Licence Appeal Tribunal File Number: 23-013926/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:
Adam Pelc
Applicant
and
Northbridge General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Estella Muyinda
APPEARANCES:
For the Applicant:
Rebbecca Phillips, Counsel
For the Respondent:
Majd Obeid, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Adam Pelc, the applicant, was involved in an automobile accident on June 15, 2022, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”).
2The applicant was denied benefits by the respondent, Northbridge General Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
3The issues in dispute are:
i. Is the applicant entitled to $2,425.47 for chiropractic services and massage, proposed by AIM Rehabilitation in a treatment plan dated December 13, 2023?
ii. Is the applicant entitled to interest on any overdue payment of benefits?
4Issues 1 and 2 in the CCRO dated April 24, 2024, were resolved between the parties. Therefore, I have not listed them as being in dispute.
RESULT
5The applicant is entitled to $2,425.47 for chiropractic services.
6The applicant is entitled to interest.
ANALYSIS
7To receive payment for a treatment and assessment plan under s. 15 and s. 16 of the Schedule, the applicant bears the burden of demonstrating on a balance of probabilities that the benefit is reasonable and necessary because of the accident.
8To 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.
9The applicant is entitled to the treatment plan for chiropractic services and massage in the amount of $3,650.00.
10The treatment plan was prepared by Dr. Patrycja Renda, chiropractor. It was submitted on December 13, 2023. The injuries outlined in the treatment plan are lumbar and other intervertebral disc disorders with radiculopathy, injury of muscles and tendons of the rotator cuff of shoulder, other specified diseases of the spinal cord, bursitis of the shoulder, and nausea. The identified goals of treatment are pain reduction, increased range of motion, a return to activities of normal living and a return to pre-accident work activities. It was noted that progress on these goals would be determined by range of movement testing, orthopaedic testing, muscle and joint palpation, neuro testing. The estimated duration of the treatment plan was 12 weeks.
11The applicant submits that his health service providers recommended a multidisciplinary approach to his treatment. In the occupational therapy in-home assessment report dated December 22, 2023, Ms. Jane Zambon, occupational therapist, recommended ongoing multidisciplinary intervention including physiotherapy, chiropractic care, massage therapy and psychological intervention.
12Further, the applicant states that in the psychological progress report dated April 22, 2024, Dr. Agnieska Krupski, psychologist, opined that due to the relationship between the applicant’s physical and psychological injuries, she recommended ongoing multidisciplinary approach to his treatment.
13Furthermore, in a letter dated June 20, 2024, Dr. Iwona Tarasiewicz, family physician, recommended facility-based treatment. Dr. Tarasiewiczi noted in the supplemental attending physician statement dated May 6, 2024, that the applicant’s treatment plan includes physiotherapy and chiropractic services.
14Although these reports were written within a 6-month period after the treatment plan was submitted in December 2023, I find that they cast light upon and support the need for chiropractic treatment at the time of the treatment plan.
15The respondent relies on the insurer examiner’s report from Dr. Naresh Murty (neurosurgeon) dated March 6, 2024. to assert that the treatment plan is not reasonable or necessary. The applicant submits that Dr. Murty opined that it was unlikely that the applicant would benefit from further facility-based treatments.
16The respondent submits that the applicant has not provided an evidentiary basis that shows the treatment plan would provide functional benefits that would improve his condition. Additionally, the respondent asserts that given that the applicant’s condition has minimally improved after receiving extensive facility-based treatment, the treatment plan was not reasonable and necessary.
Further, the respondent states that Dr. Murty opined that throughout the assessment, the applicant did not present any pain focused behaviours. I find Dr. Murty’s opinion not persuasive because in the report dated October 16, 2024. the respondent’s s.44 insurer examination assessor, Ms. Meghan Passmore, occupational therapist, stated that the applicant required breaks and exhibited frequent pain movements during his assessment. Additionally, Ms. Passmore indicated that the applicant had not returned to his pre-accident level of functioning and required personal care assistance. In sum, her assessment demonstrates that the treatment plan sought by the applicant is reasonable and necessary.
17I am persuaded by the corroborative reports from Dr. Krupski’s and Ms. Jane Zambon, including Dr. Tarasiewicz’ clinical notes upon which the applicant relies on in support of his position, as establishing that this treatment plan is reasonable and necessary.
18I find that the applicant submitted evidence through his professional health service providers that show that the applicant needs chiropractic care for his ongoing function and pain relief.
19Accordingly, I am satisfied that there is contemporaneous medical support from Dr. Krupski, Dr. Tarasiewicz and Ms. Jane Zambon with respect to the applicant’s ongoing need for chiropractic treatment in relation to the treatment plan that was submitted on December 13, 2023.
20For those reasons, I find that the applicant has demonstrated that the treatment plan is reasonable and necessary. The applicant is entitled to the treatment plan.
Interest
21I find that the applicant is entitled to the payment of interest on overdue benefits pursuant to s.51 of the Schedule.
ORDER
22The applicant is entitled to the treatment plan in the amount of $2,425.47 for chiropractic services.
23The applicant is entitled to interest.
Released: September 17, 2025
__________________________
Estella Muyinda
Adjudicator