Debdub v. Pembridge Insurance Company, 2025 CanLII 81405

Debdub v. Pembridge Insurance Company

Citation: Debdub v. Pembridge Insurance Company, 2025 ONLAT 23-010769/AABS

Licence Appeal Tribunal File Number: 23-010769/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:

Saddam Debdub

Applicant

and

Pembridge Insurance Company

Respondent

DECISION

ADJUDICATOR: Kathleen Wells

APPEARANCES:

For the Applicant: Georgiana Masgras, Counsel

For the Respondent: Diana Oliveira, Counsel

HEARD: By way of written submissions

OVERVIEW

1Saddam Debdub, the applicant, was involved in an automobile accident on November 20, 2021, 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, Pembridge Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

ISSUES

Preliminary Issue:

2The preliminary issue to be decided is:

1. Is the applicant barred from proceeding with their claim for non-earner benefits (NEB) as they failed to submit a disability certificate (OCF-3) within the time prescribed in the Schedule?

Substantive Issues:

3The substantive issues to be decided in the hearing are:

1. Is the applicant entitled to a non-earner benefit of $185.00 per week from December 20, 2023 to ongoing?
2. Is the applicant entitled to $1,000.00 ($3,977.60 less $2,977.60 approved) for a psychological assessment, proposed by Joseph Paton and Judith Pilowski in a treatment plan dated February 25, 2022?
3. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
4. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

4I find that:

1. The applicant’s claim for an NEB is statute-barred under s. 36 because he did not submit a completed OCF-3 within 104 weeks of the accident.
2. The applicant is not entitled to the remaining amount of the treatment plan in dispute.
3. The applicant is not entitled to interest.
4. The applicant is not entitled to an award.
5. The application is dismissed.

PRELIMINARY ISSUE

5I find that the applicant’s claim is statute-barred under s. 36 of the Schedule.

6Section 12 of the Schedule provides that an insurer shall pay a NEB to an insured person who sustains an impairment as a result of an accident and suffers a complete inability to carry on a normal life as a result of that accident within 104 weeks. Sections 12(3)(a) and (c) further state that the insurer is not required to pay a NEB for the first four weeks after the onset of the disability and for any period more than 104 weeks after the accident.

7Section 36(2) of the Schedule provides that an insured person must submit a completed OCF-3 with their application for NEBs. Section 36(3) disentitles an applicant to NEBs for any period before the completed disability certificate is submitted. The respondent submits that the applicant is statute-barred under s. 36 from bringing an application for non-earner benefits because the applicant has not submitted an OCF-3.

8The applicant argues that he is entitled to an NEB because he meets the medical eligibility requirements to warrant an NEB. The applicant did not address s.36 in his submissions or direct me to any evidence that an OCF-3 had been submitted.

9Therefore, based on the evidence before me, I find on a balance of probabilities that the applicant did not submit an OCF-3 as required by s. 36.

10I agree with the respondent that s.36 does not provide any exceptions to the requirement that the applicant must submit a completed OCF-3, and that an insurer is not required to make payment until the application is complete. Accordingly, the applicant is statute barred from pursuing his application for an NEB.

11Therefore, I find that the applicant is statute-barred from bringing his claim for an NEB under s. 36 of the Schedule.

SUBSTANTIVE ISSUES

Is the applicant entitled to the remaining $1,000.00 for a Psychological Assessment in a treatment plan dated February 25, 2022?

12I find that the applicant has not established that he is entitled to the remaining $1000.00 for a psychological assessment in the treatment plan dated February 25, 2022.

13To 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.

14The treatment plan, prepared by Joseph Paton, chiropractor, of Meditecs Independent Medical Examinations, sets out $2,000.00 for a psychological assessment, $200.00 in document support fees for completing the form, and $320.00 for interpreter services, which were approved by the respondent. The remaining amount set out in the treatment plan is $1,000.00 for document support fees for “medical file review.”

15The applicant submits that he has suffered a psychological impairment as a result of the accident and is therefore entitled to the treatment plan. The respondent argues that there is no evidence to support a finding that the remaining amount is reasonable and necessary.

16I find that the applicant has not met his burden to prove on a balance of probabilities that the remaining $1,000.00 in the treatment plan for medical file review is reasonable and necessary, because the applicant has not addressed the cost of the medical file review nor provided supporting evidence to justify the $1,000 documentation support fee.

17Accordingly, the applicant is not entitled to the remaining $1,000.00 for a psychological assessment in the treatment plan dated February 25, 2022.

Interest

18Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no payments are owing, no interest is due.

Award

19The applicant sought an award under s. 10 of Reg. 664. Under s. 10, the Tribunal may grant an award of up to 50 per cent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits, however the applicant made no submissions with respect to an award. For this reason, and because no payments were unreasonably withheld or delayed, the applicant is not entitled to an award.

ORDER

20I find that:

1. The applicant’s claim for a NEB is statute-barred under s. 36 because he did not submit a completed OCF-3 within 104 weeks of the accident.
2. The applicant is not entitled to the remaining amount of the treatment plan in dispute.
3. The applicant is not entitled to interest.
4. The applicant is not entitled to an award.
5. The application is dismissed.