Licence Appeal Tribunal File Number: 23-013059/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:
Ji Kai Wang
Applicant
and
TD General Insurance Company
Respondent
DECISION
ADJUDICATOR: Laura Goulet
APPEARANCES:
For the Applicant: Anil Hampole, Counsel
For the Respondent: Crystal Law, Counsel
HEARD: By way of written submissions
OVERVIEW
1Ji Kai Wang, the applicant, was involved in an automobile accident on July 24, 2019, 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, TD General Insurance Company, 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 $3,875.12 for physiotherapy services proposed by Total Recovery Rehab Centre in a treatment plan/OCF-18 dated October 27, 2023?
ii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
iii. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant is not entitled to the treatment plan for physiotherapy services or interest.
4The respondent is not liable to pay 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.
The applicant is not entitled to the treatment plan for physiotherapy services
6The applicant has not demonstrated on a balance of probabilities that the treatment plan for physiotherapy services is reasonable and necessary.
7The plan was proposed by Ahmed Afifi, physiotherapist. The plan lists the following injuries as a result of the accident: other chronic pain, dislocation, sprain and strain of joints and ligaments at neck level, pain in thoracic spine, sprain and strain of thoracic spine, low back pain, dislocation, sprain and strain of joints and ligaments of lumbar spine and pelvis, radiculopathy, injury of muscles and tendons of anterior muscle group at lower leg level, dislocation, sprain and strain of joints and ligaments at ankle and foot level, difficulty in walking, not elsewhere classified, and abnormalities of gait and mobility.
8The plan proposes an initial assessment, sixteen sessions of physiotherapy, sixteen sessions of active therapy, sixteen sessions of massage therapy, and an initial assessment report. The goals of the plan are pain reduction, increased range of motion, increase in strength, to return to activities of normal living, and to return to modified work activities.
9The applicant refers to the clinical notes and records (“CNRs”) of Dr. Christopher Tan dated August 17, 2019, which indicate that the applicant was involved in a rear end motor vehicle accident on July 24, 2019, and that his lower back was still sore. Dr. Tan recommended physiotherapy.
10The applicant also refers to Mr. Afifi’s assessment on October 27, 2023, where he indicated on the proposed plan that the applicant had difficulty sleeping, low energy and fatigued quickly, had difficulty with some housekeeping tasks, had decreased standing and walking tolerance, was unable to do tasks that require heavy lifting and carrying, and was unable to do tasks that require repetitive bending and twisting.
11The applicant submits that the proposed plan is reasonable and necessary for his recovery and ought to have been approved by the respondent.
12I note that the applicant attended to see Dr. Tan or had phone consultations with Dr. Tan on November 4, December 2, and December 9, 2019, May 29, October 15, and December 2, 2021, and March 12, April 21, April 22, May 3, November 12, and December 3, 2022. During these consultations, there was no mention of the accident, and the applicant did not report back pain or any other injuries because of the accident. The only reference to the accident and to a complaint of back pain is in Dr. Tan’s CNRs dated August 17, 2019.
13The treatment plan on its own is not sufficient evidence in support of treatment. There is a significant gap in time between the applicant’s complaint of back pain to Dr. Tan on August 17, 2019, and Mr. Afifi’s assessment on October 27, 2023. The applicant does not direct me to any other medical evidence that corroborates the injuries listed in the proposed plan. As such, I find there is insufficient evidence of physical injuries caused by the accident that are contemporaneous with the proposed treatment plan. Further, the applicant does not make submissions with respect to how the goals of the proposed plan would be met to a reasonable degree and how the overall costs of achieving them are reasonable.
14For these reasons, I find that the applicant has not established on a balance of probabilities that the treatment plan for physiotherapy services is reasonable and necessary.
Interest
15Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since there are no overdue payments, no interest is ordered.
Award
16The 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. Since no benefits were unreasonably withheld, the applicant is not entitled to an award.
ORDER
17For the above reasons, I find:
i. The applicant is not entitled to the treatment plan for physiotherapy services or interest.
ii. The respondent is not liable to pay an award.
iii. The application is dismissed.
Released: August 19, 2025
Laura Goulet
Adjudicator