Licence Appeal Tribunal File Number: 23-013688/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:
Ferdos Hamoud
Applicant
and
Allstate Insurance Company of Canada
Respondent
DECISION
ADJUDICATOR:
Robert Rock
APPEARANCES:
For the Applicant:
Anne Jayatilake, Counsel
For the Respondent:
Bryn Copp, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Ferdos Hamoud, the applicant, was involved in an automobile accident on December 24, 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, 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:
i. Is the applicant entitled to $2,907.44 for chiropractic services, proposed by Spinetec Health Care Solutions in a treatment plan/OCF-18 (“treatment plan”) dated October 27, 2023?
ii. Is the applicant entitled to $2,052.15 for chiropractic services, proposed by Spinetec Health Care Solutions in a treatment plan dated October 27, 2023?
iii. Is the applicant entitled to $774.18 ($7,255.51 less $6,481.33 approved) for psychological services, proposed by Mariam Naji in a treatment plan dated January 9, 2023?
iv. Is the applicant entitled to the assessments proposed by Meditecs HM IME, as follows:
(1) $2,881.50 for a neurological assessment, in a treatment plan dated October 27, 2023; and
(2) $2,881.50 for a chronic pain assessment, in a treatment plan dated October 27, 2023?
v. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
vi. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant has not proven on a balance of probabilities that the treatment plans in dispute are reasonable and necessary.
4The applicant is not entitled to interest or an award.
ANALYSIS
5To 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.
Two Chiropractic Services Treatment Plans
6The applicant has not proven on a balance of probabilities that the two chiropractic services treatment plans are reasonable and necessary.
7The goals of both treatment plans are pain reduction, increased range of motion, increase in strength, return to activities of normal living and both active and passive care.
8The first treatment plan for $2907.44 included 24 sessions of manipulation, multiple body sites, and documentation. The second treatment plan for X included 15 sessions of manipulation, multiple body sites, topical pain relief, and documentation.
9The applicant did not provide any submissions as to why either of these chiropractic services treatment plans are reasonable and necessary. I have also not been pointed to medical evidence that corroborates that the treatment plans are reasonable and necessary, outside of the treatment plans themselves. The applicant has not explained how the goals of the treatment plans would be met, or why two treatment chiropractic treatment plans were necessary as they were both submitted on October 27, 2023. Therefore, I find that the applicant has not met her onus.
10The applicant has not proven on a balance of probabilities that the two chiropractic treatment plans at issue are reasonable and necessary.
Psychological Service Treatment Plan
11The applicant has not proven on a balance of probabilities that she is entitled to the outstanding balance in the psychological service treatment plan.
12The outstanding balance is comprised of planning service, documentation support, and assessment, mental health, and addictions.
13The applicant has not made any submissions as to why these three activities in the treatment plan are reasonable and necessary and nor has the applicant pointed me to any evidence in support of the treatment plan. Therefore, I find she has not met her onus.
14The applicant has not proven on a balance of probabilities that she is entitled to the outstanding balance in the psychological services treatment plan.
Neurological Assessment
15The applicant has not proven on a balance of probabilities that the neurological assessment is reasonable and necessary.
16The applicant has not made any submissions as to why this neurological assessment is reasonable and necessary. I have not been directed to any specific medical evidence that would support the need for a neurological assessment. Therefore, I find that the applicant has not met her onus.
17Further, in my review of the CNRs of Dr. Stephenson, the applicant’s family doctor, I note that the applicant has a pre-existing complaint regarding headaches. The CNRs do not indicate that these headaches were as a result of the subject accident. The testing completed in association with the headache related complaints was sinus related.
18The applicant has not proven on a balance of probabilities that the neurological assessment at issue is reasonable and necessary.
Chronic Pain Assessment
19The applicant has not proven on a balance of probabilities that the chronic pain assessment is reasonable and necessary.
20The applicant has not made any submissions as to why this neurological assessment was reasonable and necessary. I have not been directed to any medical evidence that would support the need for a chronic pain assessment. Therefore, I find that the applicant has not met her onus.
21Further, in my review of the CNRs of Dr. Stephenson, I note that there is no reporting of ongoing pain, or of chronic pain. There are no referrals in the CNRs to any pain clinics.
22The applicant has not proven on a balance of probabilities that the chronic pain assessment at issue is reasonable and necessary.
Interest
23Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As there are no overdue benefit payments, no interest is owing.
Award
24The 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. As no benefit payments have been unreasonably withheld or delayed, the respondent is not liable to pay an award.
ORDER
25I find that:
i. The applicant is not entitled to treatment plans in dispute.
ii. The applicant is not entitled to interest or an award.
iii. The application is dismissed.
Released: August 11, 2025
Robert Rock
Adjudicator