Licence Appeal Tribunal File Number: 23-014686/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:
Mohammed Shujah
Applicant
and
CAA Insurance
Respondent
DECISION
ADJUDICATOR:
Melanie Malach
APPEARANCES:
For the Applicant:
Mohammed Shujah, Self-Represented
For the Respondent:
Jacqueline Fortner, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Mohammed Shujah, the applicant, was involved in an automobile accident on December 20, 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 respondent, CAA Insurance, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
2At the Case Conference on April 22, 2024, the applicant was represented by counsel. Following the Case Conference, counsel for the applicant submitted a Removal of Representative form, dated April 24, 2024. The applicant advised the Tribunal by way of e-mail on May 6, 2024, that he would be acting as a self-represented individual for the written hearing. 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.
ISSUES
3The issues in dispute are:
i. Is the applicant entitled to the assessments and services proposed by Mackenzie Medical Rehabilitation Clinic (“Mackenzie Medical”), as follows:
a) $567.52 ($1,823.60 less $1,256.08 approved) for chiropractic services, in a treatment plan dated December 22, 2022;
b) $709.40 ($2,229.50 less $1,520.10 approved) for chiropractic services, in a treatment plan dated November 9, 2022;
c) $425.64 ($1,417.70 less $992.06 approved) for chiropractic services, in a treatment plan dated May 25, 2023;
d) $269.76 ($1,525.84 less $1,256.08 approved) for chiropractic services, in a treatment plan dated August 15, 2023;
e) $55.00 ($1,857.30 less $1,802.30 approved) for chiropractic services, in a treatment plan dated October 2, 2023; and
f) $797.80 ($1,525.84 less $728.04 approved) for chiropractic services, in a treatment plan dated November 13, 2023?
ii. Is the applicant entitled to $1,130.00 for seasonal home maintenance submitted on a claim form (“OCF-6”) dated August 14, 2023?
iii. Is the applicant entitled to interest on any overdue payment of benefits?
4The respondent submits that the only disputed amounts in the treatment plans in dispute, is at Line 12 which indicates a separate cost of gloves for the use of Personal Protective Equipment (“PPE”).
RESULT
5I find that the applicant is not entitled to the balance of the treatment plans in dispute from Mackenzie Medical.
6I find that the applicant is not entitled to the OCF-6, dated August 14, 2023 for seasonal home maintenance expenses.
7I find that the applicant is not entitled to interest.
PROCEDURAL ISSUES
Document exchange and written submission deadlines
8The respondent’s request to dismiss the application due to the applicant’s failure to produce requested documents within the exchange deadline and to comply with the written submission deadline is denied. The applicant’s written submissions will be considered by the Tribunal.
9The parties attended at a Case Conference on April 22, 2024. The Case Conference Report and Order (“CCRO”), dated May 3, 2024, ordered the applicant to provide the respondent with several updated clinical notes and records (“CNRs”) within 30 calendar days following the case conference. The CCRO further ordered that the applicant was to file his submissions thirty calendar days prior to the scheduled hearing. The parties were subsequently notified that the written hearing date was January 31, 2025.
10The respondent submits that on June 17, 2024, it emailed the applicant requesting the documents ordered in the CCRO. On November 18, 2024, the respondent emailed the applicant providing him with the redacted log notes he requested at the Case Conference and again requesting the documents ordered to be produced in the CCRO. The respondent further reminded the applicant that his written submissions were ordered to be provided 30 days prior to the scheduled hearing of January 31, 2025. The respondent submits that no response was received from the applicant.
11The respondent submits that the applicant has failed to provide it with the documents ordered in the CCRO. The respondent further submits that the applicant did not submit his written submissions by the deadline of January 1, 2025. The respondent filed and served its submissions on January 10, 2025, and submits that the applicant has no intention to pursue this matter and has abandoned his application. The respondent therefore submits that this matter should be dismissed due to the applicant’s non-compliance with the CCRO.
12I find that the applicant has not provided a reply to the respondent’s submissions with respect to either of the procedural issues raised by the respondent. I agree with the respondent that the applicant did not provide the documents ordered in the CCRO and did not provide his written submissions by January 1, 2025.
13I find that with respect to the production of the documents requested in the CCRO, as the applicant is not seeking to rely upon the documents that were not provided, I do not find that the respondent has suffered significant prejudice which would justify dismissing the application, especially since it is the applicant’s burden to prove his case.
14I find that with respect to the applicant’s written submissions, these were due within 30 days before the hearing date and were provided more than a month past due. The respondent has not provided any submissions as to the prejudice it suffered as a result of the late submissions. While the applicant has not provided an explanation for the late filing of his submissions, I am exercising my discretion and including the applicant’s submissions in the hearing record. I find that dismissing this application without determining its merits is not appropriate as there is no evidence that any of the circumstances set out in Rule 3.4 and 3.5 of the Licence Appeal Tribunal Rules, would apply.
15I further find that while the respondent has submitted that the applicant abandoned the proceeding, I find that the applicant did submit his submissions, which demonstrates that he has not abandoned the proceeding. I further find that the respondent has not provided any evidence of the prejudice that it would suffer if I were to accept the applicant’s submissions as filed. Despite the applicant’s late filing and service, there is no evidence that the respondent was unable to provide submissions with respect to the issues in dispute.
16For the reasons set out above, I deny the respondent’s request to dismiss the application and accept the parties’ submissions as filed.
Jurisdiction of the Tribunal to deal with issues raised in submissions
17I find that the Tribunal does not have jurisdiction to grant the applicant payment of the remaining medical and rehabilitation benefit limits under his policy.
18The applicant in his submissions states that the respondent stopped his payments for his medical and rehabilitation benefits after five years of the accident. He claims that to date the respondent has paid him $28,646.20 and there still remains $36,353.80 under his policy limits. The applicant requests that the Tribunal order the respondent to pay him the whole or a partial balance of the medical and rehabilitation limits under his policy in order for his rehabilitation treatment to continue.
19I find that the Tribunal does not have jurisdiction to grant the order being sought by the applicant. The Tribunal’s jurisdiction is derived from s. 280(2) of the Insurance Act which pertains to the resolution of disputes regarding statutory accident benefits in accordance with the Schedule. Where an insurer denies a benefit, the insured person can apply to the Tribunal for resolution of the dispute, as described in s. 280(1) of the Insurance Act. Subsection (1) refers to disputes regarding an insured person’s entitlement to statutory accident benefits or in respect to the amount of statutory accident benefits to which an insured person is entitled.
20I find that in the present matter, there has been a request for medical and rehabilitation benefits and a home maintenance benefit submitted and denied. Therefore, I find that there is a “dispute” as defined in s. 280 of the Insurance Act. However, there is no provision in the Schedule or other authority in support of the proposition that an insured person is entitled to funds up to the limits of funding for medical and rehabilitation benefits, without reference to a specific claim for benefits. The funding limits are not a benefit under the Schedule, and the Schedule does not contemplate such a payment.
21As such, I find that the Tribunal does not have jurisdiction to adjudicate the issue of whether the applicant is entitled to the remaining medical and rehabilitation benefit limits, and as such, the issue cannot proceed to the substantive portion of the hearing.
ANALYSIS
The applicant is not entitled to the balance of the treatment plans in dispute
22I find that the applicant has not proven on a balance of probabilities that he is entitled to the balance of the treatment plans in dispute.
23To receive payment for medical and rehabilitation benefits under sections 15 and 16 of the Schedule, the applicant has the onus of proving 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 the overall costs of achieving them are reasonable.
24The applicant claims entitlement to the balance of six treatment plans proposed by Mackenzie Medical. The applicant submits that he suffers permanent injuries to both of his shoulders which has developed into chronic pain. He submits that he has developed problems to his neck for which he takes daily prescription medication. He is also suffering anxiety and a fear of driving. He submits that he does not drive for pleasure and only drives a minimal amount. The applicant did not make specific submissions as to whether the treatment plans in dispute are reasonable and necessary. The applicant has attached multiple medical documentation to his submissions, but he has not directed the Tribunal to any specific reference within these records to support his entitlement to the balance of the treatment plans in dispute.
25The respondent submits that following review of the treatment plans in dispute, it realized that it made a miscalculation with respect to the approved hourly rates of the healthcare professions. By letter dated January 9, 2025, the respondent advised the applicant that it had made a miscalculation and confirmed that the chiropractic hourly rate on each treatment plan in dispute was correctly calculated by Mackenzie Medical. It therefore advised the applicant and Mackenzie Medical that it would pay for the incurred treatment. I assume based on the respondent’s submissions that this amount owing has since been paid to the applicant or Mackenzie Medical.
26The respondent submits that the only disputed amount in the treatment plans in dispute, is at Line 12 which indicates a separate cost for gloves for the use of PPE, as follows:
a) Treatment Plan dated December 22, 2022: $44.00 for gloves, protective and therapeutic;
b) Treatment Plan dated November 7, 2022: amount for gloves, protective and therapeutic (treatment plan not provided so amount is unknown;
c) Treatment Plan dated May 25, 2023: $33.00 for gloves, protective and therapeutic;
d) Treatment Plan dated July 31, 2023: $44.00 for gloves, protective and therapeutic;
e) Treatment Plan dated October 2, 2023: $55.00 for gloves, protective and therapeutic;
f) Treatment Plan dated November 13, 2023: $55.00 for gloves, protective and therapeutic;
27The respondent submits that the additional cost of gloves submitted by Mackenzie Medical is an expense related to professional services as defined by the Professional Services Guideline, Superintendent’s Guideline No. 03/14 (“Guidelines”). It submits that this cost effectively exceeds the maximum hourly rate of chiropractic services, and therefore it is not liable for payment of same.
28The respondent submits that the Guidelines state:
Automobile insurers are not liable to pay for expenses related to professional services rendered to an insured that exceeds the maximum hourly rate set out in the Appendix.
29The respondent submits that with respect to expenses, the Guideline further states:
Expenses related to professional services” as referred to in the SABS and the Professional Services Guideline include all administrative costs, overhead, and related costs, fees, expenses, charges and surcharges. Insurers are not liable for any administrative or other costs, overhead, fees, expenses, charges or surcharges that have the result of increasing the effective hourly rates, or the maximum fees payable for completing forms, beyond what is permitted under the Professional Services Guideline.
30The respondent relies on the Tribunal decision in Marcijus v. Co-Operators, 2024 CanLII 115426 (ON LAT), where it was determined that PPE is an expense related to professional services as defined in the Guideline, which exceeded the maximum professional rate allowable. The insurer was therefore not obligated to pay for the cost.
31I find that the applicant has not made any submissions about the particulars of the treatment plans denied or whether the balance of the treatment plans in dispute are reasonable and necessary.
32I agree with the respondent that PPE is a cost to the treatment provider, and insurers are not liable to pay for administrative costs or expenses related to professional services that exceed the maximum rates under the Guideline, or for charges that have the result of increasing the rates. The respondent approved the treatment sessions with the chiropractor at the maximum rate for a chiropractor under the Guideline. I find that adding the proposed cost of PPE would effectively increase that rate to exceed the maximum amount allowable. I accordingly find that the applicant is not entitled to the expense for PPE.
33For the reasons set out above, I find that the applicant has not proven on a balance of probabilities that he is entitled to the balance claimed in Line 12 of the treatment plans in dispute for gloves.
The applicant is not entitled to seasonal home maintenance expenses
34I find that the applicant has not proven on a balance of probabilities that he is entitled to seasonal home maintenance expenses.
35Section 23(1) of the Schedule provides that an insurer shall pay up to $100.00 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.
36Section 28(2)(i) of the Schedule provides that every insurer shall offer optional benefits including an optional caregiver, housekeeping and home maintenance benefit.
37The applicant claims entitlement to an OCF-6, dated August 14, 2023, for seasonal landscaping and snow removal expenses for the years 2022-2023, in the amount of $1,130.00 as follows:
A1 Seasonal Contracting – Landscaping from May 2022 to November 2022 - $678.00
A1 Seasonal Contracting – Snow Removal from December 2022 to March 2023 - $452.00
38The applicant’s handwritten letter dated August 14, 2023, states that he has developed permanent injuries to both his shoulders and because of his day-to-day suffering, he has been unable to take care of his front and back yards. He states that he has hired the services of A1 Seasonal Contracting and encloses an invoice for their services for the years 2022-2023. He refers to an MRI report in October 2022 and another report taken two months prior, as well as a report of Dr. Carlos Lopez, his orthopedic surgeon, in support of his entitlement to these services.
39The respondent submits that the applicant is not eligible to receive home maintenance benefits. By letter dated September 20, 2023, the respondent denied the claimed expenses. The letter explains that the applicant is not eligible to claim housekeeping and home maintenance expenses because he has not been determined to have sustained a catastrophic impairment and he has not purchased optional housekeeping and home maintenance benefits.
40I agree with the respondent that the applicant is not entitled to the seasonable home maintenance expenses claimed as he did not meet the eligibility criteria pursuant to s. 23 of the Schedule. I find that there is no evidence that the applicant suffered a catastrophic impairment as defined by the Schedule and to date he has not made a claim to be determined to have a catastrophic impairment by submitting an OCF-19. In addition, I find that the applicant did not purchase optional housekeeping and home maintenance benefits, and he is therefore not entitled to claim these benefits.
41For the reasons set out above, I find that the applicant has not proven on a balance of probabilities that he is entitled to the OCF-6 for seasonable home maintenance benefits.
Interest
42Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Having found that the applicant is not entitled to the balance of the disputed treatment plans or the OCF-6 for home maintenance expenses, no payments are overdue, and therefore no interest is payable.
ORDER
43For the reasons outlined above, I find that:
i. The applicant is not entitled to the balance of the treatment plans in dispute from Mackenzie Medical;
ii. The applicant is not entitled to the OCF-6, dated August 14, 2023, for seasonal home maintenance expenses;
iii. The applicant is not entitled to interest; and
iv. The application is dismissed.
Released: September 19, 2025
Melanie Malach
Adjudicator