Boddy v. Aviva General Insurance
Licence Appeal Tribunal File Number: 23-009733/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:
Jacob Boddy
Applicant
and
Aviva General Insurance
Respondent
DECISION
ADJUDICATOR:
Rasha El Sissi
APPEARANCES:
For the Applicant:
Merella Botros, Counsel
For the Respondent:
Jonathan White, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Jacob Boddy, the applicant was involved in an automobile accident on February 11, 2016, and sought benefits pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 2010 (the “Schedule”). The applicant was denied benefits by the respondent, Aviva General Insurance and applied to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issue in dispute is:
i. Is the applicant entitled to $4,686.00 for optometric services, proposed by Amanda Sim in a treatment plan/OCF-18 dated September 7, 2021?
RESULT
3The applicant is entitled to the treatment plan in dispute.
ANALYSIS
4To receive payment for an OCF-18 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.
5The OCF-18 in dispute is for 20 in-facility sessions of vision training, anti-fatigue glasses, a vision therapy package, functional oculo-visual assessment and follow-up, and documentation. The goals are pain reduction (headaches) and return to the activities of normal living, by reducing eye strain. This is a new treatment for the applicant.
6The applicant relies on the evidence of various healthcare providers who recommend or support vision therapy to treat the applicant’s complaints. These include Dr. Aaron Tai, optometrist and Ms. Maria Paulsson, occupational therapist, as well as Dr. Amanda Sim, optometrist, who proposed the OCF-18 in dispute.
7The respondent relies on a s. 44 / IE ophthalmology assessment by Dr. Calvin Breslin, ophthalmologist dated November 22, 2022. Dr. Breslin concluded that the applicant did not sustain an oculo-visual impairment as a result of the accident. The respondent submits that, other than the applicant’s subjective reports, there is no medical evidence that the applicant experiences double vision, blurred vision or light sensitivity as a result of the accident.
8The question is whether the applicant has met his burden of demonstrating on a balance of probabilities that the OCF-18 in dispute is reasonable and necessary as a result of the accident.
9The applicant submitted medical evidence that he was diagnosed with a concussion after the accident and suffers from post-concussive symptoms related to the accident. The post-accident report of Dr. James Rutka, neurosurgeon, dated May 10, 2016, states that his post-concussive symptoms include intermittent headaches, forgetfulness and difficulty concentrating at school. Dr. Rutka referred him to a concussion specialist.
10The applicant submitted evidence from his healthcare providers discussed below that he has continuing accident-related symptoms that include headaches related to eye strain.
11The applicant points to the vision report of Dr. Tai dated August 16, 2021, addressed to Dr. Annie Hum, family doctor. Dr. Tai recorded that the applicant was experiencing bothersome eyestrain. Dr. Tai commented on “accommodative dysfunction” and “convergence insufficiency”, recommended near-work breaks, wearing glasses for near work or “VT consult”, and counselled on vision therapy.
12Dr. Sim’s functional oculo-visual report dated September 9, 2021 states that the applicant reports experiencing the following signs and symptoms of eye strain: headaches, double vision, blurry vision at near, discomfort when reading or when on computer and blurry vision when changing viewing distances. Dr. Sim diagnosed “vergence” and “accommodative dysfunction”. She recommended vision therapy to address headaches, eyestrain and other symptoms.
13In sum, the applicant has provided evidence of two separate optometrists’ reports that connect the applicant’s vision complaints with “accommodative dysfunction” and “vergence” and “accommodative dysfunction”. Their reports also connect his complaints and their diagnoses to the proposed treatment (glasses, vision therapy) and treatment goals (reduced eyestrain related pain and return to activities of normal life, i.e., studying). The reports are within 30 days of the date of the OCF-18 in dispute.
14The respondent submits that neither of the optometrists’ reports indicate that the applicant objectively has double vision, blurry vision and light sensitivity and in that way are consistent with Dr. Breslin’s “normal” report.
15However, I find that the applicant has met his onus to prove a visual impairment, given the medical evidence of post-concussive symptoms (headaches, difficulty concentrating), the agreement between the optometrists on the diagnoses, and his self-reported bothersome eyestrain and other relevant symptoms. In addition, Dr. Breslin noted the applicant had light sensitivity though not clinically significant, as well as dry eye disease.
16The applicant submits that he did not realize the extent of his vision problems until he had to move to online schooling in 2020. I accept this explanation of the delay in initiating vision therapy as it is supported by Ms. Paulsson’s opinion dated March 1, 2022 on his future needs in her scope of practice as an occupational therapist. She states that the applicant continues to experience headaches, which become intrusive with studying and spending long periods of time before a computer, which negatively impacts the applicant’s ability to focus, attend and stay engaged. Her opinion specifically supports the glasses and vision therapy proposed in the disputed OCF-18 to reduce visual strain and thereby reduce headaches and improve attention span.
17I place weight on Ms. Paulsson’s opinion because she has been the applicant’s occupational therapist starting in 2020 when he moved to online schooling. Her opinion supports the connection between the applicant’s accident-related post-concussive symptoms and his vision complaints in the context of helping the applicant rehabilitate from acquired brain injury.
18Therefore, I find that the applicant has met his burden to show that the treatment plan in dispute is reasonable and necessary as a result of the accident. Accordingly, the applicant is entitled to the treatment plan in dispute.
ORDER
19For the above reasons, I find that:
i. The applicant is entitled to the treatment plan in dispute.
Released: May 2, 2025
Rasha El Sissi
Adjudicator