Citation: Wei v. Cooperators General Insurance Co., 2025 ONLAT 23-000294/AABS

Licence Appeal Tribunal File Number: 23-000294/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:

Li Li Wei

Applicant

and

Co-operators General Insurance Company

Respondent

DECISION

ADJUDICATOR: Georgina Blanas

APPEARANCES:

For the Applicant: Anil Hampole, Counsel

For the Respondent: Jonathon Kahane-Rapport, Counsel

HEARD: By way of written submissions

OVERVIEW

1Li Li Wei, the applicant, was involved in an automobile accident on March 11, 2018, 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 Co-operators General Insurance Company, the respondent, Co-operators 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 $1,142.52 ($4,416.71 less $3,274.19 approved) for chiropractic services, recommended by Total Recovery Rehab Centre in an OCF-18/treatment plan (“plan”) dated March 20, 2021?

ii. Is the applicant entitled to $4,115.12 for chiropractic services, recommended by Total Recovery Rehab Centre in a plan submitted April 30, 2021?

iii. Is the applicant entitled to $3,989.56 for physiotherapy services recommended by Total Recovery Rehab Centre in a plan submitted June 30, 2021?

iv. Is the applicant entitled to interest on any overdue payment of benefits?

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?

RESULT

3The applicant is not entitled to the treatment plans, interest, or an award.

ANALYSIS

Is the applicant entitled to the $1,142.52 unapproved portion of the treatment plan dated March 20, 2021, for chiropractic services?

4I find that the applicant has not demonstrated on a balance of probabilities that the unapproved portions of the March 20, 2021, treatment plan for chiropractic services is reasonable and necessary. Therefore, the applicant is not entitled to the outstanding balance of this plan.

5To 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.

6The treatment plans were proposed by Dr. Georgia Palantzas, Chiropractor, of Total Recovery Rehab Centre. The primary goals included pain reduction, improvement in range of motion, enhanced strength and stability and facilitation of the applicant’s return to pre-accident levels of functionality. The treatment plan proposed 16 chiropractic sessions, 16 exercise/strength and balance training sessions, 12 acupuncture sessions, documentation support and transportation expenses.

7April 23, 2021, the respondent agreed to approve $3,274.19 of the plan which included assessment (examination) of total body in the amount of $200.00, 12 sessions of chiropractic treatment in the amount of $1,353,72, 12 sessions of acupuncture in the amount of $676.92, and documentation support activity in the amount of $366.63.

8Therefore, $1,142.52 of the unapproved portion of the treatment plan that is in dispute (4 sessions of chiropractic treatment in the amount of $451.24, 4 sessions of exercise/strength and balance training in the amount of $225.64, 4 sessions of acupuncture in the amount of $225.64, and Transportation in the amount of $240.00).

9The respondent submits that the parties resolved this issue, the applicant has not withdrawn this issue in dispute and therefore it is before me on appeal. The applicant’s claim for the remaining $1,142.52 is inadmissible. As evidenced by the letter dated April 23, 2021 (referenced by the parties reached an agreement on April 22, 2021, wherein the respondent partially approved the treatment plan ($4,416.71 less $3,274.19 approved). In exchange for this payment, the applicant’s counsel agreed to withdraw the remaining $1,142.52 from the LAT application. The applicant submits she is entitled to the outstanding $1,142.52 for chiropractic services, relying on Dr. Palantzas’ clinical notes and records (“CNRs”) and treatment plan. The applicant points to previously filed notes recording a decline in her activities of daily living and housekeeping capacity and recommending additional therapy.

10I find this issue was resolved by agreement, as the parties referred to The Co-operators’ April 23, 2021, letter confirming the April 22, 2021, agreement between the applicant’s counsel and respondent’s counsel to withdraw the LAT application in exchange for partial approval of $3,274.19 from $4,416.71 of the March 20, 2021, OCF-18 from Dr. Palantzas, Total Recovery Rehab Centre. Accordingly, the applicant is not entitled to the outstanding balance of $1,142.52, as the parties resolved this issue in dispute.

Is the applicant entitled to $4,115.12 for chiropractic services dated April 30, 2021?

11I find, on a balance of probabilities, that the proposed request for chiropractic services has not been supported by new medical evidence to establish the need for ongoing treatment and as a result, I find the request for chiropractic treatment is not reasonable and necessary.

12The applicant submits that, at the time of the accident, she was pregnant and taken to the hospital where she was examined and released later the same day. She reports difficulty sleeping, low energy, fatigue, limitation in performing some housekeeping tasks, decreased standing and walking tolerance, inability to lift or carry items 10 lbs, decreased driving tolerance, and inability to perform her duties as an accountant. The applicant’s submissions rely on Dr. Palantzas, and Physiotherapist Mr. Ahmed Aifil as set out in an OCF-18 dated April 30, 2021, which was submitted approximately three years post-accident.

13The respondent submits that the applicant was examined and discharged within two hours of arriving at the hospital on the day of the accident. She continued working in her accounting role, thereafter, commenced parental leave in September 2018, and gave birth to a healthy child on October 19, 2018. The LAT application was filed more than three years after the accident. Relying on the report of Dr. Jean Pierre Carco and the section 44 insurer’s examination (“IE”) by Dr. Raymond Zabeiliauskas, Physiatrist, dated July 12, 2021, the respondent submits the applicant had made a full recovery before resuming therapy in 2021. The respondent further maintains that, at most, the applicant sustained soft tissue strains which would have resolved within two to three months, and certainly within six months, of the accident.

14The treatment plan proposed by Mr. Ahmed Afifi, Physiotherapist, of Total Recovery Rehab Centre, and sought funding for proposed chiropractic treatments, with goals to reduce pain levels associated with; pain reduction, increase in strength, increased range in motion, return to activities of normal living, and return to modified work activities.

15I find that the request for treatment is not supported by the medical evidence. The IE from Dr. Raymond Zabieliauskas, Physiatrist, Dr. Billy Mango, Psychologist and Dr. Jean Pierre Sarco, Physiatrist, concluded that the applicant had fully recovered from soft tissue injuries and did not require further treatment beyond home exercises and occasional pain management. The IE reports determined that the applicant had reached maximum medical recovery, and that additional treatment would not provide significant benefit. The timing of the treatment plan submission (three years post-accident) raised concerns about its relevance and necessity. The applicant did not point me to evidence in support of on-going complaints from her family doctor or any other medical practitioner in support of the treatment plan, nor did the applicant point me to evidence, that would warrant the request for treatment three-years post-accident. I prefer the evidence of the IE assessors, whose conclusions are consistent and corroborated across multiple assessments.

Is the applicant entitled to $ 3,989.56 for physiotherapy services dated June 30, 2021?

16I find that the applicant is not entitled to the treatment plans for chiropractic and physiotherapy services dated June 30, 2021, as she has not demonstrated that they are reasonable and necessary.

17The treatment plan was prepared by Mr. Afifi, Physiotherapist, and sought funding for physiotherapy services, including therapeutic exercises, soft tissue mobilization, and pain management strategies aimed at alleviating chronic musculoskeletal pain and improving functional movement.

18The goals of the treatment plan included enhancing mobility and flexibility to reduce stiffness and discomfort, improving strength and endurance to facilitate a return to daily activities, reducing reliance on medication, and promoting long-term functional independence through active rehabilitation.

19The applicant submits that the treatment plans are necessary to address chronic pain and functional impairments related to the motor vehicle accident. She reports ongoing musculoskeletal pain in her neck, back, and shoulders, along with reduced mobility and difficulty performing household chores and work tasks. She relies on CNRs from Dr. Jiun-An Lai, documenting symptoms of pain, dizziness, and disrupted sleep on April 15, 2019, prescribing physical therapies (massage, physiotherapy, acupuncture). Dr. Lai prescribes medication that include Naproxen, on March 27, 2020. The applicant relies on CNRs citing a March 2, 2021, consultation with Dr. Shahzad Qureshi for neuropathy, where no muscle weakness or range-of-motion limitation was recorded. Dr. Qureshi noted a follow-up in three months, no further CNRs are recorded.

20The respondent submits that the proposed treatment plan is not reasonable or necessary. It argues that the applicant sustained only minor injuries and reached maximum medical recovery, rendering further facility-based treatment unwarranted. The respondent notes that the applicant was released from the hospital shortly after the accident and continued to work until she went on childbirth leave for unrelated reasons. The treatment plans were submitted more than three years post-accident, which further questions their relevance and necessity.

21In support of its position, the respondent relies on the following evidence:

i. Dr. Billy Mango’s psychological assessment dated December 31, 2018, which found no psychological impairment affecting the applicant’s ability to function.

ii. Dr. Jean Pierre Sarco’s physiatry report dated May 6, 2019, which found no significant accident-related impairments, identified only soft tissue injuries, and concluded that no further facility-based rehabilitation was required.

iii. Dr. Raymond Zabieliauskas’ physiatry report dated July 12, 2021, which concluded the applicant had fully recovered from her soft tissue injuries and recommended only home exercises and over-the-counter medication as needed.

22I prefer the respondent’s evidence. The IE assessments conducted by Drs. Mango, Sarco, and Zabieliauskas were thorough, objective, and consistent. These reports collectively establish that: the applicant has fully recovered from minor soft tissue injuries; there is no clinical basis for further chiropractic or physiotherapy services; and the applicant's psychological and functional capacity remains intact, with no documented impairments preventing her from performing daily activities or work.

23On a balance of probabilities, the applicant has not established that the proposed treatments are reasonable and necessary. I find that the applicant has not met the burden. The record consists of self-reports without corroborating medical evidence.

Interest

24Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As there are no overdue benefits, interest is not payable.

Award

25I find that the respondent is not liable to pay an award.

26The 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.

27As no benefits have been found to be withheld or delayed, I find there is no award payable.

ORDER

28I find that:

i. the applicant is not entitled to $1,142.52 ($4,416.71 less $3,274.19 approved) for chiropractic services.

ii. the applicant is not entitled to $4,115.12 for chiropractic services.

iii. the applicant is not entitled to $3,989.56 for physiotherapy services.

iv. The applicant is not entitled to an award.

v. The applicant is not entitled to interest.

vi. The application is dismissed.