Citation and Parties

Citation: Abdi v. Co-operators General Insurance Company, 2025 ONLAT 23-003157/AABS Licence Appeal Tribunal File Number: 23-003157/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: Habiba Abdi (Applicant) and Co-operators General Insurance Company (Respondent)

Decision

Adjudicator: Bernard Trottier

Appearances: For the Applicant: Mohamed Doli, Counsel For the Respondent: Julianne Brimfield, Counsel

Heard: By Way of Written Submissions

OVERVIEW

1Habiba Abdi (the “applicant”) was involved in an automobile accident on July 30, 2022, 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 Cooperators General Insurance Company (the “respondent”) 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 attendant care benefits in the amount of $2110.12 per month, from February 2, 2023 to date and ongoing?
2. Is the applicant entitled to a non-earner benefit of $185.00 per week, from August 23, 2022 to date and ongoing?
3. Is the applicant entitled to $4,845.56 for chiropractic services, proposed by South Keys Health Centre in a treatment plan/OCF-18 (“plan”) dated February 12, 2023?
4. Is the applicant entitled to $2,095.25 for an in-home attendant care assessment, proposed by South Keys Health Centre in a plan dated January 29, 2023?
5. Is the applicant entitled to $3,890.80 for occupational therapy services, proposed by South Keys Health Centre in a plan dated February 2, 2023?
6. Is the applicant entitled to $5,876.00 for a chronic pain assessment, proposed by Humber River Medical Diagnostics in plan dated June 20, 2023?
7. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

3For the reasons that follow, I find that:

1. The applicant is not entitled to attendant care benefits.
2. The applicant is not entitled to a non-earner benefit.
3. The applicant is not entitled to the disputed treatment plans.
4. The applicant is not entitled to interest.

ANALYSIS

The applicant is not entitled to attendant care benefits

4I find that the applicant has failed to prove on a balance of probabilities that she is entitled to attendant care benefits (“ACBs”) in the amount of $2,110.12 per month, from February 2, 2023 to date and ongoing.

5Section 19 of the Schedule states that an insurer shall pay for all reasonable and necessary expenses incurred by or on behalf of an insured person as a result of an accident for ACBs provided by an aide or attendant. Section 42(1) of the Schedule provides that an application for ACBs must be in the form of, and contain the information required to be provided in, a document entitled Assessment of Attendant Care Needs (“Form 1”).

6The applicant submits that she is entitled to attendant care benefits based on an in-home attendant care assessment conducted by Ms. Saoussen Ataya, occupational therapist (“OT”) with South Keys Health Centre, on January 23 and 24, 2023. Ms. Ataya recommended attendant care in an OT in-home assessment report and Form 1, both dated January 30, 2023. In her assessment, Ms. Ataya observed that the applicant had difficulty standing for more than five minutes and was completely unable to crouch, kneel or squat due to physical limitation and pain. In her Form 1, Ms. Ataya recommended attendant care assistance as follows:

Activity	Minutes per Week
Grooming: shaving and hair care	155
Preparing, serving and feeding meals	630
Assistance in walking	180
Bathroom hygiene, bedroom cleaning and clothing care	360
Coordination of attendant care	30
Assistance with exercise/stretching program	420
Bathing	35
Total	1,810

7The recommended times above resulted in an estimated attendant care requirement of 129.7 hours per month. When multiplied by the hourly rates in the Schedule for each category of activity, the value of ACBs calculated by Ms. Ataya is $2,110.12 per month.

8The applicant submits that the insurer’s examination (“IE”) report of Dr. Abdul-Wahab Khan, physiatrist, dated January 9, 2023, supports the applicant’s position that she is entitled to ACBs. The applicant submits that Dr. Khan’s report states that the applicant had limited range of motion in her neck, shoulders and lumbar spine and that the applicant’s strength was reduced globally due to pain.

9The applicant submits further that the IE report of Dr. Cindi Goodfield, psychologist, dated January 9, 2023, supports the applicant’s position that she is entitled to ACBs when Dr. Goodfield noted that the applicant’s psychological conditions were reactive to her physical symptoms as the applicant reported that she was in constant pain.

10In addition, the applicant submits that her attendant care needs are supported by the opinion of Dr. Hien Ta, chronic pain specialist, who noted in his report of October 5, 2023 that the applicant is very limited in her self-care, home-making and housekeeping activities due to chronic pain and post-concussion symptoms.

11In response to the Form 1 and medical records submitted by the applicant, the respondent requested paper-review IEs by Dr. Khan and Dr. Goodfield, as well as an in-home attendant care assessment by Ms. Amanda Boyd, OT. The paper-review reports of Dr. Khan and Dr. Goodfield are both dated March 8, 2023. Ms. Boyd assessed the applicant on March 7, 2023 and provided her responsive attendant care assessment report and Form 1 on April 3, 2023.

12Dr. Khan had previously conducted the in-person physiatry IE mentioned above on November 16, 2022. Dr. Goodfield had previously conducted the in-person psychological IE mentioned above on December 6, 2022. The earlier in-person IEs were requested to determine whether the applicant was entitled to treatment outside of the Minor Injury Guideline (“MIG”), to non-earner benefits (“NEBs”) and to a treatment plan for psychological services. Following the IEs, the applicant was removed from the MIG due to an adjustment disorder diagnosis of Dr. Goodfield. Dr. Khan opined that the applicant’s physical injuries were “minor” as defined by the Schedule and did not require treatment outside of the MIG.

13The respondent submits that the applicant’s self-reports to Dr. Khan and Dr. Goodfield, on her self-care, parenting, studying and home-making activities, are inconsistent with the requested level of attendant care of Ms. Ataya’s Form 1. The respondent relies on the applicant’s reports to Dr. Khan that, post-accident, she had returned to light housekeeping chores and was generally independent with personal care, ambulation, transfers and driving. The respondent relies also on the reports to Dr. Goodfield that, post-accident, she had returned to light housekeeping, cooking, preparing her children’s lunches and driving, and was largely independent in self-care. In particular, the respondent submits that it is difficult to accept that a person with attendant care needs as described in Ms. Ataya’s Form 1 would continue full-time studies to become a nurse.

14In his paper-review report of March 8, 2023, Dr. Khan opined that the applicant did not require further treatment for her soft tissue injuries and that she did not require attendant care services because the applicant had no objective accident-related physical impairments or ongoing musculoskeletal pathology, consistent with his findings during his previous examination.

15In her paper-review report of March 8, 2023, Dr. Goodfield opined that the applicant’s adjustment disorder did not necessitate attendant care services, because the applicant had resumed those activities she feels physically capable of managing.

16In her report dated April 3, 2023, Ms. Boyd noted that the applicant demonstrated sub-maximal effort during the assessment and declined most physical tasks that she was requested to demonstrate. In her formal musculoskeletal assessment, Ms. Boyd noted that the applicant was observed to have limited range of motion with all movements. However, Ms. Boyd observed during informal testing and movement around the house that the applicant was functional with all movements. As a result, Ms. Boyd assessed that the applicant’s range of motion was “functional”. Ms. Boyd concluded that the applicant demonstrated the range of motion and strength necessary to complete the majority of her personal care tasks. Ms. Boyd prepared a Form 1 proposing $0.00 per month for ACBs.

17The applicant argues that the respondent provided two contradictory reports by Ms. Boyd after the in-home attendant care assessment of March 7, 2023. The applicant argues that the “first report”, dated April 3, 2023, opines that the applicant would benefit from 10 weeks of OT services to assist with pain management and to improve her function. The applicant argues that Ms. Boyd’s “revised report” of April 17, 2023 opines that the applicant does not require any further OT services. The applicant notes that she received both the first report and the revised report on April 17, 2023.

18The applicant posits that the respondent hid the first report and asked Ms. Boyd to revise her report, noting that Ms. Boyd completely changed her opinion on whether the applicant required any further OT services between the two reports. She notes further that this apparent change of opinion was not based on any further assessments. The applicant posits that the change of opinion was groundless and argues that Ms. Boyd’s reports should be disregarded due to the inconsistencies between the two reports.

19The respondent admits that Ms. Boyd’s first report opined that the applicant would benefit from OT services to assist with pain management and functional improvement, but that it also opined that the treatment plan for OT services was not reasonable and necessary because the applicant had demonstrated functional improvement and strength required for daily tasks. The respondent notes that both the first report and the revised report opine that the applicant did not require any attendant care. The respondent submits that the revised report merely corrected the internal inconsistency in the first report.

20I am not persuaded by the applicant’s argument that the respondent aimed to hide the inconsistency in Ms. Boyd’s first report and that her opinion should be given less weight. I am persuaded by the respondent’s argument that a revised report was issued to correct the internal inconsistency in the first report. For that reason, I accept that the revised report is an accurate reflection of Ms. Boyd’s opinion on the applicant’s entitlement for ACBs.

21I find that the applicant has not demonstrated that she requires the ACBs described in the Form 1 of Ms. Ataya because the reported attendant care needs are contradicted by the applicant’s self-reports to Dr. Khan and Dr. Goodfield. I find that Ms. Ataya’s assessment of the need for attendant care assistance with bathroom/bedroom cleaning, laundry and meal preparation is inconsistent with the applicant’s reports to Dr. Khan and Dr. Goodfield that she had resumed light housekeeping, cooking and preparing her children’s lunches.

22I assign more weight to the report of Ms. Boyd than to that of Ms. Ataya since Ms. Boyd’s assessment is consistent with the medical evidence before me, namely that the applicant’s musculoskeletal injures were minor. I am persuaded by Ms. Boyd’s observations that the applicant had the necessary range of motion and strength to complete the tasks identified on Ms. Ataya’s Form 1 and that the applicant appeared to exaggerate her attendant care needs.

23I find that the applicant did not meet the burden of proving that she was entitled to any ACBs beyond February 2, 2023. The applicant’s self-reports to IE assessors and the findings of Ms. Boyd persuade me that the applicant’s recovery was such that she was able to perform most self-care and household duties without assistance.

24I find as well that the applicant did not provide any evidence that she incurred any attendant care services, or that a caregiver sustained an economic loss to provide attendant care services before they were denied by the respondent.

25As with all benefits defined by the Schedule, the burden lies with the applicant to prove entitlement to benefits. I find that the applicant has not met her burden. For the reasons above, I find that on a balance of probabilities the applicant is not entitled to any ACBs.

The applicant is not entitled to a non-earner benefit

26I find that the applicant has failed to prove on a balance of probabilities that she is entitled to a non-earner benefit (“NEB”) of $185.00 per week, from February 2, 2022 to date and ongoing.

27Section 12(1) provides that an insurer shall pay an NEB to an insured person who sustains an impairment as a result of the accident, if the insured person suffers a complete inability to carry on a normal life as a result of and within 104 weeks after the accident. Section 3(7)(a) defines a “complete inability to carry on a normal life” as “an impairment that continuously prevents the person from engaging in substantially all of the activities in which the person ordinarily engaged before the accident.” The Court of Appeal set out the guiding principles for NEB entitlement in Heath v. Economical (2009 ONCA 391) (“Heath”) which, generally, focuses on a comparison of the applicant’s pre- and post-accident activities.

28At the time of the accident, the applicant was enrolled in summer classes for the second year of a two-year registered practical nurse program at Collège La Cité in Ottawa. On August 5, 2022 (seven days post-accident), the applicant visited the emergency department of the Ottawa Hospital Civic Campus, where she was diagnosed with a concussion. On August 23, 2022, Dr. Benjamin Matheson, chiropractor, prepared a Disability Certificate/OCF-3 indicating that the applicant suffered a complete inability to carry on a normal life.

29The applicant submits that pre-accident she was basically healthy and was actively engaged in parenting, household chores, studies and community / recreational activities. The applicant submits that since the accident, she has great difficulty performing her daily activities due to her physical and psychological impairments.

30The applicant submits that the accident affected her ability to pursue her studies at Collège La Cité and that she required accommodations such as more time for examinations and lab sessions, reduced lighting and allowances for sitting instead of standing.

31In support of her argument for entitlement to an NEB, the applicant directs me to the clinical notes and records (“CNRs”) of Christine Derouin, nurse practitioner with the Carlington Community Health Centre (“CHCC”), where she notes on November 23, 2022 that the applicant showed symptoms of concussion including headache, neck pain, photophobia, phonophobia, fatigue, dizziness and difficulty with concentrating, memory and sleeping. As a result, Ms. Derouin referred the applicant to the Ottawa Headache Centre for a neurological assessment.

32In addition, the applicant submits the following medical evidence in support of her argument for entitlement to an NEB:

1. The OT in-home assessment report of Ms. Ataya, dated January 30, 2023.
2. A treatment and injury report of Dr. Matheson, dated February 8, 2023;
3. CNRs of the emergency department at the Ottawa Hospital Civic Campus, dated February 8, 2023;
4. CNRs of the CCHC, from several years pre-accident to December 14, 2023;
5. CNRs of the South Keys Health Centre, from February 1, 2023 to September 1, 2023; and
6. The chronic pain assessment report of Dr. Ta, dated October 5, 2023.

33The respondent submits that the applicant’s submissions do not address the criteria for entitlement to an NEB as described in Heath. The respondent argues that the applicant has not presented any first-hand evidence of her pre- and post-accident activities that would indicate that she is unable to engage in substantially all of her pre-accident activities.

34The respondent argues that the applicant reported “difficulty” with various parenting, self-care and housekeeping tasks in the assessment reports and CNRs that she submitted as evidence, but that she did not demonstrate a “complete inability to carry on a normal life”. The respondent argues further that the applicant has not demonstrated “an impairment that continuously prevents the person from engaging in substantially all of the activities in which the person ordinarily engaged before the accident”.

35In support of its arguments, the respondent relies on the applicant’s report to Dr. Khan, on November 16, 2022, where she stated that she did not miss any time from her nursing program post-accident and she reported having continued with most of her pre-accident activities including driving, self-care and light housekeeping.

36The respondent also relies on the applicant’s report to Dr. Goodfield, on December 6, 2022, where she reported that her typical day post-accident involved completing prayers, preparing her children’s lunches and dinner, going to classes, caregiving and doing her own homework and helping her children with theirs.

37In her reply submissions, the applicant argues that the Schedule does not require that a student must be unable to continue with their studies to be entitled to a non-earner benefit. She argues that her studies have been dramatically affected by her injuries, and that even with accommodations her program has been delayed.

38The applicant’s reports to the IE assessors persuade me that the applicant does not have an impairment that continuously prevents her from engaging in substantially all of her pre-accident activities. I find that the considerable medical evidence provided by the applicant does not demonstrate that the applicant had a complete inability to carry on a normal life as a result of the accident.

39Specifically, I find the applicant was able to carry on her nursing studies (albeit delayed and with accommodations), prepare meals, perform light housekeeping, drive and provide caregiving for her children. While not exhaustive, I find that this list of activities is substantial and demonstrates that the applicant was not prevented from engaging in substantially all of the activities in which she ordinarily engaged before the accident. I find that these post-accident activities persuade me that the applicant does not suffer from a “complete inability to carry on a normal life”.

40Based on the evidence before me, I find that the applicant has not met her burden in establishing that she meets the test of entitlement to an NEB. As a result, she is not entitled to an NEB.

The applicant is not entitled to the proposed chiropractic treatment plan

41I find that the applicant has failed to prove on a balance of probabilities that she is entitled to chiropractic services totalling $4,845.56, proposed by South Keys Health Centre in a treatment plan dated February 12, 2023.

42To 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.

43The applicant submits that she suffers from ongoing physical impairments that warrant further chiropractic treatment. The applicant submits that her nurse practitioner, Ms. Derouin, in her CNRs of November 23, 2022, notes that the applicant did not feel that medication was helpful for pain or sleep.

44The applicant submits further that the applicant’s treating chiropractor, Dr. Matheson, noted on February 1, 2023 that the applicant had been experiencing severe pain, hence the proposed treatment plan.

45The respondent submits that in his physiatry IE report of January 9, 2023, Dr. Khan opined that the applicant suffered soft tissue injuries and that his diagnosis was consistent with that of Ms. Derouin, who had not made any referrals to a physical medicine specialist at that time. The respondent submits as well that there is no evidence that the applicant attended Ms. Derouin’s referral to the Ottawa Headache Centre or that she was referred to a neurologist.

46In his paper-review report of March 8, 2023, Dr. Khan opined that the applicant did not require any further treatment for her soft tissue injuries, and that the proposed treatment plan was not reasonable and necessary. The respondent argues that the applicant has not obtained an expert opinion from a physician that comments on the reasonableness and necessity of the proposed treatment plan. The respondent argues that the treatment plan, in and of itself, is insufficient to establish the criteria for reasonableness and necessity.

47I find that the applicant has provided insufficient corroborating evidence, apart from the opinion of Dr. Matheson, on the goals of the proposed treatment, how the goals would be met to a reasonable degree and that the overall costs of achieving them are reasonable. I assign less weight to the opinion of Dr. Matheson because of the self-interest he would have in providing the proposed services. I find that the applicant’s mention to her nurse practitioner, that medication was ineffective for her pain, does not persuade me that further chiropractic treatment is reasonable and necessary given other therapeutic alternatives.

48I prefer the opinion of Dr. Khan over that of Dr. Matheson, because Dr. Khan’s opinion is consistent with the independent reports of The Ottawa Hospital and the CCHC. These reports agree with Dr. Khan’s assessment that the applicant suffered soft tissue injuries. I find the applicant has provided insufficient reasons from an independent health practitioner for the cost of the treatment plan at that point in her recovery.

49For the reasons above, I find on a balance of probabilities that the applicant has not demonstrated that the proposed treatment plan for chiropractic services is reasonable and necessary.

The applicant is not entitled to the proposed in-home attendant care assessment

50I find that the applicant has failed to prove on a balance of probabilities that she is entitled to an in-home attendant care assessment for $2,095.25, proposed by South Keys Health Centre in a plan dated January 29, 2023.

51As with any treatment or assessment plan, 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.

52In support of her argument that an in-home attendant care assessment is reasonable and necessary, the applicant relies on the attendant care assessment report of Ms. Ataya, dated January 30, 2023 and the chronic pain assessment report of Dr. Ta dated October 5, 2023.

53Ms. Ataya opined that the applicant required significant attendant care as described in her report and Form 1. Dr. Ta noted that the applicant was very limited in her activities of daily living including self-care, home-making and housekeeping, which the applicant argues is corroborating evidence that the applicant required attendant care.

54In response to the proposed attendant care assessment, the respondent requested the above-mentioned paper-review IE reports from Dr. Khan and Dr. Goodfield, as well as its own IE attendant care assessment by Ms. Boyd. All three IEs opined that the applicant was not entitled to the ACBs proposed in Ms. Ataya’s Form 1, and that she was not entitled to the attendant care assessment.

55The respondent argues that the applicant has the burden to establish that she requires the services sought, not the respondent to disprove it. The respondent argues that the applicant has not provided corroborating medical evidence to advance her claim that an attendant care assessment was reasonable and necessary because, it argues further, the applicant’s written submissions merely critique Ms. Boyd for having submitted a revised report.

56I find that the report of Ms. Ataya, by itself, is insufficient to prove that the assessment was reasonable and necessary since it would be tautological to say that the ensuing report is proof of its necessity. I must turn to the argument advanced by the applicant that the chronic pain assessment of Dr. Ta corroborates that the attendant care assessment is reasonable and necessary. In her submissions, the applicant did not direct me to any other specific medical evidence that an attendant care assessment was reasonable and necessary.

57In his report, Dr. Ta notes that changes occurred to the applicant’s functions post-accident. He notes that due to the accident she has lost some patient care training in her nursing program and has delayed her graduation. In addition, he notes the applicant’s reported difficulties with self-care, housekeeping and recreational activities, quoting the assessment of Ms. Ataya.

58In his report, Dr. Ta notes the applicant’s self-rating on a pain disability index on a scale of 0 to 10 to measure the degree to which aspects of her life are disrupted by chronic pain, where 0 indicates no disability and 10 indicates the worst possible disability. The appliance rates her pain disability as 10 out of 10 for recreational and occupational activities, and 9 out of 10 for family/home responsibilities, social activity and self-care.

59I find that the report of Dr. Ta is unpersuasive in providing corroboration to the reasonableness and necessity of an attendant care assessment. I find the applicant’s self-reports of her pain levels and functional impacts are inconsistent with the CNRs of the applicant’s nurse practitioner, Ms. Derouin, as well as with her reports to the IE assessors. For this reason, I assign the report of Dr. Ta less weight in assessing her functional abilities.

60I find that the applicant has not met her burden in demonstrating that the proposed in-home attendant care assessment is reasonable and necessary. I find that the applicant did not provide sufficient corroborating medical evidence that demonstrated how the goals of the assessment would be met to a reasonable degree and that the overall costs of achieving them are reasonable.

61For the reasons above, I find on a balance of probabilities that the applicant has not demonstrated that the proposed treatment plan for an in-home attendant care assessment is reasonable and necessary.

The applicant is not entitled to the proposed OT services

62I find that the applicant has failed to prove on a balance of probabilities that she is entitled to OT services totalling $3,890.80 proposed by South Keys Health Centre in a plan dated February 2, 2023

63The applicant submits that she required OT services to help manage her home environment due to the injuries suffered in the accident. The applicant’s main argument for her entitlement to OT services is that Ms. Boyd’s first report, mentioned earlier, indicated that the applicant would benefit from OT services to assist her with pain management and to improve her function. Ms. Boyd’s first report stated that OT treatment should be provided on a weekly basis for 10 weeks.

64The respondent submits that Ms. Boyd’s revised report, sent to the applicant on same date as the first report (April 17, 2023), corrects the inconsistency that was identified in the first report. The respondent submits that the revised report is an accurate reflection of Ms. Boyd’s opinion. As I found earlier, I accept the respondent’s submission on the validity of the revised report because, in her first report, Ms. Boyd opined that the treatment plan for OT services was not reasonable and necessary. In both the first and revised reports, Ms. Boyd opined that OT services were not reasonable and necessary because the applicant had demonstrated functional improvement and strength required for daily tasks.

65I assign little weight to the inconsistency in Ms. Boyd’s first report as a demonstration of the applicant’s entitlement to the proposed OT services.

66The respondent submits that, based on Dr. Khan’s opinion in his paper-review report dated March 8, 2023, the applicant did not require further treatment for her soft tissue injuries and therefore did not require the requested OT services.

67The respondent submits as well, based on Dr. Goodfield’s opinion in her paper-review report dated March 8, 2023, that the applicant did not require OT services due to her diagnosed adjustment disorder.

68I find the lack of corroborating medical evidence, such as a recommendation from the applicant’s nurse practitioner, leads me to assign less weight to Ms. Ataya’s report than to the opinions of Ms. Boyd, Dr. Khan and Dr. Goodfield.

69For the reasons above, I find on a balance of probabilities that the applicant has not met her burden of demonstrating that the proposed treatment plan for OT services is reasonable and necessary.

The applicant is not entitled to the proposed chronic pain assessment

70I find that the applicant has failed to prove on a balance of probabilities that she is entitled to a chronic pain assessment for $5,876.00 proposed by Humber River Medical Diagnostics in a plan dated June 7, 2023.

71On June 15, 2023, the applicant was assessed by Dr. Ta for chronic pain. An OCF-18 for the assessment was submitted to the respondent on June 20, 2023 and the assessment plan was denied on July 4, 2023.

72In his report, Dr. Ta opines that the applicant suffers from:

1. Chronic pain syndrome;
2. Whiplash associated disorder of the neck and lower back (WAD3), with radiation down the left arm;
3. Myofascial pain of the left shoulder girdle;
4. Cervical neck pain with left radiculopathy down the left arm;
5. Post-concussion syndrome;
6. Post-traumatic headaches from concussion versus cervicogenic versus post-traumatic migraines features;
7. Left greater occipital nerve pain on palpation which may exacerbate headaches; and
8. Underlying mood disorder on initial screening questionnaire for depression, anxiety, and post-traumatic stress disorder.

73To treat the applicant’s chronic pain diagnosis, Dr. Ta recommended injection of her greater occipital nerve and sacroiliac joints for headache relief and lower back pain. The applicant submits that the chronic pain assessment should be approved because of her ongoing complaints of pain from the date of the accident to the date she was assessed by Dr. Ta.

74The applicant submits that her pain complaints are supported by the CNRs of Ms. Derouin of CCHC, Dr. Matheson and Rima Patel, physiotherapist, (both of South Keys Health Centre) and The Ottawa Hospital.

75The respondent submits a treatment plan in and of itself is insufficient to establish that the treatment or assessment is reasonable and necessary. The respondent argues that the Tribunal finds that generally there must be other evidence available to corroborate the need for the treatment plan, citing 16-001539 v Wawanesa Mutual Insurance Company, 2017 CanLII 82039 (ON LAT) (“Wawanesa”).

76The respondent submits that there was no evidence from the applicant’s nurse practitioner, Ms Derouin, to support the need for a chronic pain assessment. The respondent submits that Ms. Derouin does not refer to any chronic pain symptoms as described by the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 6th Edition, 2008 (the “AMA Guides”) for chronic pain, criteria that are generally accepted by the Tribunal.

77Although Dr. Ta diagnosed the applicant with chronic pain syndrome, the applicant did not direct me to specific examples of functionally disabling pain in Dr. Ta’s report. I find as well that in her submissions the applicant did not direct me to specific examples of functionally disabling pain, as described by the AMA Guides, in the CNRs of Ms. Derouin, South Keys Health Centre or The Ottawa Hospital. I do not find that the weight of the evidence before me indicates that the applicant is functionally disabled by pain.

78Lastly, the respondent submits that the applicant is silent in her submissions on why the chronic pain assessment is proposed to cost $5,876.00, which is more than the $2,000.00 cap per assessment in the Schedule. The respondent argues that the applicant made no submissions on whether this type of assessment could be pursued through an OHIP-funded provider. The respondent submits as well that the applicant did not pursue the CCHC’s referral to the Ottawa Headache Centre for a neurological assessment. The respondent argues that the applicant has not demonstrated that the overall costs of achieving the goals of the assessment are reasonable compared to alternatives.

79I find that the applicant did not direct me to any specific evidence of corroborating chronic pain symptoms as described in the AMA Guides, from a practitioner other than Dr. Ta, that would persuade me that the chronic pain assessment was reasonable and necessary.

80For the reasons above, I find on a balance of probabilities that the applicant has not met her burden of demonstrating that the proposed treatment plan for a chronic pain assessment is reasonable and necessary.

Interest

81Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Given that no benefits are overdue, no interest is payable.

ORDER

82For the reasons above, I find that:

1. The applicant is not entitled to attendant care benefits.
2. The applicant is not entitled to a non-earner benefit.
3. The applicant is not entitled to the disputed treatment plans.
4. The applicant is not entitled to interest.

83The application is dismissed.