Licence Appeal Tribunal File Number: 23-003348/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:
Anthony Okafor-Ogbujiagba
Applicant
and
Security National Insurance Company
Respondent
DECISION
ADJUDICATOR:
Laura Goulet
APPEARANCES:
For the Applicant:
Georgiana Masgras, Counsel
For the Respondent:
Matthew Nieuwland, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Anthony Okafor-Ogbujiagba, the applicant, was involved in an automobile accident on April 3, 2018, 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.
2This matter was scheduled to proceed by way of a videoconference hearing. In response to the applicant’s motion dated May 3, 2024, on May 6, 2024, the Tribunal ordered that the matter proceed by way of a written hearing.
ISSUES
3The issues in dispute are:
i. Is the applicant entitled to the assessments proposed by Meditecs, as follows:
i. $3,972.34 ($6,168.81 less $2,196.47 approved) for social work services proposed in a treatment plan/OCF-18 (“plan”) dated February 22, 2023?
ii. $707.08 ($1,447.42 less $740.34 approved) for social work services proposed in a plan dated March 7, 2022?
ii. Is the applicant entitled to $300.00 for eye care submitted on a claim form (OCF-6) dated April 25, 2022?
iii. Is the applicant entitled to $815.00 for health supplements and transportation submitted on an OCF-6 dated February 12, 2023?
iv. Is the applicant entitled to $10.089.62 for case management services proposed by Meditecs in a plan dated December 8, 2022?
v. Is the applicant entitled to $11,738.44 for rehab support services proposed by Meditecs in a plan dated April 24, 2023?
vi. Is the applicant entitled to $5,270.00 for dental repairs proposed by Dawson Dental Centre in an OCF-6 dated October 20, 2021?
vii. Is the applicant entitled to $2,787.95 for an attendant care assessment proposed by Meditecs in a plan dated August 21, 2023?
viii. Is the applicant entitled to $2,958.00 for a vision therapy assessment proposed by Visual Sense in a plan dated September 7, 2023?
ix. Is the applicant entitled to $9,696.31 for psychological services recommended by Tobias Chung, Abdullahi Hussein and Meditecs in a plan dated November 1, 2023?
x. Is the applicant entitled to $2,787.95 for an in-home assessment recommended by Tobias Chung in a plan dated November 4, 2023?
xi. Is the applicant entitled to the cost of an eye exam in the amount of $75.00 claimed on an OCF-6 and denied by the respondent on November 9, 2023?
xii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
xiii. Is the applicant entitled to interest on any overdue payment of benefits?
4In response to the applicant’s motion on December 12, 2023, on January 11, 2024, the Tribunal ordered that the issues set out in ix, x, and xi, above, be added.
5In response to the applicant’s motion dated May 3, 2024, on May 6, 2024, the Tribunal confirmed that the applicant withdrew his claim for a catastrophic impairment determination.
RESULT
6The applicant is not entitled to the plans in dispute, the OCF-6s, or interest.
7The respondent is not liable to pay an award.
PROCEDURAL ISSUE
8In his submissions, the applicant refers to some of the evidence in his document brief. In his conclusion, the applicant makes general submissions as follows:
i. In light of the overwhelming evidence provided as tabs to these submissions, it is credible that the applicant has suffered from catastrophic injuries from the accident;
ii. The applicant has undergone several treatments for his rehabilitation to good health and will continue to undergo several such treatments to bring him back to good health; and
iii. It is only just and fair for the applicant to receive benefits from the respondent that are currently denied to him.
9In paragraph 19 of the Case Conference Report and Order (“CCRO”) dated October 20, 2023, the Tribunal ordered that submissions shall make specific reference to the evidence and law by tab and page number, and that the hearing adjudicator may choose not to review evidence not so referenced. This order was made again by the Tribunal in its Motion Order dated May 6, 2024, at paragraph 7(f).
10I note that the applicant’s document brief contains 92 tabs with a total of 4,031 pages. The document brief is not bookmarked and tabbed. Further, in the index to the document brief, the applicant did not reference the documents to page numbers.
11In making my findings, I have considered the applicant’s submissions, as well as any evidence in the document brief that was referred to by the applicant. In accordance with the Orders of the Tribunal in the CCRO dated October 20, 2023, and the Motion Order dated May 6, 2024, I have not considered any of the evidence in the document brief that was not specifically referenced by the applicant.
ANALYSIS
12To 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.
The applicant is not entitled to the remaining amount of $3,972.34 for social work services
13The applicant has not established on a balance of probabilities that the outstanding amount of $3,972.34 in the plan for social work services dated February 22, 2023 is reasonable and necessary.
14The plan was proposed by Dr. Joseph Allen, chiropractor, and Abdullahi Hussein, social worker. The goals of the plan are to continue to help decrease mental and emotional psychological symptoms, to provide coping mechanisms, to reduce any stress, anxiety, or depressive symptoms, and to return to activities of normal living.
15In his submissions, the applicant refers to a progress report prepared by Mr. Hussein dated December 31, 2022. The report indicates that Mr. Hussein is a social worker and a psychotherapist. The applicant submits that Mr. Hussein diagnoses the applicant with severe PTSD, anxiety, and depression, and recommends an additional twenty sessions of psychotherapy treatment. I find that as a social worker and psychotherapist, Mr. Hussein is not qualified to make psychological diagnoses.
16The applicant submits that the plan targets the improvement of the applicant’s mental health, which deteriorated because of the accident. The applicant relies on the information in the treatment plan with respect to the applicant’s injuries, which he submits include severe depression, anxiety, and PTSD. The applicant submits that the plan proposes twenty sessions of mental health therapy and that the respondent partially approved eight sessions of therapy. The applicant argues that this does not make sense, as there is no clear-cut guarantee for a specific timeline of psychological recovery, and the rejection of twelve sessions by the respondent is an arbitrary number.
17The applicant did not make submissions with respect to why the additional twelve sessions of social work services are reasonable and necessary. Further, he did not refer me to medical evidence, aside from the treatment plan itself and the progress report of Mr. Hussein, who is one of the authors of the plan, in support of twenty sessions of social work services. I find the disputed treatment plan, on its own, is insufficient to establish that the plan is reasonable and necessary.
18Given the lack of corroborating medical evidence, I find the applicant has not demonstrated on a balance of probabilities that the outstanding amount of the treatment plan for social work services dated February 22, 2023 is reasonable and necessary.
The applicant is not entitled to the remaining amount of $707.08 for social work services
19The applicant has not established on a balance of probabilities that the outstanding amount of $707.08 in the plan for social work services dated March 7, 2022 is reasonable and necessary.
20The treatment plan is not in evidence before me. The applicant submits that an invoice was sent to the respondent in the amount of $1,447.42, and that it was partially approved in the amount of $740.34.
21The applicant did not make submissions with respect to why the outstanding amount of the treatment plan is reasonable and necessary or direct me to any medical evidence in this regard.
22For these reasons, I find that the applicant has not established on a balance of probabilities that the outstanding amount of the plan for social work services dated March 7, 2022 is reasonable and necessary.
The applicant is not entitled to the plan for case management services
23The applicant has not established on a balance of probabilities that the treatment plan for case management services is reasonable and necessary.
24The plan was proposed by Dr. Joseph Allen, chiropractor. The goals of the plan are to return to activities of normal living, and to reduce the applicant’s stress and provide a means of better communication between the applicant, health care professionals and his adjuster. The plan lists the case manager’s duties as follows: case coordination; organization of the case file after an extensive document review has been conducted; decreasing service fragmentation; liaison for the entire rehab, legal and insurer team; assessing and reassessing the efficacy of services provided to the applicant; and client advocacy.
25The applicant submits that, since the accident, he has visited health and medical centres far too frequently to get better and these visits included a lot of paperwork, which he is finding difficult to manage on his own. The applicant submits that this can be seen from the applicant’s vast medical records. The applicant argues that case management is necessary for him to concentrate on his well-being and that this finding has been seconded by his health professionals.
26The treatment plan on its own is not compelling evidence in support of treatment. The applicant does not direct me to evidence of any of the applicant’s treating health practitioners recommending the services proposed in the disputed plan.
27For these reasons, I find that the applicant has not established on a balance of probabilities that the treatment plan for case management services is reasonable and necessary.
The applicant is not entitled to the plan for rehab support services
28The applicant has not established on a balance of probabilities that the plan for rehab support services is reasonable and necessary.
29The plan was proposed by Dr. Allen, chiropractor. The goals of the plan are pain reduction, increased range of motion, increase in strength, to promote, restore, rehabilitate and/or maintain quality of life and well being, and “to support the development of strengths while addressing social, emotional, physical, spiritual.”
30In support of his position, the applicant relies on the treatment plan in dispute, pointing to Dr. Allen’s comments that the applicant reports a great benefit from rehab social work sessions in that they have provided symptom relief and functional gains.
31As noted above, the treatment plan on its own is not compelling evidence in support of treatment. The applicant does not direct me to evidence of any of the applicant’s treating health practitioners recommending the need for the services proposed in the disputed plan.
32For these reasons, I find that the applicant has not established on a balance of probabilities that the treatment plan for rehab support services is reasonable and necessary.
The applicant is not entitled to the plan for an attendant care assessment
33The applicant has not established on a balance of probabilities that the treatment plan for an attendant care assessment is reasonable and necessary.
34The plan for an attendant care assessment dated August 21, 2023 was proposed by Dr. Tobias Chung, chiropractor. The goals of the plan are to assess the applicant’s current living situation to determine the need for assistive devices, assistance at home with activities of daily living and recommended treatment options/lifestyle changes.
35In support of his position, the applicant refers to comments made by Dr. Chung in the disputed treatment plan. Dr. Chung indicated that as a result of the accident, the applicant experienced functional ability limitation and difficulties performing activities of daily living due to pain and discomfort with bending, lifting, twisting, prolonged sitting, standing and walking. Dr. Chung further indicated that the applicant reported ongoing depression, anxiety, and sleep disturbance which negatively impact his ability to perform activities of daily living and recreational activities at the same level. The applicant also refers to several barriers to the applicant’s recovery that are listed in Part 9 of the plan.
36The applicant does not direct me to evidence of any of the applicant’s treating health practitioners recommending the need for the services proposed in the disputed plan.
37For these reasons, I find that the applicant has not established on a balance of probabilities that the treatment plan for an attendant care assessment is reasonable and necessary.
The applicant is not entitled to the plan for vision therapy
38The applicant has not established on a balance of probabilities that the plan for vision therapy is reasonable and necessary.
39The plan was proposed by Dr. Tanya Polonenko, neuro-optometrist. The plan proposes Nikon SeeMax Ultimate 1.6 index with scratch resistance coating and anti reflection coating; Relaxsee 1.6 index with a scratch resistance and anti reflection coating with E50 blue tint; Maui Jim Mauibrillant polarized single vision lens; Nike 7014 light weight plastic frame; Lacoste 2692 light weight plastic frame; and Maui Jim 798 onshore gloss black sunglass frame. The plan indicates that the applicant’s glasses prescription is no longer accurate post-cataract surgery. Dr. Polonenko indicates that the applicant recently had cataract surgery to remove the traumatic cataract from the accident. The goal of the plan is to reduce visual symptoms since the accident and to return to activities of normal living.
40In his submissions, the applicant refers to a Functional Oculo-Visual Report dated November 24, 2022 prepared by Dr. Polonenko. Dr. Polonenko indicates that the applicant reported that during the accident, his bifocal glasses shattered into his left eye. Dr. Polonenko’s diagnosis is Post Concussion/Trauma Vision Syndrome that includes severe fusional vergence dysfunction, severe convergence insufficiency, reduced depth perception, oculomotor dysfunction, reduced visual spatial processing and processing speed, and visual perceptive deficits.
41The applicant submits that the plan was denied by the respondent because there is no compelling medical evidence that the diagnosis of cataract is accident related. The applicant argues that with these serious injuries to his eyes, “it is quite illogical to state a lack of correlation between the diagnosis of cataract” and the accident, considering that these eye injuries can easily be accompanied with chronic or post-injury comorbidities in the applicant.
42I have reviewed Dr. Polonenko’s report dated November 24, 2022 and I note that it does not address the issue of the applicant’s need for a new glasses prescription post-cataract surgery.
43I am persuaded by the insurer’s examination conducted on January 10, 2024 by Dr. Calvin Breslin, specialist in ophthalmology, because it is contemporaneous with the treatment plan dated September 7, 2023. After conducting an ophthalmological examination, Dr. Breslin indicated that the applicant had bilateral cataract surgery with an excellent visual result, and that, other than mild-to-moderate dry eyes, the remainder of the ocular examination was functionally normal. Dr. Breslin opined that the applicant did not sustain an oculovisual injury or impairment in the accident.
44Other than the disputed treatment plan, the applicant has not directed me to any corroborating contemporaneous medical evidence that the vision care proposed in the plan is reasonable and necessary as a result of accident-related impairments.
45For these reasons, I find that the applicant has not established on a balance of probabilities that the treatment plan for vision care is reasonable and necessary.
The applicant is not entitled to the plan for psychological services
46The applicant has not established on a balance of probabilities that the treatment plan for psychological services is reasonable and necessary.
47The plan was proposed by Dr. Chung, chiropractor, and Abdullahi Hussein, social worker. The goals of the plan are to help decrease mental and emotional psychological symptoms and provide coping mechanisms to reduce any stress, anxiety, or depressive symptoms, and to return to activities of normal living.
48The applicant submits that the applicant’s psychological disorders, as listed in the treatment plan, demonstrate the seriousness of his psychological condition that warrants chronic intervention.
49In his submissions, the applicant also refers to a Psychiatric Assessment Report prepared by Dr. Shrenik Parekh, psychiatrist, on March 31, 2021, who diagnosed the applicant to be moderately to severely depressed, mentally severely ill, and fully disabled. Although Dr. Parekh assesses the applicant and makes psychological diagnoses, he does not make recommendations for treatment. Further, I note that this assessment is not contemporaneous with the treatment plan in that it was conducted on March 31, 2021, two years, and seven months prior to the proposed plan.
50Other than the treatment plan which was proposed in part by Mr. Hussein, and the separate progress report prepared by Mr. Hussein on December 31, 2022, the applicant does not refer me to any contemporaneous medical evidence in support of the plan, nor does he direct me to evidence of any medical practitioners who recommend the proposed treatment in the disputed plan.
51For these reasons, I find that the applicant has not established on a balance of probabilities that the treatment plan for psychological services is reasonable and necessary.
The applicant is not entitled to the plan for an in-home assessment dated November 4, 2023
52The applicant did not put into evidence the plan for an in-home assessment dated November 4, 2023. Further, in his submissions, the applicant referred to the plan dated August 21, 2023, which has already been addressed in this decision at paragraphs 33 to 37, above. For these reasons, I find that the applicant has not established on a balance of probabilities that the plan for an in-home assessment dated November 4, 2023 is reasonable and necessary.
The OCF-6 claims
53The applicant bears the onus of establishing on a balance of probabilities that the goods and services claimed on an OCF-6 are reasonable and necessary.
The applicant is not entitled to the OCF-6 for eye care
54The applicant has not established on a balance of probabilities that the OCF-6 for eye care is reasonable and necessary.
55The applicant filed into evidence the claim form dated April 25, 2022 as well as a receipt that the amount of $300.00 was paid to Visual Sense Eye Care on April 21, 2022.
56The applicant submits that the applicant submitted a claim form in the amount of $300.00 to the respondent for his eye treatment, which is a plaguing problem for him since the accident, and that the respondent denied the claim stating that it has already approved the OCF-18s. The applicant does not make any further submissions with respect to this claim form. The applicant does not direct me to evidence of a medical practitioner who recommends “eye care,” nor does the applicant direct me to evidence with respect to what the “eye care” entails.
57Based on the evidence before me, I find that the applicant has not established on a balance of probabilities that the OCF-6 for eye care is reasonable and necessary.
The applicant is not entitled to the OCF-6 for health supplements and transportation
58The applicant has not established on a balance of probabilities that the OCF-6 for health supplements and transportation is reasonable and necessary.
59The applicant submits that the respondent denied the OCF-6 for health supplements prescribed by Dr. Grundy and three transportation trips to the doctor for treatment of his accident-related injuries on the grounds that the treatment was experimental in nature.
60The applicant does not make submissions with respect to why the OCF-6 is reasonable and necessary, nor does he direct me to medical evidence in support of the expense.
61For these reasons, I find that the applicant has not established on a balance of probabilities that the OCF-6 for health supplements and transportation is reasonable and necessary.
The applicant is not entitled to the OCF-6 for dental repairs
62The applicant has not established on a balance of probabilities that the OCF-6 for dental repair work is reasonable and necessary because he does not make any submissions in this regard.
The applicant is not entitled to the OCF-6 for the cost of an eye exam
63The applicant has not established on a balance of probabilities that the OCF-6 for an eye exam is reasonable and necessary.
64The applicant submits that due to the severe injury to the applicant’s eye at the time of the accident, an eye exam is necessary to gauge his recovery process. The applicant further submits that the accident aggravated his pre-existing eye problems.
65I have reviewed Dr. Polonenko’s report dated November 24, 2022, which indicates that she has been providing vision rehabilitation to the applicant. Dr. Polonenko does not recommend an eye exam in the report.
66The applicant did not direct me to evidence of a medical practitioner who recommends an eye exam.
67For these reasons, I find that the applicant has not established on a balance of probabilities that the OCF-6 for an eye exam is reasonable and necessary.
Interest
68Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since there are no overdue payments, no interest is ordered.
Award
69The 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. Since no benefits were unreasonably withheld, the applicant is not entitled to an award.
ORDER
70For the above reasons, I find:
i. The applicant is not entitled to the plans in dispute, the OCF-6s, or interest.
ii. The respondent is not liable to pay an award.
iii. The application is dismissed.
Released: April 22, 2025
__________________________
Laura Goulet
Adjudicator