Rasha Sharifa v. Coachman Insurance Company, 2025 CanLII 35917

Licence Appeal Tribunal File Number: 22-013743/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:

Rasha Sharifa

Applicant

And

Coachman Insurance Company

Respondent

DECISION

ADJUDICATOR: Gareth Neilson

APPEARANCES:

For the Applicant: Kelisa Reyes, Paralegal

For the Respondent: Jason Goodman, Counsel; Faiza Ikram, Counsel

HEARD: Heard by way of written submissions

OVERVIEW

1Rasha Sharifa, the applicant, was involved in an automobile accident on March 18, 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 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 $49.88 ($1,339.53 less $1,269.65 approved) for chiropractic services, proposed by Dun-Dix Healthcare Clinic Inc. in a treatment plan/OCF-18 (“plan”) submitted on July 29, 2021?

ii. Is the applicant entitled to $1,844.90 for chiropractic services, proposed by Dun-Dix Healthcare Clinic Inc. in a plan submitted on May 10, 2022?

iii. Is the applicant entitled to $2,200.00 for a chronic pain assessment, proposed by Rehab and Pain Management Inc. in a plan submitted on January 2, 2023?

iv. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?

v. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

3The applicant is not entitled to the disputed treatment plans, an award, or interest.

ANALYSIS

Applicant’s arguments regarding s.38(8) of the Schedule

4Further to the medical evidence that will be discussed later in this decision, the applicant is arguing that the respondent’s denial(s) of the treatment plans were improper.

5The applicant argues that treatment plan listed under issue (i) was improperly denied as the submission date of the plan was July 29, 2021 and the denial date was August 10, 2021, outside of the 10 business day window provided by s.38(8). The applicant continues that the denial letter dated August 10, 2021 further fails to comply with the Schedule as the denial did not provide specific medical reasons for the denial.

6The applicant makes the same argument for treatment plans listed under issues (ii) and (iii). In the case of treatment plan listed under issue (ii) the submission date was May 10, 2022 and denied on May 25, 2022. Additionally, treatment plan listed under issue (iii) was submitted on January 2, 2023 and denied on January 17, 2023.

7Section 38(8) of the Schedule states that “Within 10 business days after it receives the treatment and assessment plan, the insurer shall give the insured person a notice that identifies the goods, services, assessments and examination described in the treatment and assessment all of the other reasons why the insurer considers any goods, services, assessments and examinations, or the proposed costs of them not to be reasonable and necessary.”

8The applicant has asserted that the denial letters were outside the 10 day business period described in the Schedule and I completely disagree. The applicant has failed to take into consideration statutory holidays and weekends in their calculation of the 10 day business period. In each case, the respondent did reply within the 10 day business period and therefore I affirm that the respondent was in compliance with Schedule O. Reg. 34/10 S.38 (8).

9After reviewing the denial notices provided by the applicant and considering their position, I do not find that these denial letters constitute a violation of the Schedule. The respondent’s denial letters clearly define why the applicant’s claim is being denied and the options available to the applicant, should they disagree with the denial. The medical arguments regarding these issues will be addressed below. I find that the respondent has not violated Schedule O. Reg. 34/10 S.38 (8).

(i) The applicant is not entitled to $49.88 ($1,339.53 less $1,269.65 approved) for chiropractic services;

(ii) The applicant is not entitled to $1,844.90 for chiropractic services;

(iii) The applicant is not entitled to $2,200.00 for a chronic pain assessment.

10The applicant was partially approved for treatment plan (i) and the remainder was denied under the MIG limits. For all the treatment plans in dispute the applicant has failed to prove that based on the balance of probabilities the treatment plans in dispute are reasonable and necessary.

11To receive payment for a treatment and assessment plan under sections 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.

12The applicant relies primarily upon the reports of Physiotherapist Patel, Dr. Al Shami, Dr. Abdululmajeed, Dr. Goodfield and Dr. El-Saidi. The applicant argues that they suffered from dizziness, difficulty sleeping, knee pain, back pain, neck pain and anxiety. The applicant also points to the fact that she had to stop working and has struggled with activities of daily living (ADL), including household chores. The applicant further argues that Dr. Goodfield diagnosed the applicant Adjustment Disorder with Mixed Anxiety and Depressed Mood. The applicant submits that the treatment plans in dispute are reasonable and necessary and the goals of the treatment plans are clearly defined. Lastly, the applicant argues that the limited treatment that they did receive was beneficial and should be allowed to continue to access physical therapy treatment. The respondent relies primarily on the report by Dr. Dessouki. The respondent argues that from a physical perspective the applicant’s injuries were predominantly minor in nature and did not need any formalized physical therapy. The respondent argues that the applicant did not seek any medical treatment until two weeks after the accident and argues that there are large gaps in the applicant seeking any medical attention for any condition that could be considered to be related to the accident.

13I agree with the respondent that the applicant has failed to prove, based on a balance of probabilities that the two chiropractic treatment plans in dispute are reasonable and necessary. The applicant refused any treatment at the scene of the accident and took two weeks before she sought any medical attention. While the applicant did seek medical attention for other issues since the accident, the periodic nature of reporting ailments that may or may not be associated to the accident, is not satisfactory enough for the applicant to meet their burden of proof onus.

14The applicant argues that the chronic pain assessment (issue iii), is reasonable and necessary and relies on Dr. Al-Jazrawi’s report. Dr. Al-Jazrawi opines that the applicant has been suffering from chronic pain for over a year and it has been disrupting her ADLs, sleep and has contributed to anxiety issues. The applicant argues that there is enough compelling medical evidence to investigate whether or not the applicant has chronic pain and therefore the assessment should be deemed reasonable and necessary.

15The respondent argues that they denied the assessment based on the reports from Dr. Dessouki and Dr. Goodfield. Dr. Dessouki opined that the applicant did not suffer from ongoing musculoskeletal issues and had reached maximum physical recovery. Furthermore Dr. Goodfield opined that a chronic pain assessment was not needed as part of a psychological assessment.

16The applicant had significant gaps between complaints to her family doctor regarding any physical pain. And it is not entirely clear that any of the pain reporting can be directly tied to the motor vehicle accident. Therefore, at this time the applicant has not met their onus necessary to be granted a chronic pain assessment.

Interest

17Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no benefits are overdue, no interest is awarded.

Award

18The 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.

19As no benefits were unreasonably withheld or delayed, the applicant is not entitled to an award.

ORDER

20I order the following:

i. The applicant is not entitled to $49.88 ($1,339.53 less $1,269.65 approved) for chiropractic services.

ii. The applicant is not entitled to $1,844.90 for chiropractic services.

iii. The applicant is not entitled to $2,200.00 for a chronic pain assessment.

iv. The respondent is not liable to pay an award under s.10 of Reg. 664.

v. The applicant is not entitled to interest on overdue payments.