Adjei v. Allstate Insurance Company of Canada, 2025 CanLII 75773

Licence Appeal Tribunal

Citation: Adjei v. Allstate Insurance Company of Canada, 2025 ONLAT 23-012855/AABS

Licence Appeal Tribunal File Number: 23-012855/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:

Enock Effah Adjei

Applicant

and

Allstate Insurance Company of Canada

Respondent

DECISION

VICE-CHAIR: Julian DiBattista

APPEARANCES:

For the Applicant: Dayana Soto Santana, Paralegal

For the Respondent: No submissions received

HEARD: By way of written submissions

OVERVIEW

1Enock Effah Adjei, the applicant, was involved in an automobile accident on June 22, 2023, 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, Allstate Insurance Company of Canada, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

ISSUES

2The issues in dispute are:

1. Is the applicant entitled to an income replacement benefit (“IRB”) in the amount of $400.00 per week from June 29, 2023, and ongoing?
2. Is the applicant entitled to $3,452.96 for physiotherapy, proposed by Martin Spine in a treatment plan/OCF-18 (“plan”) submitted March 25, 2024?
3. Is the applicant entitled to $3,790.70 ($2,892.98 approved, $897.72 remaining in dispute) for psychological treatment, proposed by 101 Assessments in a plan submitted December 4, 2023?
4. Is the applicant entitled to the assessments proposed by 101 Assessments, as follows: i. $2,460.00 for an orthopaedic assessment, in a plan submitted December 8, 2023; and ii. $2,460.00 for a neurological assessment, in a plan submitted March 11, 2024?
5. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
6. Is the applicant entitled to interest on any overdue payment of benefits?

3The applicant has narrowed the issues in dispute in his initial submissions:

i. MIG and the treatment plan for a psychological assessment submitted October 16, 2023 are no longer in dispute; and ii. Issue number 3 has been partially approved.

4The issues set out above have been updated to reflect these submissions.

RESULT

5I find that the applicant is not entitled to an IRB or the disputed treatment plans.

6As there are no benefits overdue or withheld, the applicant is not entitled to interest or an award under s.10 of Reg 664.

7This application is dismissed.

PROCEDURAL ISSUES

The respondent did not make submissions

8Counsel for the respondent has not made submissions in this hearing. A notice of written hearing was sent to the respondent’s counsel of record via email on April 25, 2025.

9The applicant’s submissions were served on the respondent’s counsel of record on November 12, 2024.

10The Tribunal has no record of submissions being received or served by the respondent.

11In accordance with s. 7(2) of the Statutory Powers Procedure Act R.S.O. 1990, c. S.22 I am satisfied that notice of the written hearing was given to the respondent and the hearing will continue without submissions from the respondent.

ANALYSIS

The applicant has not proven entitlement to an Income Replacement Benefit

12I find the applicant is not entitled to an IRB.

13To receive payment for an IRB under s. 5(1) of the Schedule, the applicant must be employed at the time of the accident and, as a result of and within 104 weeks after the accident, suffer a substantial inability to perform the essential tasks of that employment. The applicant must identify the essential tasks of their employment, which tasks they are unable to perform and to what extent they are unable to perform them. The applicant bears the burden of proving, on a balance of probabilities, that they meet the test.

14The applicant submits that they should be entitled to an IRB as they cannot perform the essential tasks of their employment.

15The applicant first visited his family physician Dr. Beharry on July 26, 2023. Dr. Beharry notes note that the applicant was experiencing back pain, neck pain, shoulder pain, worsening headaches and sleep interruptions. Dr. Beharry diagnosed whiplash associated disorder. Dr. Beharry did not identify the essential tasks of the applicant’s employment or make a finding on whether or not the applicant could perform them.

16Dr. Beharry referred the applicant to Dr. Neil Verma, physician, of the Releva Chronic Pain Clinic. Dr. Verma completed an assessment on March 13, 2024. Dr. Verma’s impressions included myofascial pain syndrome post motor vehicle collision, tension headaches post motor vehicle collision and right elbow tendinopathy. Dr. Verma did not identify the essential tasks of the applicant’s employment or make a finding on whether or not the applicant could perform them.

17The applicant was then referred to Dr. Reuven Lexier, orthopaedic surgeon, on March 21, 2024. Dr. Lexier suspects that the pain originates from the cervical region. He recommends the applicant is referred to a neurologist. Dr Lexier does not believe the applicant is a candidate for orthopaedic surgery. Dr. Lexier ordered a cervical spine x-ray. The subsequent x-ray report of Dr. Sohemmer, notes that no soft tissue swelling is evident, and there is a moderate disc space narrowing at C5/C6. Dr Lexier did not identify the essential tasks of the applicant’s employment or make a finding on whether or not the applicant could perform them.

18The applicant then underwent a s.25 examination with Dr. Konstantinos Papazoglou, psychologist, on November 11, 2023.

19Dr. Papazoglou diagnosed the applicant with an adjustment disorder.

20However, Dr. Papazoglou noted that the applicant has reported his injuries have prevented him from returning to work and he recommends a work site/occupational demands assessment to properly document the pertinent physical and functional demands of his occupation.

21There is no evidence before me that such an assessment was ever sought or completed. In any event, Dr. Papazoglou did not identify the essential tasks of the applicant’s employment and whether or not the applicant could perform them.

22The applicant submits a s. 44 psychological assessment report from an assessment with Dr. Chris Friesen, psychologist, on February 27, 2024.

23The applicant submits this assessment as his self reports noted by Dr. Friesen indicate that he cannot complete the tasks of his employment.

24However, Dr. Friesen found that the applicant did not suffer a substantial inability to perform the essential tasks of his employment.

25The applicant submits a s.44 assessment report from Dr. B. Jaroszynski, orthopaedic surgeon. The applicant contends that his self reports noted in this assessment corroborate his inability to perform the essential tasks of his employment.

26Dr. Jaroszynski, assessed the applicant on March 6, 2024. However, Dr. Jaroszynski found that the applicant suffered from soft tissue injuries and did not suffer a substantial inability to perform the tasks of his employment.

27I note that while the assessors have indicated that the applicant is reporting pain, they have not made recommendations or findings that he is unable to perform the essential tasks of his employment.

28To meet the test for an IRB, the applicant must identify the essential tasks of his employment, which tasks he is substantially unable to perform.

29As the essential tasks of employment have not been identified by any of the evidence before the Tribunal, I find that the applicant has not met his burden to prove that he is entitled to an IRB.

The applicant is not entitled to any of the disputed OCF-18s

30To 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 treatment and assessment plan 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 physiotherapy treatment

31I find that the applicant is not entitled to physiotherapy treatment proposed in a plan submitted March 25, 2024.

32There have been no submissions made on the goals of this treatment plan, and whether the goals would be met to a reasonable degree. The details of the treatment proposed have not been provided to the Tribunal in the applicant’s submissions.

33The disputed treatment plan has not been submitted to the Tribunal as evidence.

34As such, I am unable to make findings on what the goals of the treatment plan were and whether or not they would be met to a reasonable degree. I am also unable to make findings of whether or not the costs of the plan are reasonable, as the applicant has not made submissions and has not pointed me to evidence of the breakdown of the treatment proposed and the costs associated with it.

35Therefore, I find that the applicant has not met their burden to prove that the treatment proposed is reasonable and necessary.

The applicant is not entitled to psychological treatment

36I find that the applicant is not entitled to psychological treatment proposed in a plan submitted December 4, 2023.

37I note that the applicant was recommended to receive psychological treatment by both the s.25 assessor Dr. Papazoglou and the s.44 assessor, Dr. Friesen.

38I also note that the applicant has submitted that this treatment plan has been partially approved by the respondent.

39There have been no submissions made on the goals of the remaining items covered by this treatment plan, and whether the goals would be met to a reasonable degree. The details of the unapproved items proposed have not been provided to the Tribunal in the applicant’s submissions.

40In addition, the disputed treatment plan has not been submitted to the Tribunal as evidence.

41As such, I am unable to conduct an analysis on the items which remain denied.

42I have not been provided submissions or evidence outlining which services were approved, which were denied and the reasons for continued denial.

43Therefore, I find that the applicant has not met their burden to prove that the treatment proposed and denied is reasonable and necessary.

The applicant has not proven entitlement to any of the proposed assessments

44I find that the applicant has not proven entitlement to any of the proposed assessments.

45The applicant submits that they should be entitled to an orthopaedic assessment proposed in an OCF-18 dated December 8, 2023 and a neurological assessment proposed in an OCF-18 dated March 11, 2024. Copies of the OCF-18s for these respective assessments have not been submitted as evidence to the Tribunal.

46There have been no submissions made on the goals of these assessment plans, and whether the goals would be met to a reasonable degree. The details of the assessments have not been provided to the Tribunal in the applicant’s submissions.

47In addition, the applicant was referred by Dr. Beharry to an Orthopaedic Surgeon, Dr. Lexier, who conducted an assessment on March 21, 2024. Without specifics on the goals for the proposed assessment, it would be duplicative to the assessment already conducted at the behest of Dr. Beharry.

48I note that Dr. Lexier did recommend an assessment by a neurologist. However, the disputed OCF-18 has not been provided as evidence and no submissions have been made to allow me to make a finding on if the proposed assessment aligns with Dr. Lexier’s recommendations.

49Therefore, I am unable to make findings on what the goals of the assessments are and whether or not they would be met to a reasonable degree. I am also unable to make findings of whether or not the costs of the plan are reasonable, as I have not been provided with an itemized breakdown of the treatment proposed and the costs associated.

50As it is the applicant’s burden to prove entitlement, I find that the applicant has not met that burden. The applicant is not entitled to any of the disputed assessment plans.

Interest

51As no benefits are overdue, there is no entitlement to interest.

Award

52As no benefits have been unreasonably withheld or delayed, there is no basis for me to consider an award under s.10 of Reg 664

ORDER

53For the reasons above I find that:

i. The applicant is not entitled to an Income Replacement Benefit; ii. The applicant is not entitled to any of the disputed OCF-18s; iii. The applicant is not entitled to interest on overdue payments; iv. The applicant is not entitled to an award under s.10 of Reg 664; and v. This application is dismissed.