Licence Appeal Tribunal File Number: 24-003448/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:
Said Quraishi
Applicant
and
Security National Insurance Company
Respondent
DECISION
ADJUDICATOR:
John Mazzilli
APPEARANCES:
For the Applicant:
Said Quraishi, Applicant
For the Respondent:
Derek Vihvelin, Counsel
Katherine Dempsey, Counsel
Kevin Temple, Counsel
Court Reporter:
Guido Riccioni
HEARD: by Videoconference:
April 7,8,9 and 10, 2025
OVERVIEW
1Said Mustafa Quaraishi (the “applicant”) was involved in an automobile accident on January 14, 2015, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (the “Schedule”). The applicant was denied benefits by Security National 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:
i. Has the applicant sustained a catastrophic impairment as defined by the Schedule under Criterion 7 & 8.
ii. Is the applicant entitled to $5,496.26 for neuro-psychological examination, proposed by Dr. John Gillman in a treatment plan/OCF-18 (“plan”) dated January 20, 2024?
iii. Is the applicant entitled to attendant care benefits in the amount of $10,245.00 per month from August 1, 2023 to date and ongoing?
iv. Is the applicant entitled to housekeeping and home maintenance benefits in the amount of $14,648.88 from October 1, 2021 to date and ongoing?
RESULT
3The applicant is not catastrophically impaired as defined by the Schedule under Criterion 7 or 8.
4The applicant is not entitled to the plan for a neuro-psychological examination.
5The applicant is not entitled to attendant care benefits.
6The applicant is not entitled to housekeeping and home maintenance benefits.
PROCEDURAL ISSUES
7On April 1st, 2025, the applicant’s counsel advised the Tribunal that it would no longer be representing the applicant. On April 4th, 2025, the applicant advised the Tribunal by way of e-mail that he would be acting as a self-represented individual for the hearing commencing on April 7, 2025. As the applicant advised the Tribunal of his intention to act as a self-represented individual pursuant to Rule 24.3 of the Licence Appeal Tribunal Rules, 2023 (“Rules”), the applicant’s former counsel is no longer the Counsel of record for this matter. At the outset of the hearing, the applicant again advised that he would be acting as a self-represented individual, and he requested that the hearing proceed as scheduled. I advised the applicant that, considering his counsel’s recent withdrawal, he could make oral submissions seeking an adjournment of this matter.
8The applicant continued to advise the Tribunal that he wished to proceed as a self-represented individual. He did not make any oral submissions requesting an adjournment of this hearing. I advised the applicant throughout the proceeding of how we were to proceed and asked if he had any questions about the proceeding. The applicant was able to follow the proceeding and was given numerous breaks to collect his thoughts and to arrange for any witnesses he wished to call as he did not identify any witnesses that would be testifying to support his case while setting the hearing schedule for the proceeding.
9The applicant’s former counsel of record had provided the Tribunal and the respondent with a witness list and a document brief in accordance with the Licence Appeal Tribunal Rules, 2023. I advised the applicant that he could refer to the document brief and the witness list, however, any evidence the applicant wished to rely on from the brief would need to be specifically identified and entered as an exhibit.
10On the second day of the hearing, the applicant informed the Tribunal that he did not have a copy of his document brief and the respondent’s counsel emailed both a copy of their brief and the applicant’s brief to the applicant. The applicant advised that he had received both document briefs and I allowed the applicant time to review the briefs. Once he had an opportunity to review, I again advised the applicant that I would only accept the evidence he identified as exhibits and not the entirety of the document brief. He acknowledged this instruction and identified exhibits accordingly that were admitted into evidence on the third and fourth days of the hearing.
11During the hearing, I continued to encourage the applicant to call any expert witnesses that were identified on his witness list to arrange a time for their testimony. I maintained a flexible witness schedule throughout the proceeding to accommodate the applicant should he be able to produce a witness. The applicant advised the Tribunal that he had spoken to one of the medical experts identified on his witness list but stated that he lacked the financial means to pay for the requested fees by the medical experts to appear and testify at the hearing.
12The applicant was respectful, timely, and courteous through the entirety of the proceedings and at the end of the proceeding he thanked the Tribunal and the respondent for the time and latitude extended to him throughout the proceeding. In addition, the applicant thanked the Tribunal for their efforts to assist him in navigating the hearing process. He indicated he believed he had received a fair hearing.
ANALYSIS
Causation
13The determinative issue is whether “but for” the 2015 accident, the applicant would have sustained the psychological or physical impairments underlying his catastrophic impairment claim. I find that on a balance of probabilities it does not.
14The applicant submits that his physical and mental impairments are due to the injuries sustained in the subject motor vehicle accident. Although in his closing remarks he acknowledges that his 2017 accident could have possibly worsened his condition, he maintains that his impairments began after the 2015 accident, and that this accident is the root cause of his impairments.
15The respondent argues that the applicant’s injuries from the accident were minor in nature. It argues that, as a result of the accident, the applicant did not lose consciousness or sustain head injuries such as a concussion and required minimal medical intervention in the approximate two years following the accident. The respondent submits that it closed the applicant’s accident benefits file on March 13, 2017, for inactivity because the applicant did not attend treatment in twelve weeks. In sum, it submits the accident did not cause the applicant’s physical or psychological impairments that form the basis for this application for catastrophic determination.
16The respondent further argues that the applicant was involved in a more serious accident in 2017 and that the applicant’s declining mental health is due to several non-accident life stressors such as the applicant’s financial strain due to carrying multiple mortgages on two homes leading to foreclosure. It further argues that the deterioration of the applicant’s marriage was due to marital breakdown following a miscarriage, intra-family litigation threats, potential fraud investigations, and religious conflicts with his extended family.
17It is well established that the appropriate test to determine causation in accident benefit cases is the “but for” test, which was confirmed by the Divisional Court in Sabadash v. State Farm et al., 2019 ONSC 1121(Sabadash). To satisfy this test, the applicant must demonstrate on a balance of probabilities that “but for” the 2015 accident, he would not have suffered the impairments forming the basis for his catastrophic-impairment (“CAT”) claim. The Court in Sabadash sets out that the existence of pre-existing medical issues does not negate an insurer’s liability. Further, the Court states that the accident need not be the only cause of the impairment, but it must be a necessary cause. The Court further instructs the decision maker to conduct a robust analysis given the unique circumstances of the case at hand.
18In analyzing causation, it is necessary to compare the applicant’s pre- and post-accident life to determine to what extent any accident-related impairment affected his ability to function.
19The applicant testified that pre-accident he was emotionally and physically fit, enjoyed attending the gym, and did not have the physical, emotional, sleep disturbances and anxiety that began after the 2015 accident. He testified that in the ten years preceding the 2015 accident he had a functional life. He purchased his first home with his wife in 2014, started a family, and took on full adult responsibilities. He testified that he was married in 2014, they had their first child in 2015 and their second child in 2016. He testified that he worked for Pepsi as a sales representative.
20After the accident, he continued to work for Pepsi. In 2016, he went on paternity leave and travelled to St. Lucia for a “baby moon.” Upon return from paternity leave, he had difficulties in his job performance due to the sequela from the 2015 accident. He was subsequently dismissed from his employment at Pepsi some time in 2017.
21He testified that due to his financial obligations, he obtained employment with TD Insurance as a broker working in a call centre in early 2018, a job that required him to pass an insurance exam. He testified that he was unable to maintain this job because of the progression of his accident-related symptomology. He testified that he had difficulty sleeping and emotional issues including anxiety after the accident.
22The applicant testified that his symptoms were compounded by his financial situation. The applicant testified that he and his wife purchased a second home in and around 2018 before the sale of their first home, and that due to the real estate market crash they were unable to sell either home and relied on multiple mortgages, lines of credits, and credit cards. This resulted in approximately $16,000.00 of monthly carrying cost expenses that ultimately resulted in the couple losing both homes. The applicant also testified that his wife had a miscarriage in 2018 and that in 2019, his wife left with his three children, and he has only seen them twice since.
23In considering the applicant’s testimony in light of the medical reporting in evidence, I find that it to be consistent with the description of his pre-accident functioning. This is because the medical evidence before me indicates that non-accident-related stressors in the applicant’s life as listed above, and not the accident of 2015, caused his physical and psychological conditions. I was pointed to limited medical evidence to support the applicant’s claim between the years of 2015 and 2017.
24On January 16, 2015, two days after the accident, the applicant attended what appears to be a follow up appointment with Dr. Ganeshalingam, his family doctor, in relation to some previous blood work. At this appointment, Dr. Ganeshalingam’s clinical notes show that there was no head injury, no loss of consciousness and no ambulance called at the scene of the accident, which corroborates the respondent’s position that as a result of the accident, the applicant did not lose consciousness or sustain head injuries such as a concussion, and required minimal medical intervention in the approximate two years following the accident.
25Dr. Ganeshalingam recorded the applicant’s complaints of neck pain, pain between shoulders, difficulty falling asleep and flashbacks of the accident. Dr. Ganeshalingam further notes that there were no neurological symptoms, the applicant looks well, has normal gait and no facial asymmetry, his visual fields intact to light touch, and that the applicant’s symmetric reflexes are intact.
26In a follow up appointment on January 30, 2015, with Dr. Ganeshalingam, the applicant advised that he was attending physiotherapy and that he was sore after the exercises, so he only continued with massages. He also reported that he is still scared, not sleeping well, and complains of fatigue and exhaustion after work. The applicant further complains about reliving the accident, reports he has feelings of guilt, he is forgetful, and worries about his baby’s future.
27He further reports to Dr. Ganeshalingam that he is slow at work, unable to focus, forgetful and unable to help with chores at home, however there is no follow up physical or psychological medical evidence in the two years following this appointment. This two-year gap in medical evidence does not support the applicant’s claim to catastrophic impairment from the 2015 accident.
28The CNRs from the two above visits with Dr. Ganeshalingam were the only CNRs provided as evidence until a February 7, 2017, appointment, two years following the accident that again do not support that the accident was a necessary cause of the applicant’s impairments.
29The CNRs from Dr. Ganeshalingam on February 7, 2017, show an inconsistency between the applicant’s testimony and the CNRs, which raise credibility concerns.
30The February 7, 2017, CNRs from Dr. Ganeshalingam record the applicant took a four-month trip to Afghanistan which contradict the applicant’s testimony that he never returned to Afghanistan since immigrating to Canada. Further the applicant’s sleepwalking pre-date the accident. I was not pointed to evidence from the applicant that would satisfy the Tribunal that his longstanding sleep issues were exacerbated by the 2015 accident or but for the accident this condition has caused him to become catastrophically impaired in accordance with the Schedule.
31The CNRs further complicate the applicant’s claim that the 2015 accident was the cause of his impairments because the CNRs show that the applicant has longstanding pre-accident sleep issues, sleepwalking and is unsure if he has sleep apnea. He reports he felt better while away in Afghanistan, however on his return home, he feels like he is back to ground zero and feels stressed out about sleepwalking.
32While the CNR of February 2017 suggests that the applicant was experiencing psychological symptoms, the reporting of Dr. Ganeshalingam does not tie the applicant’s symptoms to the 2015 accident. In addition, I find that the approximate two-year gap in medical records does not support the applicant’s claim that but for the accident he would not have experienced these symptoms, nor was I pointed to evidence that the 2015 accident exacerbated the applicant’s symptomology.
33The evidence before me also includes Dr. Ganeshalingam’s CNRs from September 14, 2018, when the applicant required a doctor’s note as he was away from work due to stress. The applicant reported to Dr. Ganeshalingam that he was experiencing stress because of financial and housing issues. The notes do not reference the 2015 accident but do reference a claim for long term disability (LTD) made at the time.
34The applicant’s claim to catastrophic impairment from the 2015 accident is further complicated by another family physician, Dr. Jagathesan, who completed the applicant’s LTD application dated September 25, 2018. Dr. Jagathesan notes that stress and anxiety are the applicant’s primary diagnoses. Dr. Jagathesan notes that the applicant first reported these symptoms on January 31, 2018, which is approximately three years post accident.
35Furthermore, I note that the LTD application specifically asks the applicant if his injuries are due to a motor vehicle accident and the applicant has checked off the “no” box, which the applicant testified to be an oversight on his part again raising credibility issues. The applicant’s acknowledgement in his LTD application that his impairments are not related to motor vehicle accident does not support his argument that the 2015 accident was the root cause of his impairments.
36In addition, the applicant’s LTD provider arranged for an independent medical assessment on March 12, 2019, conducted by Dr. Margolese, psychiatrist. In her report dated March 19, 2019, Dr. Margolese did not identify any accident-related impairments. Dr. Margolese also notes that there is very little documentation on the file and specifically no physician notes prior to his illness. This does not support the applicant’s position that the 2015 accident was a necessary cause of his impairments.
37Dr. Margolese diagnosed the applicant with major depressive disorder, severe, with anxious distress. She further opined that the applicant’s precipitating factors appear to be primarily his financial stress as well as feelings of a lack of support from his family and that this has complicated or perpetuated his current situation which includes his wife’s health issues and the worsening of his financial situation month by month and ongoing family conflict and estrangement.
38I placed full weight to the report of Dr. Margolese because the corroborating evidence is supportive of her report, that the 2015 accident did not cause or exacerbate the applicant’s impairment.
39It is important to note that in his 2024 CAT report, Dr. Gilman, psychologist noted the applicant’s life stressors as listed above, however, Dr. Gilman does not address causation in his report or indicate whether and to what extent any of these stressors contributed to his impairment ratings. I will discuss Dr. Gilman’s report and Dr. Fern’s executive summary below in my decision.
40For example, the applicant’s CAT reports reference the applicant’s 2015 accident and his abundant life stressors, however, they do not directly address the question of causation. I place little weight on these reports, and on the question of causation, I place more weight on the contemporaneous reporting of Dr. Jagathesan, Dr. Ganeshalingam, and Dr. Margolese, which, I find are not supportive of a finding in the applicant’s favour.
41It is evident to me that the applicant has had to deal with very difficult life stressors. However, I find on a balance of probabilities that the medical evidence does not support the applicant’s claim that the 2015 accident was a necessary cause of his impairments.
Whole Person Impairment (“WPI”) Criterion 7
42Although my finding with respect to causation is sufficient to deny the application, I will also briefly address the medical evidence in support of the applicant’s claim to catastrophic impairment under criterion 7 and 8.
43I find that the applicant has not demonstrated, on a balance of probabilities, that he has sustained a combination of physical and psychological impairments as a result of the injuries sustained in the accident that results in a whole person impairment (“WPI”) of 55% or greater.
44To meet the threshold of catastrophic impairment under Criterion 7, the applicant must prove that he has a combination of physical and psychological impairment ratings from medical professionals that meet the 55% WPI threshold.
45The psychological impairment rating is determined in accordance with the methodology set out in the American Medical Association Guides, 4th edition (“Guides”). The psychological WPI impairment rating is combined with the physical WPI rating from the Guides using the Combined Values Table. An impairment percentage derived by means of the Guides is intended to represent an informed estimate of the degree to which an individual’s capacity to carry out daily activities has been diminished due to injuries sustained in the accident. It is important to note that a 53% WPI is to be rounded up to 55% in accordance with the Guides, while a 52% WPI is to be rounded down to 50%.
46The applicant relies on an executive summary report completed by Dr. Fern, orthopaedic surgeon, dated January 22, 2024. Based on this report, the applicant submits that as a result of the accident, he has suffered at minimum a 50% WPI when combining his physical impairments of 17%, as assigned by Dr. Getahun, and 40% WPI assigned for his psychological impairments by Dr. Gilman, neuropsychologist, in his report dated January 20, 2024. Dr. Fern also provides a WPI of 53% when attributing an additional 5% WPI with respect to sleep disturbance identified by Dr. Gilman.
47In his report, Dr. Fern also calculates the applicant’s WPI to be potentially as high as 66% WPI when factoring ratings from Ms. Gronkowska, psychological associate, because Ms. Gronkowska assigned a 57% WPI for psychological impairments.
48First, I find that Ms. Gronkowska is not qualified to give a rating in accordance with the Guides as Ms. Gronkowska is a psychological associate and her report does not reference any supervision from a psychologist, which renders her findings in accordance with the Guides to be invalid. In addition, the applicant did not tender any evidence in support of Ms. Gronkowska’s qualifications to assign ratings in accordance with the Guides. Therefore, I place no weight to her report. Further, I find that Dr. Fern’s reliance on Ms. Gronkowska’s rating diminishes the persuasiveness of his opinion, as Dr. Fern ought to have recognized that a psychological associate is not qualified to provide a psychological impairment WPI in accordance with the Guides.
49Finaly, even if I accepted Dr. Gilman’s WPI of 40% assigned to the applicant’s psychological impairment and Dr. Getahun’s WPI of 17% assigned to the applicant’s physical impairments, I place no weight on the 5% WPI for the applicant’s sleep disturbances for two reasons.
50First, the medical evidence indicates the applicant has a pre-existing sleep condition which is not addressed in Dr. Gilman’s report. Second, and more importantly, I place greater weight on the evidence of the respondent’s assessor, Dr. Oshidari, physiatrist on this point because he was made available to testify and explain his position regarding the applicant’s sleep disturbances in accordance with the AMA Guides.
51At the hearing, Dr. Oshidari testified that to assign a WPI% for sleep disturbances, the applicant would require a neurological examination in accordance with the Guides, but there is no evidence that Dr. Gilman, the applicant’s assessor conducted a neurological examination on the applicant. Accordingly, I find that as a result of the accident, the applicant has sustained a 0% WPI attributable to sleep disturbances because a neurological examination was not conducted to arrive at the WPI% in Dr. Gilman’s assessment.
52Further, I place little weight on Dr. Gilman’s report because while Dr. Gilman appears to be aware of the applicant’s life stressors and the applicant’s 2017 accident, he does not provide a causation analysis in his report. In addition, Dr. Gilman did not complete a full document review of the applicant’s medical files. For example, Dr. Gilman did not review the respondent’s multidisciplinary catastrophic impairment reports dated September 30, 2021, nor Dr. Rosenblat’s psychiatric report dated June 28, 2021, which was completed approximately two and half years before Dr. Gilman’s report and closer to the date of the accident.
53I also note that Dr. Gilman’s report raises questions that are not adequately explained. Dr. Gilman indicates in his report that “the applicant’s ongoing subjective reports of pain were not consistent with his objective findings during his assessment” but does not address this inconsistency when giving his opinion that the applicant’s “severe anxiety and psychological depression together with severe chronic pain, stemming from post traumatic physical injuries sustained interrupting this man’s everyday functioning.” Dr. Gilman’s report does not indicate what the objective findings were that are not consistent with the applicant’s subjective reports, or how this relates to the 2015 accident. Further and although included on the applicant’s witness list, Dr. Gilman did not testify.
54I place more weight on the report of Dr. Rosenblat and his testimony because Dr. Rosenblat’s assessment presented me with a more accurate depiction of the applicant’s accident-related psychological impairments because, as set out above, Dr. Rosenblat’s assessment included a full document review of the applicant’s medical file and because Dr. Rosenblat’s assessment was conducted approximately six years post accident, closer to the events in question than that of Dr. Gilman’s assessment which was conducted approximately nine years post accident.
55Finally, in accordance with the combined values chart of the Guides, even if I accept the applicant’s 40% WPI rating (psychological) and the applicant’s 17% WPI rating (physical) this equates to a combined value of 50% WPI which does not satisfy the threshold of 55% WPI to be deemed CAT, therefore the applicant has failed to demonstrate that he is catastrophically impaired under criterion 7.
56For the reasons set out above, I find on a balance of probabilities that the applicant has not met his onus to prove that he is catastrophically impaired as a result of the 2015 accident under criterion 7.
Criterion 8 Mental and Behavioral
57I find that the applicant has not met his onus of having a Class 4 marked impairment or greater in any of the four domains of Criterion 8 as a result of the accident. Given the date of the accident, the applicable version of the Schedule requires the applicant to prove only one class 4 or greater impairment.
58To determine whether an insured person is catastrophically impaired under Criterion 8, the Tribunal considers whether the accident caused a mental or behavioral disorder, the impact of the disorder to the person’s life, and the level of impairment as described in section 3.1(1) 8 of the Schedule. The applicant bears the onus to prove on a balance of probabilities that he is catastrophically impaired. The test to determine whether the applicant has sustained a catastrophic impairment is a legal test and not a medical test (see Liu v. 1226071 Ontario Inc. (Canadian Zhorong Trading Ltd.), 2009 ONCA 571).
59Next, Criterion 8 requires evidence of the insured person’s impairment levels due to a mental or behavioural disorder. Impairment levels are to be assessed in relation to four functional domains: (1) activities of daily living; (2) social functioning; (3) concentration, persistence, and pace and (4) adaptation (deterioration or decomposition in work or work like settings). To meet the Schedule’s threshold for a catastrophic impairment designation under Criterion 8, an individual must demonstrate that the mental or behavioural impairments he suffered have resulted in a Class 4 impairment (marked impairment) or a Class 5 (extreme impairment) in at least one domain. These impairments are assessed under the 4th edition of the AMA Guides. Mental and behavioural impairments are rated according to how seriously they affect a person’s useful daily functioning. The domains of functioning and the levels of impairment are outlined in the chart below:
Area or Aspect of Functioning
Class 1: No Impairment
Class 2: Mild Impairment
Class 3: Moderate Impairment
Class 4: Marked Impairment
Class 5: Extreme Impairment
Activities of Daily Living
No impairment is noted
Impairment levels are compatible with most useful functioning
Impairment levels are compatible with some, but not all useful functioning
Impairment levels significantly impede useful functioning
Impairment levels preclude useful functioning
Social Functioning
Concentration, Persistence and Pace
60The applicant submits that he is CAT in accordance with Criterion 8 and relies on the report of Dr. Gilman, psychologist dated January 20, 2024, an executive summary completed by Dr. Fern, orthopaedic and spinal surgeon dated January 22, 2024, and the report of Janice Kim, occupational therapist dated November 12, 2021. In his report Dr. Gilman opines that the applicant has a class 4 marked impairment in the domains of activities of daily living, social function, concentration persistence and pace, and a class 5 extreme impairment in adaptation.
61The respondent argues that the applicant has not sustained catastrophic injuries under criterion 8 as a result of the 2015 accident and relies on the report of Dr. Rosenblat, psychiatrist dated September 30, 2021 and his addendum report dated April 17, 2024, an activities of daily living assessment completed by Lynn Rutledge, occupational therapist dated June 28, 2021, and a community functional assessment completed by Lynn Rutledge, occupational therapist dated June 29, 2021. In his report Dr. Rosenblat opines that the applicant sustained a class 2 to 3 (mild to moderate) impairment in the activities of daily living, concentration, persistence and pace, social functioning, and class 2 (mild) impairment in the domain of adaptation.
62I find the applicant has not met his burden to prove he is CAT under Criterion 8 because the contemporaneous medical evidence is at odds with Dr. Gilman’s report, therefore I place little weight on Dr. Gilman’s report for the reasons set out above and for the following reasons:
63Dr. Gilman appears to base his entire rating in the four domains of Criterion 8 on a DSM 5 World Health Disability Assessment Schedule (“WHODAS”) test, without explaining how the score results specifically apply to the four domains or providing supporting comments specifically addressing the four domains under Criterion 8.
64Dr. Gilman did not testify at the hearing leaving the Tribunal to solely rely on Dr. Gilman’s report which lacks detail of testing, methodology, and does not address causation while being alive to the applicant’s life stressors. Dr. Gilman’s three-and-a-half-page report is vague, not persuasive, and inconsistent with the contemporaneous medical evidence from other health practitioners. For example, one page of his report incorporates bullet points from Janice Kim’s occupational therapy report, which I cannot corroborate because the occupational therapy report provided to me as evidence is completely illegible.
65In addition, Dr. Gilman’s report was conducted almost nine years after the 2015 accident whereas the respondent’s CAT reports were conducted in 2021 approximately six years post accident which I find to be more persuasive because they contained a detailed occupational therapy assessment in the applicant’s home which lasted four hours and fifteen minutes and a community functional assessment which lasted three hours and twenty minutes which gives more credibility and insight to the applicant’s day to day life as corroborated by Dr. Rosenblat which do not support a finding of catastrophic impairment under criterion 8. Having reviewed the depth and quality of the evidence from the parties, I find the respondent’s evidence to be more persuasive than the applicant’s.
66For the reasons set out above, I find on a balance of probabilities that the applicant has not met his onus to prove that he is catastrophically impaired as a result of the 2015 accident under criterion 8.
Neuropsychological treatment plan
67I find that the applicant is not entitled to $5,496.26 for the neuro-psychological examination, proposed by Dr. John Gilman.
68To receive payment for a treatment and assessment plan under sections 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.
69The applicant did not make any submission or provide evidence to support his claim for a neuro-psychological examination. As such the applicant has not met his onus to prove he is entitled to the disputed treatment plan.
70Therefore, I find on a balance of probabilities that the applicant is not entitled to the treatment plan for a neuro-psychological examination.
Home maintenance and Housekeeping
71The applicant is not entitled to housekeeping and home maintenance in the amount of $14,648.88.
72Section 23 of the Schedule states that the insurer shall pay up to $100 per week for reasonable and necessary additional expenses incurred by or on behalf of an insured person as a result of an accident for housekeeping and home maintenance services, if, as a result of the accident, the insured person sustains a catastrophic impairment that results in a substantial inability to perform the housekeeping and home maintenance services that he or she normally performed before the accident.
73The applicant testified that he resides in his parents’ home and that his mother looks after the household duties such as housekeeping and that his former counsel submitted the paperwork for this claim.
74The respondent denied the applicant’s claim to housekeeping and home maintenance in a letter dated February 8, 2024, citing the applicant’s failure to meet the threshold under s. 23 as the reason for the denial.
75Having found that the applicant is not catastrophically impaired in accordance with Criterion 7 or 8, the applicant is not entitled to benefits for home maintenance and housekeeping as these benefits only apply to a person who is catastrophically impaired. Accordingly, I find that the applicant is not entitled to $14,648.88 for home maintenance and housekeeping.
Attendant Care
76The applicant is not entitled to $10,245.00 per month for attendant care benefits from August 1, 2023, to date and ongoing.
77Section 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 attendant care services (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, the version of the document entitled Assessment of Attendant Care Needs (“Form-1”).
78The applicant testified that he was unaware of the documentation that was submitted in his claim for attendant care benefits because his previous counsel managed all submissions to the respondent in this regard.
79The respondent submitted that a proper Form-1 was not provided and on February 8, 2024, it denied the applicant’s claim to attendant care benefits for the period of August, September, October, November, and December of 2023. The expenses incurred during this period were before a properly completed Form-1 was submitted and only expenses incurred for a period after the Form-1 is received will be considered. While s. 42(4) of the Schedule permits the insurer to pay attendant care benefits before a Form-1 is submitted, that choice is solely at the option of the insurer, and there is no evidence that the respondent did so.
80As a proper Form-1 was not submitted by the applicant to the respondent and the applicant made no further submissions on this issue, I find on a balance of probabilities that the applicant is not entitled to the disputed attendant care benefits.
Interest
81Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no benefits are payable, interest is not owing.
ORDER
82It is ordered that:
i. The applicant has not sustained a catastrophic impairment as defined by the Schedule under Criterion 7 or 8.
ii. The applicant is not entitled to a neuro-psychological examination.
iii. The applicant is not entitled to attendant care benefits.
iv. The applicant is not entitled to housekeeping and home maintenance benefits.
v. The application is dismissed.
Released: August 25, 2025
__________________________
John Mazzilli
Adjudicator