Manson v. Wawanesa Mutual Insurance Company, 2025 CanLII 39283

Citation: Manson v. Wawanesa Mutual Insurance Company, 2025 ONLAT 23-007532/AABS

Licence Appeal Tribunal File Number: 23-007532/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:

Shainell Manson

Applicant

and

Wawanesa Mutual Insurance Company

Respondent

DECISION

ADJUDICATOR: Estella Muyinda

APPEARANCES:

For the Applicant: Rozanna Karim, Paralegal

For the Respondent: Ken Yip, Counsel

HEARD: By Way of Written Submissions

OVERVIEW

1Shainell Manson, the applicant, was involved in an automobile accident on September 3, 2020, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”).

2The applicant was denied benefits by the respondent, Wawanesa Mutual Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

ISSUES

3The issues in dispute are:

1. Is the applicant entitled to $2,635.40 for chiropractic services, proposed by Mackenzie Medical Rehabilitation Centre in a treatment plan/OCF-18 (“plan”) dated February 7, 2022?
2. Is the applicant entitled to $2,522.16 for a Psychological Assessment, proposed by Q Medical in a treatment plan dated January 27, 2022?
3. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

4I find that the applicant is not entitled to chiropractic services in the amount of $2,635.40.

5I find that the applicant is entitled to a psychological assessment in the amount of $2,522.16.

6The applicant is entitled to interest on any overdue payment of benefits, pursuant to s. 51 of the Schedule.

ANALYSIS

Chiropractic Treatment Plan

7I find that the applicant has not established that the treatment plan for chiropractic services submitted on February 7, 2022, is reasonable and necessary.

8To 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.

9To 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.

10The applicant claims that the chiropractic treatment is necessary because her physical and mental health have been significantly affected by the accident.

11The respondent objects to the chiropractic treatment plan at issue on the basis that the proposed treatment plan does not meet the test of being reasonable and necessary. It submits that the treatment plan for chiropractic treatment was denied based on the IE report of Dr. Tansey, who concluded that that there was no ongoing impairment from the applicant’s injuries. The respondent added that this conclusion is supported by the additional IE reports of Dr. V. Naumetz (orthopedic surgeon) dated March 31, 2023, and Ms. Cottrell (occupational therapist) in her report dated April 21, 2023.

12The applicant submitted a copy of the treatment plan/OCF-18 for chiropractic services prepared by Dr. Ryan Pagnanelli dated February 7, 2022. To determine whether the applicant is entitled to the chiropractic treatment I must consider whether the treatment goals are reasonable and necessary. However, the treatment plan was missing sections relating to the goals of the chiropractic services. The applicant has the onus to identify the goals of treatment and how the goals would be met in order to demonstrate on a balance of probabilities that the treatment plan is reasonable and necessary. The applicant did not provide any specific submissions identifying the goals of the treatment plan, how the goals would be met or referring to the evidence in support of the treatment plan.

13Further, the applicant’s evidence consists of a treatment plan relating to the Application for Accident Benefits (OCF-1) dated September 8, 2020, Disability Certificate (OCF-3) dated September 23, 2020, completed by Dr. Bohdan Osoba, (chiropractor) and the clinical notes and records from Mediwise Healthcare Centre from September 5, 2020, to February 22, 2021. The treatment plan in dispute was submitted one year after the clinical notes and records from Mediwise were submitted more than a year after the applicant’s remaining evidence. Upon review of the evidence, I find that the applicant has not provided compelling support for the treatment plan, because the evidence submitted is not contemporaneous. Furthermore, the applicant did not make any specific submissions about the reasonableness and necessity and stated goals of the plan, or how such goals would be met. Accordingly, I cannot find that the treatment plan is reasonable and necessary.

14Based on the foregoing, I find, that the applicant has not met their burden to prove that the treatment plan is reasonable and necessary. Therefore, the applicant has not established on a balance of probabilities that she is entitled to the treatment plan.

15I find that the psychological assessment treatment plan is reasonable and necessary as discussed below.

16The applicant has a pre-existing condition diagnosed by Dr. Mariam Abdurrahman (psychiatrist) as schizoaffective disorder and bi-polar subtype, in a report dated July 12, 2017. Subsequent s. 25 assessors’ reports made by Dr. Harinder Mrahar, (psychologist) Dr. Dragica Visnjevac Fink (psychologist), and Dr. Konstantine Zaknanis (neuropsychologist) corroborate Dr. Abdurrahman’s diagnosis.

17The applicant relies on the psychological assessment report of Dr. Mrahar, dated February 12, 2021, who opined that the applicant suffers from significant psychological/emotional impairments as a direct consequence of the accident and its sequelae. She diagnosed the applicant as having developed emotional/psychological problems which are consistent with an adjustment disorder (with mixed anxiety and depressed mood). Dr. Mrahar recommended sixteen sessions of psychotherapy and a reassessment of the applicant to determine if further treatment is warranted.

18Further, the applicant relies on the psychological treatment plan dated January 27, 2022, by Dr. Fink, in which he stated that the goal of the applicant’s assessment was to acquire, validate and interpret data needed to identify and evaluate her psychological, emotional and social repercussions following the accident. Additionally, the doctor said that the functional goals of the assessment were to identify if a psychological impairment exists, formulate recommendations to assist in the alleviation of symptoms and return the applicant to normal activities of daily living.

19Furthermore, the applicant had a psychological assessment by Dr. Zaknanis on May 26, 2022. Dr. Zaknanis diagnosed the applicant with Major Depressive Disorder with Anxious Distress and noted that the applicant’s pre-existing depression symptoms were exacerbated by the accident. I note that the diagnosis of Dr. Zaknanis is corroborated by Dr. Mrahar’s psychological report.

20The applicant submits that the treatment plan for a psychological assessment by Dr. Zaknanis is reasonable and necessary, as her mental health has been significantly affected by the accident. The applicant claims that the psychological assessment is needed to develop a treatment plan that will address the psychological factors that may be hindering her physical rehabilitation.

21The respondent objects to the treatment plan at issue on the basis that the proposed assessment is not reasonable and necessary. Further, the respondent submits that permitting the applicant to have an additional psychological assessment will be a duplication of service.

22The respondent relies on the Insurer Examination (IE) s. 44 psychological report by Dr. Karen Spivak, (psychologist), dated June 30, 2021, to deny the treatment plan. In her report, Dr. Spivak opined that the applicant’s accident-related injuries were of a mild to moderate level of emotional distress. She said that the injuries were not of a magnitude to constitute a psychological impairment or to interfere in any substantial way with the applicant’s ability to engage in the activities of daily living. I am not persuaded by Dr. Spivak’s opinion, and I find that it does not support the respondent’s assertion that there is duplication of services. Upon review of Dr. Zaknanis report, I am persuaded that the additional psychological assessment is necessary to find out if any further treatment is necessary and whether the applicant’s accident-related psychological injuries are ongoing.

23I find that the applicant has demonstrated on a balance of probabilities that the psychological assessment is reasonable and necessary.

INTEREST

24Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule.

25The applicant is entitled to interest on the treatment plan for a psychological assessment in accordance with s. 51.

ORDER

26I find that:

a. the applicant is not entitled to $2,635.40 for chiropractic services; b. the applicant is entitled to the treatment plan for a psychological assessment; c. the applicant is entitled to interest on any overdue payment of benefits, pursuant to s. 51 of the Schedule.