue payment of benefits?
3The Case Conference Report and Order (“CCRO”) dated January 17, 2024 lists an issue in dispute for psychological services in the amount of $2,056.08, in a plan dated August 23, 2023, proposed by Somatic Assessments and Treatment Clinic (“SOMA”). However, in the respondent’s written hearing submissions, there is evidence that SOMA withdrew the plan on behalf of the applicant on August 30, 2023. Therefore, the Tribunal does not have jurisdiction to consider this issue under sections 280(1) and 280(2) of the Insurance Act, and I have removed it from the issues in dispute.
RESULT
4The applicant is not entitled to the disputed treatment plan as the applicant has not proven on a balance of probabilities that it is reasonable and necessary. The applicant is also not entitled to interest or an award.
ANALYSIS
5To receive payment for a treatment 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. 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 same are reasonable.
The applicant is not entitled to the proposed physiotherapy services
6I find that the applicant has not demonstrated that the treatment plan in dispute for physiotherapy services is reasonable and necessary as a result of his accident-related impairments.
7The applicant submitted a treatment plan dated January 7, 2022, for physiotherapy services in the amount of $4,008.42, proposed by Frank Huang, physiotherapist of Goodhealth Wellness Centre. The proposed treatment plan included fifteen 1-hour physiotherapy sessions, fifteen 1-hour massage therapy sessions, ten 1-hour chiropractic sessions, a wrist brace, and completion of the OCF-18. The goals of the plan are for pain reduction, increase strength and range of motion and to return the applicant to activities of normal living.
8The applicant argues that the proposed treatment is reasonable and necessary, however, he has not provided any medical evidence from his doctors in support of this treatment plan.
9The applicant relies on the treatment plan in dispute and a psychological report dated January 19, 2022, by Dr. Mehrdad Pojhan, psychologist. However, Dr. Pojhan is not qualified to diagnose the applicant’s physical injuries, or to comment on whether the proposed treatment is reasonable and necessary.
10In support of its position that the applicant is not entitled to the treatment plan, the respondent points to the Insurer’s Examination (“IE”) report dated November 15, 2021, by Dr. Yong-Kyong Michael Ko, physiatrist. In his report, Dr. Ko indicates that the applicant sustained soft tissue injuries to his neck, back and right wrist as a result of the accident. The respondent submits that Dr. Ko opined that the applicant has full range of motion in his neck, back and right wrist, and he is independent ion all his activities of daily living. In a subsequent report dated February 16, 2022, Dr. Ko did not change his opinion after reviewing the plan in dispute, and he concluded that the plan is not reasonable and necessary since the stated goals have been achieved.
11I find that the applicant has not provided contemporaneous medical evidence in support of the treatment plan, and I have assigned no weight to the report of Dr. Pojhan since he is not qualified to comment on physical rehabilitation. I rely on the respondent’s evidence because Dr. Ko is a specialist in physical rehabilitation, and he has found that the proposed plan is not reasonable and necessary.
12I find the applicant has not met his burden of establishing entitlement to the treatment plan for physiotherapy services dated January 7, 2022. There is insufficient medical information provided by the applicant in support of the proposed treatment.
Interest
13Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since no benefits have been unreasonable withheld or delayed, there is no interest payable.
Award
14The applicant sought an award under s. 10 of Reg. 664.
15Under 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. Since no benefits have been unreasonably withheld or delayed, there is no basis for an award.
ORDER
16For the reasons set out above, I find that:
i. The applicant is not entitled to the treatment plan in dispute.
ii. The applicant is not entitled to interest or an award.
iii. The application is dismissed.
Released: March 20, 2025
Lisa Holland
Adjudicator```