Licence Appeal Tribunal File Number: 23-006483/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:
Khaled Nour
Applicant
and
TD General Insurance Company
Respondent
DECISION
ADJUDICATOR: Robert Rock
APPEARANCES:
For the Applicant: Alessandra Ottaviano, Counsel
For the Respondent: Jonathan White, Counsel
HEARD: By way of written submissions
OVERVIEW
1Khaled M Nour, the applicant, was involved in an automobile accident on August 12, 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 as set out in the case conference report and order dated February 7, 2024 are:
i. Is the applicant entitled to $2,829.73 for physiotherapy services, proposed by HealthMax Physio – North York in an OCF-18/treatment plan (treatment plan) dated March 10, 2022?
ii. Is the applicant entitled to $3,557.70 for case manager services, proposed by Rehab First in a treatment plan dated January 2, 2023?
iii. Is the applicant entitled to $2,115.05 for an OT Community Situational Assessment, proposed by Rehab First in a treatment plan dated December 5, 2022?
iv. Is the applicant entitled to $2,115.05 for an OT In-Home Situational Assessment, proposed by Rehab First in a treatment plan dated December 5, 2022?
v. Is the applicant entitled to $5,650.00 for a CAT Psychiatric Assessment, proposed by Dr. Sujay Patel PsycIME in a treatment plan dated May 10, 2023?CAT
vi. Is the applicant entitled to $11,526.00 for CAT Assessments, proposed by Dr. Lisa Becker, Omega Medical Associates in treatment plan dated March 21, 2023?
vii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
viii. Is the applicant entitled to interest on any overdue payment of benefits?
3This matter was originally scheduled as a videoconference hearing as per the Case Conference Report and Order (CCRO) released on February 7, 2024. On August 19, 2024, a Motion Order was released that converted the hearing to a written hearing, and revised the issues in dispute to remove: Catastrophic impairment and income replacement benefits.
4The remaining issues left in dispute according to the Motion Order were six treatment plans outlined as the issues above.
5Subsequent to the Motion Order, the respondent has fully approved four of the treatment plans and has partially approved the two CAT treatment plans. In their submissions, the applicant has indicated they no longer wish to dispute the remaining amount of the partially approved CAT treatment plans.
RESULT
6As the applicant is not disputing the outstanding amounts for the two CAT treatment plans in dispute, I make no finding on these plans.
7The applicant is not entitled to an award.
8The applicant is not entitled to interest.
ANALYSIS
9The applicant in their written submissions states that the applicant does not wish to dispute the remaining amount of the partially approved treatment plans.
10As set out above, based on the information provided by the respondent, the Motion Order outlined 6 treatment plans in dispute. The respondent fully approved 4 of the treatment plans, and partially approved 2 of them.
11Therefore, there are no treatment plans in dispute.
Interest
12Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. The applicant is entitled to interest in accordance with s. 51 on the overdue payment of benefits for the four approved treatment plans (physiotherapy services, case manager services, OT Community Situational Assessment, and OT In-Home Situational).
Award
13The 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.
14The applicant argues that the respondent has operated in a lack of good faith and fairness in determining IRB.
15The respondent argues that the applicant has not led any evidence to support their award claim, nor did they comply with the CCRO to provide particulars of the claim within 30 days of receiving the redacted log notes, which they received on March 22, 2024.
16I find the applicant is not entitled to an award. The applicant has not pointed or directed me to evidence i that would support it’s claim that the respondent operated in a lack of good faith or fairness in determining IRB. I find that the respondent did not unreasonably withhold or delay the payment of benefits.
17The applicant is not entitled to an award.
ORDER
18I find that:
i. As the applicant is not disputing the outstanding amounts for the two CAT treatment plans, I make no finding on these plans.
ii. The applicant is not entitled to an award.
iii. The applicant is entitled to interest in accordance with s. 51 on the overdue payment of benefits for the four approved treatment plans.
iv. The application is dismissed.
Released: September 12, 2025
Robert Rock
Adjudicator