Licence Appeal Tribunal File Number: 23-007604/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:
Andrew Lee
Applicant
and
Aviva Insurance Company of Canada
Respondent
DECISION
ADJUDICATOR:
Matthew Frontini
APPEARANCES:
For the Applicant:
Diana Villalta, Paralegal
For the Respondent:
Tefiney E Scarlett, Paralegal
HEARD:
By way of written submissions
OVERVIEW
1Andrew Lee, the applicant, was involved in an automobile accident on September 19, 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, Aviva Insurance Company of Canada, 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 $2,486.00 for physiotherapy services, proposed by Downsview Healthcare in a treatment plan/OCF-18 (“treatment plan”) dated May 12, 2023?
ii. Is the applicant entitled to $1,286.00 for physiotherapy services, proposed by Dr. G. C. Lynd in a treatment plan dated May 22, 2021?
iii. Is the applicant entitled to $1,286.00 for physiotherapy services, proposed by Dr. G.C. Lynd in a treatment plan dated June 21, 2021?
iv. Is the applicant entitled to $3,308.00 for physiotherapy services, proposed by Downsview Healthcare in a treatment plan dated May 8, 2023?
v. Is the respondent liable to pay an award under s. 10 of Reg. 664 of 50% of the benefits payable, because it unreasonably withheld or delayed payments to the applicant?
vi. Is the applicant entitled to interest on any overdue payment of benefits pursuant to the s. 51 of the Schedule?
3The applicant’s submissions included submissions on whether his injuries are predominantly minor as defined in s. 3 of the Schedule and therefore subject to treatment within the $3,500.00 Minor Injury Guideline limit (“MIG”).
4The respondent submits that the applicant was removed from the MIG on November 9, 2020. This issue was not also listed as an issue in dispute in the case conference report an order, dated February 16, 2024 (“CCRO”).
5Based on the parties’ submissions and the respondent agreeing the applicant is not subject to the MIG, therefore the MIG will not be addressed as part of this decision.
6The applicant’s submissions also request an award under s. 10 of Reg. 664 of 50% of the benefits payable, because it unreasonably withheld or delayed payments. This issue was not listed as an issue in dispute in the CCRO. I note that the respondent addressed the issue of an award in its responding submissions.
7Given that the respondent has substantively engaged on this issue, I have listed it as an issue in dispute in subparagraph 3(v) above and the issue of an award will be addressed as part of this decision.
RESULT
8I find that:
i. The applicant is not entitled to $1,286.00 for physiotherapy services, proposed by Dr. G. C. Lynd in a treatment plan dated May 22, 2021.
ii. The applicant is not entitled $1,286.00 for physiotherapy services, proposed by Dr. G.C. Lynd in a treatment plan dated June 21, 2021.
iii. The applicant is not entitled $3,308.00 for physiotherapy services, proposed by Downsview Healthcare in a treatment plan dated May 8, 2023.
iv. The respondent is not liable to pay an award under s. 10 of Reg.
v. The applicant is not entitled to interest on any overdue payment of benefits pursuant to the s. 51 of the Schedule.
vi. The application is dismissed.
ANALYSIS
The applicant is not entitled to any of the disputed treatment plans
9I find that the applicant has not established on a balance of probabilities that he is entitled to any of the disputed treatment plans.
10To receive payment for a treatment and assessment plan under ss. 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.
11The applicant’s written submissions briefly list various medical records and then proceed to simply state that the applicant is entitled to each treatment plan in dispute. The applicant does not provide any submissions regarding the treatment plans themselves, their goals in relation to the applicant’s injuries, the reasonableness of meeting those goals or the reasonableness of the plans’ costs.
12In the absence of specific submissions regarding the reasonableness and necessity of any of the treatment plans in dispute, I find that the applicant has not met his onus to establish on a balance of probabilities that he is entitled any of these benefits.
Interest
13As I have found that the applicant is not entitled to any of the disputed treatment plans and there are no overdue payment of benefits, therefore, he is not entitled to interest pursuant to s. 51 of the Schedule.
Award
14I find that the applicant has not established that she is entitled to an award.
15The 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.
16The applicant’s written submissions do not point to any specific facts or make any specific arguments as to why an award is warranted in this application. Given the lack of specific submissions on this issue, I find that applicant has not established that the respondent unreasonably withheld or delayed the payment of any benefit. As such, the applicant is not entitled to an award.
ORDER
17I find that:
i. The applicant is not entitled to $2,486.00 for physiotherapy services, proposed by Downsview Healthcare in a treatment plan dated May 12, 2023.
ii. The applicant is not entitled to $1,286.00 for physiotherapy services, proposed by Dr. G. C. Lynd in a treatment plan dated May 22, 2021.
iii. The applicant is not entitled $1,286.00 for physiotherapy services, proposed by Dr. G.C. Lynd in a treatment plan dated June 21, 2021.
iv. The applicant is not entitled $3,308.00 for physiotherapy services, proposed by Downsview Healthcare in a treatment plan dated May 8, 2023.
v. The respondent is not liable to pay an award under s. 10 of Reg.
vi. The applicant is not entitled to interest on any overdue payment of benefits pursuant to the s. 51 of the Schedule.
vii. The application is dismissed.
Released: September 18, 2025
Matthew Frontini
Adjudicator