Licence Appeal Tribunal File Number: 23-009088/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:
Mary Grace Cabasan
Applicant
and
Economical Mutual Insurance Company
Respondent
DECISION
ADJUDICATOR: Lisa Holland
APPEARANCES:
For the Applicant: Michael Yermus, Counsel Karl Girdhari, Counsel
For the Respondent: Jeremy Hanigan, Counsel
HEARD: By Way of Written Submissions
OVERVIEW
1Mary Grace Cabasan, the applicant, was involved in an automobile accident on February 18, 2019, 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, Economical Mutual 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 $2,200.00 for an orthopaedic assessment, proposed by Oshawa Physiotherapy and Rehabilitation Centre, in a treatment plan/OCF-18 (“plan”) dated June 17, 2021?
ii. Is the applicant entitled to $4,639.25 for physiotherapy services, proposed by Mackenzie Medical Rehabilitation Centre, in a plan dated May 27, 2021?
iii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
3The parties agreed in their written hearing submissions that issue 1 listed in the Case Conference Report and Order (“CCRO”), dated February 9, 2024 is no longer in dispute. Therefore, I do not need to determine whether the applicant’s injuries fall within the Minor Injury Guideline (“MIG”) as part of this hearing.
4In its written hearing submissions, the respondent submits that issue 3 listed in the CCRO dated February 9, 2024 is no longer in dispute, since it was approved by letter dated April 11, 2024. Since the respondent has filed a copy of letter dated April 11, 2024, with approval of plan dated August 15, 2023 for a psychological assessment, and the applicant has not filed a reply, I have removed this issue from the listed issues in dispute.
RESULT
5The applicant is not entitled to the disputed treatment plans.
6As there are no delayed or overdue benefits, no interest is payable.
7The respondent is not liable to pay an award.
ANALYSIS
8To 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 an orthopaedic assessment
9I find that the applicant has not established on a balance of probabilities that she is entitled to the June 17, 2021 plan for an orthopaedic assessment.
10The applicant submits generally that the disputed plans are reasonable and necessary to reduce the effects of her disability and facilitate her return to activities of daily living. The applicant further submits that the goals of the disputed plans are pain reduction, increase range of motion and strength and to return the applicant to her activities of daily living.
11The applicant makes no specific submissions to address whether an orthopaedic assessment is reasonable and necessary as a result of the accident. Further, the applicant has not met her burden of establishing whether the disputed plan is reasonable and necessary.
12The applicant has not provided a copy of the proposed plan for an orthopaedic assessment. Therefore, it is not possible to determine the goals of the assessment.
13The respondent points to the Insurer Examination (“IE”) report dated July 26, 2021, by Dr. Ahmad Belfon, general practitioner. The respondent submits that Dr. Belfon opined that the applicant’s myofascial pain will resolve over time with a home exercise program and pharmacological management.
14I find that the evidence before me does not corroborate the need for the plan dated June 17, 2021, by Muzammil Ansari, physiotherapist of Oshawa Physiotherapy and Rehabilitation Centre, in the amount of $2,200.00 for an orthopaedic assessment.
15I find that after reviewing ultrasound reports of the applicant’s left shoulder and radiological examinations of the lumbar spine, Dr. Belfon opined that the applicant sustained uncomplicated soft tissue injuries with no objective signs of impairment. Dr. Belfon concluded that since the applicant had no objective limitations or restrictions, an orthopaedic assessment is not reasonable and necessary.
16As the applicant did not make submissions with respect to this treatment plan, or submit it into evidence, I find on a balance of probabilities that the applicant has not established entitlement to the orthopaedic assessment since she has not addressed whether the plan is reasonable and necessary.
The applicant is not entitled to physiotherapy services
17I find that the applicant has not demonstrated on a balance of probabilities that the plan in dispute for physiotherapy services is reasonable and necessary as a result of her accident-related impairments.
18The applicant submits generally that the disputed plans are reasonable and necessary to reduce the effects of her disability and facilitate her return to activities of daily living. The applicant further submits that the goals of the disputed plans are for pain reduction, increase range of motion and strength and return to her activities of daily living.
19The applicant makes no specific submissions to address whether the proposed physiotherapy services are reasonable and necessary as a result of the accident. Further, the applicant has not met her burden of establishing whether the disputed plan is reasonable and necessary.
20Further, the applicant has not provided a copy of the proposed plan for physiotherapy services. Therefore, it is not possible to determine the goals of the treatment.
21The respondent relies on the IE report dated April 4, 2024 by Dr. Belfon, and his opinion that further treatment is not reasonable and necessary for the applicant’s uncomplicated soft tissue injuries. The respondent submits that the applicant reported to Dr. Belfon that she discontinued her rehabilitation efforts after she started working as an office cleaner in September 2021, which demonstrates that she has substantial improvement in her activities of daily living.
22I find that the medical evidence suggests that the applicant does not have physical restrictions in her activities of daily living, which would require the need for treatment. In IE report dated April 4, 2024, the applicant reported to Dr. Rod Day, psychologist that her back pain is not related to the accident. The applicant further reported to Dr. Day that she has two cleaning jobs, and she works 13 hours per day with no restrictions in either her job duties as a custodian or in her previous activities.
23I find the applicant has not met her burden of establishing entitlement to the plan for physiotherapy services dated May 27, 2021, submitted by Dr. Jennifer Violante, chiropractor of Mackenzie Medical Rehabilitation Centre. The evidence before me does not corroborate the need for the proposed treatment for physiotherapy services.
24There are no submissions on how the treatment plan goals would be met to a reasonable degree, nor on the overall costs being reasonable. Therefore, I find on a balance of probabilities that she is not entitled to this treatment plan.
The applicant is not entitled to interest and an award
25Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule.
26Since no benefits have been unreasonably withheld or delayed, there is no interest payable.
27Under s. 10 of Reg. 664, 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.
28Since the applicant isn’t owed any benefits, there is no basis for an award.
ORDER
29For the reasons outlined above, I find that:
i. The applicant is not entitled to the treatment plans in dispute.
ii. The applicant is not entitled to interest or an award.
iii. The application is dismissed.
Released: April 10, 2025
Lisa Holland
Adjudicator