Licence Appeal Tribunal File Number: 23-013199/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:
Areeb Pasha
Applicant
and
Aviva General Insurance
Respondent
DECISION
ADJUDICATOR: Harouna Saley Sidibé
APPEARANCES:
For the Applicant: Maria Papadopoulos, Paralegal
For the Respondent: Alicia Edwards, Counsel
HEARD: By way of written submissions
OVERVIEW
1Areeb Pasha, the applicant, was involved in an automobile accident on July 11, 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 the respondent, Aviva General Insurance, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issues in dispute are:
Is the applicant entitled to the services and treatments proposed by Alma Rehab, as follows: i. $3,244.58 for chiropractic services, in an OCF-18/treatment plan (treatment plan) submitted February 8, 2023; ii. $2,912.56 for chiropractic services, in a treatment plan submitted June 1, 2023; iii. $2,912.56 for chiropractic services, in a treatment plan submitted August 5, 2023; and iv. $1,848.83 for psychological treatment, in a treatment plan submitted January 12, 2024?
Is the applicant entitled to the assessments proposed by Ontario Independent Assessment Centre, as follows: i. $2,350.00 for a chronic pain assessment, in a treatment plan dated March 6, 2023;
Is the applicant entitled to interest on any overdue payment of benefits?
3In his submissions, the applicant withdrew several issues identified in the Case Conference Report and Order (“CCRO”) dated May 6, 2024. These are entitlement to an income replacement benefit of $209.46 per week from May 1, 2023, ongoing, and funding for the following assessments proposed by Ontario Independent Assessment Centre: a functional abilities evaluation ($1,850.00), a cognitive assessment ($1,950.00), an orthopedic assessment ($2,350.00), a devices IHAC assessment ($2,668.18), a biopsychosocial assessment ($2,000.00), a fitness membership assessment ($2,618.20), and an EMG assessment ($2,618.20).
4The hearing proceeded only on the remaining issues regarding the plans for chiropractic services, psychological services, and chronic pain assessment, as well as the issue of interest as set out above.
RESULT
5For the reasons below, I find that:
- The applicant is entitled to the chronic pain assessment treatment plan, with interest pursuant to s. 51.
- The applicant is not entitled to the remaining disputed treatment plans.
ANALYSIS
6To 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.
Is the applicant entitled to the treatment plans for chiropractic services?
7I find that the treatment plans dated February 8, 2023 ($3,024.62), June 1, 2023 ($2,741.48), and August 5, 2023 ($1,746.92) are not reasonable and necessary.
8The treatment plans submitted by Alma Rehab include a variety of services such as acupuncture, chiropractic care, physiotherapy, massage therapy, functional exercise, and spinal manipulation. The stated goals of these plans are to reduce pain, improve range of motion and strength, and facilitate a return to activities of daily living.
9The applicant asserts that the proposed plans are reasonable and necessary to manage ongoing neck and back pain caused by the accident. He references clinical notes that document a reduced range of motion, pain scores, and functional limitations.
10The respondent disputes the necessity of the plans, citing a section 44 insurer’s examination conducted by Dr. Alan Kruger, a physician, on March 9, 2023. Dr. Kruger stated that the applicant’s range-of-motion limitations resulted from self-limiting behaviour and were not supported by objective neurological findings. The respondent also references surveillance footage from April 2023 showing the applicant performing activities such as lifting, bending, squatting, and walking his dog without visible difficulty.
11I have reviewed the clinical notes and records (“CNR”s) from the applicant’s treating physicians. Many of the complaints documented in these records are unrelated to the accident, including dermatological issues (see, for example, CNR dated January 28, 2023).
12The imaging reports do not support the need for chiropractic treatment. On December 2, 2022, Dr. Taha Bandukwala, a radiologist, found no significant abnormalities. Importantly, there is no indication that Dr. Bandukwala recommended chiropractic care. Similarly, the July 9, 2023, CNR by Dr. Andrew Peppin reported an essentially normal study, with no evidence of disc herniation, extrusion, or central spinal canal stenosis. Dr. Peppin did not recommend chiropractic services. On February 13, 2023, Dr. Eran Hayeems also reported normal findings in the vertebral bodies and conus medullaris. As with the other radiologists, Dr. Hayeems did not suggest chiropractic treatment.
13The applicant was initially evaluated by Dr. Bahauddin Danial, a family physician, on July 23, 2022. Dr. Danial diagnosed possible lumbosacral and cervical strain and recommended massage therapy, physiotherapy, and mobility exercises. There was no indication that chiropractic treatment was recommended.
14On November 24, 2022, and again on February 24, 2023, Dr. Sanja Paleksic, a physical medicine and rehabilitation physician, observed ongoing stiffness and diffuse body pain, attributing the worsening condition to a lack of appropriate treatment. The doctor emphasized the importance of both passive and active modalities. There is no indication that chiropractic treatment was included among the recommended interventions.
15On June 20, 2023, neurologist Dr. Viachislav Prigozhikh reported that the applicant remained symptomatic 11 months after the accident, with a guarded outlook for full recovery. Dr. Prigozhikh noted ongoing symptoms including neck pain, neuropathic complaints, and lumbar discomfort. He recommended home neck exercises, treatment for neuropathy, and using a lumbar brace, but did not endorse chiropractic care services.
16Dr. Kruger’s insurer examination on March 3, 2023, acknowledged the applicant’s ongoing symptoms but concluded that they were consistent with uncomplicated soft tissue injuries. He found no significant musculoskeletal or neurological impairments and opined that the applicant had reached maximum medical improvement (“MMI”).
17Dr. Kruger reaffirmed his opinion in a review paper dated March 9, 2023. In an addendum dated June 20, 2023, he reiterated that the applicant’s injuries were uncomplicated soft tissue injuries and did not require additional treatment such as a fitness membership or personal training. There is no indication that chiropractic treatment was recommended.
18Considering the whole evidence, the treatment plans submitted by Alma Rehab are not supported as reasonable or necessary. Although the applicant reports ongoing symptoms, the objective medical evidence, including multiple imaging studies and assessments by both treating and independent medical professionals, does not substantiate the need for continued extensive physical therapy. Notably, none of these professionals recommended chiropractic services.
19While some treating physicians have recommended ongoing therapy, I place greater weight on Dr. Kruger’s opinion that the applicant has reached MMI and that the injuries are soft tissue in nature, without significant impairment. Although physical therapy was recommended by two physicians, those recommendations do not appear to be contemporaneous with the treatment plans under review, and none of the physicians recommended chiropractic care.
20Accordingly, on a balance of probabilities, I find that the chiropractic treatment plans are not reasonable and necessary.
Is the applicant entitled to the treatment plan for psychological services?
21I find that the psychological treatment plan dated January 12, 2024, for the amount of $1,848.83, is neither reasonable nor necessary.
22The plan recommends 12 psychological therapy sessions aimed at treating symptoms of depression, anxiety, and post-traumatic stress.
23The applicant asserts that the accident either caused or worsened psychological conditions, including major depressive disorder, anxiety, and PTSD. He supports this with reports from Dr. Susan Mackenzie, a psychiatrist (May 9, 2023), diagnosing major depressive disorder with anxious distress, and Dr. Prakash Babani (April 21, 2023), diagnosing major depressive disorder and PTSD.
24The respondent contends that the applicant’s psychological impairments existed before the accident and that his current behaviour does not align with disabling psychological symptoms. Surveillance evidence indicates the applicant is participating in social and daily activities without obvious psychological distress.
25I have reviewed the CNRs and found that the applicant has a longstanding history of mental health issues that predate the accident. The records indicate that he has been under the care of mental health professionals, including Dr. Navin Kaicker and Dr. Prakash Babani, since at least 2018 (see progress reports from October 2018 to May 2024).
26On November 21, 2022, Victoria Brandolisio of Alma Rehab reported that the applicant was experiencing significant psychological symptoms after the accident, including major depressive disorder, adjustment disorder, and PTSD. She noted increased anxiety and fear related to motor vehicle tasks and recommended cognitive behavioural therapy.
27Similarly, in a report dated January 17, 2023, psychologist Dr. Konstantinos Papazoglou diagnosed the applicant with adjustment disorder with anxiety, recurrent severe major depressive disorder, and specific phobia related to driving and being a passenger. Both professionals appeared to rely heavily on the applicant’s subjective self-reports, which Dr. MacKenzie later reviewed and found difficult to reconcile with her own clinical observations and assessment (see paras 28, 30).
28Psychiatrist Dr. Mackenzie, in her April 16, 2024, report, acknowledged the applicant’s prior history of major depressive disorder, which had supposedly resolved before the accident. Notably, Dr. MacKenzie performed her own in-person assessment of the applicant, alongside reviewing reports by Brandolisio and Dr. Papazoglou, and her findings questioned the reliability and consistency of the reported psychological symptoms. She noted a recurrence of symptoms after the accident but ultimately found the applicant’s self-reported history unreliable after reviewing surveillance footage. Consequently, she was unable to reach a conclusive judgment on the applicant’s current mental health condition.
29Based on the totality of the evidence, I find that the psychological treatment plan dated January 12, 2024, is not reasonable and necessary.
30While the applicant has a documented history of mental health concerns, I am not persuaded that the proposed psychological treatment is reasonable and necessary in the context of this accident. Although some assessors attribute the recurrence of symptoms to the accident, I do not accept those conclusions. In particular, Dr. Mackenzie’s report raises concerns about the reliability of the applicant’s self-reported symptoms, and her inability to reach a definitive diagnosis following review of surveillance footage further weakens the evidentiary basis for the treatment plan. I place greater weight on Dr. Mackenzie’s report as it is the most comprehensive and takes into account extensive evidence, including surveillance.
31Accordingly, on a balance of probabilities, I find that the treatment plan is not reasonable and necessary.
Is the applicant entitled to the treatment plan for chronic pain assessment?
32The purpose of assessments is to determine whether a condition exists. For an insured, they bear the onus of demonstrating that there are grounds on which to believe that a condition exists that would warrant further investigation by way of an assessment.
33I find that the proposed chronic pain assessment, dated March 6, 2023, for the amount of $2,350.00, is reasonable and necessary.
34The plan requests funding for a chronic pain assessment to examine the nature and extent of the applicant’s reported pain, which he claims is ongoing and disproportionate to the physical findings.
35The applicant states that, despite normal imaging and neurological findings, he continues to experience ongoing pain that affects his daily life. He contends that a chronic pain assessment is needed to understand better and manage these symptoms.
36The respondent opposes the plan, citing normal neurological findings, conclusions from Dr. Kruger’s insurer examination, and surveillance evidence demonstrating the applicant engaging in daily activities without apparent distress. They argue that there is no objective basis for a chronic pain assessment.
37Dr. Barbara Connolly, a neurologist, reported on November 7, 2023, that the applicant’s neurological examination showed no objective deficits. Although the applicant reported numbness in his right arm and both legs, there were no reflex changes or weakness, indicating neurological injury. She diagnosed the applicant with post-traumatic headaches featuring migraine and cervicogenic qualities, and she noted the potential for medication overuse headaches. She also confirmed that the applicant did not suffer a concussion in the accident and attributed cognitive symptoms to pain and distress.
38In a record dated February 24, 2023, Dr. Paleksic recommended referral to a chronic pain management clinic for nerve blocks and exercise to address neck stiffness. He warned against medication use that was not providing improvement.
39On June 20, 2023, neurologist Dr. Viachislav Prigozhikh diagnosed the applicant with chronic pain, further supporting the need for a specialized assessment to determine suitable treatment options.
40Considering all the evidence, I find that the chronic pain assessment plan dated March 6, 2023, is reasonable and necessary.
41Although imaging and neurological examinations have not shown significant objective deficits, the applicant continues to report persistent pain that interferes with daily activities. Because chronic pain is a complex condition that may not always align with objective findings, the diagnosis by Dr. Prigozhikh and the recommendations from Dr. Paleksic for specialized pain management support the need for further evaluation. An assessment is, therefore, a clinically appropriate step to understand the nature and extent of the applicant’s symptoms.
42Accordingly, on a balance of probabilities, I conclude that the assessment plan is reasonable and necessary.
Interest
43Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. The applicant is entitled to interest on the treatment plan for a chronic pain assessment in accordance with s. 51.
ORDER
44For the above reasons, it is ordered that:
i. The applicant is entitled to the chronic pain assessment treatment plan, with interest pursuant to s. 51. ii. The applicant is not entitled to the remaining disputed treatment plans.
Released: August 28, 2025
Harouna Saley Sidibé Adjudicator