[M.M] v. Security National Insurance Company
RECONSIDERATION DECISION
Before: Ulana Pahuta
Licence Appeal Tribunal File Number: 23-002017/AABS
Case Name: [M.M] v. Security National Insurance Company
Written Submissions by:
For the Applicant: Kelisa Reyes, Paralegal
For the Respondent: Arfa Saeed, Counsel
OVERVIEW
1On March 24, 2025, the applicant requested reconsideration of the Tribunal’s decision dated February 28, 2025 (“decision”).
2In this decision, I found that the applicant was not entitled to the treatment plan (“OCF-18”) for physiotherapy services, the cost for medical expenses submitted on an OCF-6 claim form, interest, or an award.
3The grounds for a request for reconsideration are found in Rule 18.2 of the Licence Appeal Tribunal Rules, 2023 (“Rules”). To grant a request for reconsideration, the Tribunal must be satisfied that one or more of the following criteria are met:
a) The Tribunal acted outside its jurisdiction or committed a material breach of procedural fairness;
b) The Tribunal made an error of law or fact such that the Tribunal would likely have reached a different result had the error not been made; or
c) There is evidence that was not before the Tribunal when rendering its decision, could not have been obtained previously by the party now seeking to introduce it, and would likely have affected the result.
4The applicant is requesting reconsideration pursuant to Rule 18.2(b) with respect to the OCF-18 for physiotherapy services. He submits that I erred in law in finding that the respondent’s denial notices for the OCF-18 complied with s. 38 of the Statutory Accident Benefits Schedule – Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”). He requests an order confirming that he is entitled to the cost of the OCF-18, interest and an award.
5The respondent submits that the applicant failed to identify an error of law or fact with respect to the decision. It requests that the applicant’s reconsideration request be dismissed.
RESULT
6The applicant’s request for reconsideration is dismissed.
ANALYSIS
7The test for reconsideration under Rule 18.2 involves a high threshold. The reconsideration process is not an opportunity for a party to re-litigate its position where it disagrees with the Tribunal’s decision, or with the weight assigned to the evidence. The requestor must show how or why the decision falls into one of the categories in Rule 18.2.
Rule 18.2 - No error in law in finding that the respondent was compliant with s. 38
8The respondent had provided three denial notices in response to the OCF-18 for physiotherapy services dated September 23, 2021. In paragraphs 19 to 21 of the decision, I noted that while the respondent’s initial denial notice failed to provide a medical reason for the denial, the subsequent notices dated February 17, 2022 and January 4, 2024 cured the non-compliance. The applicant submits that I erred in law by improperly applying s. 38 of the Schedule with respect to the February 17, 2022 and the January 4, 2024 notices.
9With respect to both the February 17, 2022 and the January 4, 2024 notices, the applicant argues that the notices did not inform the applicant of the services and assessments the respondent did not agree to pay for, as required by s. 38(8) of the Schedule. The applicant further submits that the January 4, 2024 notice did not provide a sufficient reason for the denial. Finally, the applicant argues that I erred in considering whether the January 4, 2024 notice complied with s. 38(8) of the Schedule, since it was provided after receipt of an IE report, and as such, s. 38(14) is applicable rather than s. 38(8).
10I find that the applicant has not established an error in law.
11While in paragraphs 19 to 21 of the decision I did not expressly address the issue of whether the notices identified the goods, services and assessments that the respondent did not agree to pay for, I note that in his submissions at the initial hearing, the applicant’s arguments centered on whether the respondent had provided a medical reason in its notices.
12However, even considering the applicant’s argument as part of this reconsideration request, I find that I did not err in law in my determination that the notices were compliant with the Schedule. The February 17, 2022 notice identified the OCF-18 by date and treatment provider, and noted that its insurer’s examination (IE) assessor was unable to make a determination as to whether the applicant was entitled to any of the goods or services outlined in the OCF-18. The IE report was included and the respondent made a s. 33 request for clinical notes and records for the previous two years from the applicant’s health practitioner.
13The final denial on January 4, 2024 similarly identified the OCF-18 by date and treatment provider and stated that the applicant was not entitled to any of the goods or services outlined in the OCF-18. The applicant argues that the respondent was obliged to identify the goods and services it was denying. I find that the denied services were appropriately identified, as the respondent stated that the applicant was not entitled to “any” of the services described in the OCF-18.
14The applicant does not direct me to any provision in the Schedule or caselaw that holds that an itemized breakdown of services is required, particularly in a situation where the full amount of the OCF-18 is being denied, as opposed to a situation where an OCF-18 is only partially denied. In the present matter, it was clear as to what services were being denied.
15With respect to the applicant’s argument that the January 4, 2024 notice did not provide sufficient reasons for the denial, I find that the applicant is trying to re-litigate his position from the initial hearing. In paragraphs 20 to 21 of the decision I provided reasons for why I found the denial to be sufficient. While the applicant may disagree with my finding, the reconsideration process is not intended to serve as an opportunity for a party to re-litigate their position because they disagree with the decision.
16Finally, the applicant submits that in my decision, I improperly applied s. 38(8) when considering the January 4, 2024 notice, rather than s. 38(14) of the Schedule. However, I note that in the applicant’s initial hearing submissions, he was arguing that the respondent’s denial notices were non-compliant with s. 38(8) of the Schedule and as such, the OCF-18 was payable pursuant to s. 38(11). The applicant did not raise the issue of non-compliance with s. 38(14) at the hearing. In paragraphs 19 to 21 of the decision, I found that the respondent’s initial denial notice was non-compliant with s. 38(8) of the Schedule. As such, I then considered whether the respondent’s subsequent notices dated February 17, 2022 and January 4, 2024 complied with s. 38(8), and found they did. I find that the applicant has not established that I erred in law in my consideration of s. 38(8) and the respondent’s denial notices.
17I find that the applicant has not satisfied the criteria in Rule 18.2(b) for reconsideration based on an error of law.
CONCLUSION & ORDER
18For the reasons noted above, I dismiss the applicant’s request for reconsideration.
Ulana Pahuta
Adjudicator
Tribunals Ontario – Licence Appeal Tribunal
Released: June 4, 2025