Licence Appeal Tribunal File Number: 23-010585/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:
Alicia Thomas
Applicant
and
Aviva Insurance Company
Respondent
DECISION
ADJUDICATOR:
Nishant Nayak
APPEARANCES:
For the Applicant:
Danielle Montinaro, Paralegal
For the Respondent:
Aleah Thomas, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Alicia Thomas, the applicant, was involved in an automobile accident on December 8, 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, Aviva 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:
Is the applicant entitled to $2,597.36 for chiropractic services proposed by Toronto Medical Centre in an OCF-18/treatment plan (“plan”) submitted March 21, 2023?
Is the applicant entitled to $1,970.00 for a neurological assessment proposed by Toronto Medical Centre in a plan submitted March 21, 2023?
Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
3The issue of an award was not listed as an issue in dispute for this hearing, however the applicant made submissions regarding an award and the respondent provided a response in their submissions. Therefore, I have added it as an issue in dispute.
RESULT
4The applicant has not proven, on a balance of probabilities, that she is entitled to the treatment plan for chiropractic services in dispute.
5The applicant has not proven, on a balance of probabilities, that she is entitled to the treatment plan for the neurological assessment in dispute.
6As there are no unreasonably withheld or delayed payments, no award is due.
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 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.
a) The applicant is not entitled to the chiropractic services treatment plan.
8The applicant has not proven, on a balance of probabilities, that the treatment plan for chiropractic services is reasonable and necessary.
9The OCF-18 authored by Dr. Shadi Jahandideh, chiropractor, identifies the goals of the treatment plan as: pain reduction, increased range of motion, increased strength, return to activities of normal living, and restore pre-accident levels of function.
10In support of the two treatment plans in dispute, the applicant relies upon the self-reports of her pain levels from the psychological IE assessments by Dr. Cheryl Bradbury, Dr. Shahriar Moshiri and Dr. Debra Mendel, as well the psychological assessment report completed with Toronto Medical Centre by Dr. Svetlana Gabidulina. The applicant further relies on the clinical notes and records (“CNRs”) of her family physician, Dr. Geoffrey Forbes.
11The respondent relies upon its IE assessment and paper review by Dr. Ahmad Belfon, family medicine and the IE assessment by Dr. Maria Nesterenko, family medicine. They both opined that this treatment plan is not reasonable and necessary. Both doctors opined that the applicant sustained soft-tissue sprain/strain injuries to her neck, back and shoulders, which typically heal within 8-12 weeks. Furthermore, there is no objective evidence of any ongoing musculoskeletal impairment attributable to the accident and the applicant has returned to her activities of normal living long ago. They also stated that the applicant had functional ranges of motion in her neck, back and shoulders and she has already undergone formal, facility-based treatment, from which she has achieved maximum therapeutic benefit, as corroborated by her self-reported 70% overall improvement. In conclusion, there is no clinical indication or justification for any further facility-based treatment.
12I do not place much weight on the psychological assessments the applicant relies upon in support of the chiropractic services treatment plan. They have no relevance to the issue in dispute. Furthermore, an acknowledgment of pain in these reports does not translate into a recommendation for further chiropractic treatment. Those assessors did not render opinions on whether chiropractic treatment was reasonable and necessary.
13I then find that the bulk of the CNRs of Dr. Forbes pertain to issues not related to the accident. For the occasions on which the accident is referenced, they are mostly in relation to psychological issues. There is a referral prepared by Dr. Forbes in 2024, nearly six years after the accident, for physiotherapy. However, there are no corroborating clinical notes from Dr. Forbes to show any ongoing, accident-related physical complaints from January 2019 until April 2024. I find this note is an outlier in the bulk of the medical evidence, as there are no contemporaneous CNRs from Dr. Forbes regarding accident-related physical complaints necessitating the need for chiropractic treatment. Nevertheless, the referral was made for physiotherapy, and not for chiropractic treatment.
14Accordingly, I find that the applicant has not demonstrated that the chiropractic treatment plan in dispute is reasonable and necessary as a result of the accident.
b) The applicant is not entitled to the neurological assessment treatment plan.
15I find that the applicant has not proven, on a balance of probabilities, that the treatment plan for a neurological assessment is reasonable and necessary.
16The OCF-18 was authored by Dr. Shadi Jahandideh, chiropractor. Along with the CNRs of Dr. Forbes and her self-reporting to the psychological assessors mentioned in the previous section, the applicant relies on the OCF-3 prepared by Dr. Mir Reza Nabavi, chiropractor.
17The respondent relies on an IE assessment completed by Dr. Garry Moddel, neurologist. Dr. Moddel opined the neurological assessment is not reasonable and necessary as there is no evidence of neurological impairment as a result of the December 8, 2018 motor vehicle accident.
18Dr. Forbes assessed the applicant with major depression in January 2019, and she was referred to a psychologist. Five subsequent visits to Dr. Forbes were not related to accident. Dr. Forbes’s CNRs from May, June and December 2021 mentioned psychological sequalae, as well as Major Depressive Disorder and Generalized Anxiety Disorder. The CNRs of Dr. Forbes from March 4, 2022 to November 23, 2022 were unrelated to the accident. The March 2023 CNRs of Dr. Forbes mentions the applicant contracting COVID-19 in 2021 and expressed concerns about Long COVID. Dr. Forbes’s CNRs from March 28, 2023 to October 19, 2023 were again unrelated to the accident. The April 2024 CNRs of Dr. Forbes had a referral note for physiotherapy treatment. Based on these CNRs, I find that Dr. Forbes has not noted any neurological symptoms or complaints and has not recommended a neurological assessment, nor did he refer the applicant to a neurologist in relation to any accident-related complaints.
19Chiropractors and psychologists are not medically qualified to provide opinions on neurological matters. Other than the self-reports of the applicant, I am not directed to evidence of any potential neurological issues or any recommendation that would warrant the need for a neurological assessment.
20I find that the applicant has not met her onus to prove, on a balance of probabilities, that a neurological assessment is reasonable and necessary.
21The applicant is not entitled to the treatment plan for a neurological assessment.
Award
22The 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. As no benefits have been unreasonably withheld or delayed, no award is due.
ORDER
23For the above reasons, I find:
The applicant is not entitled to payment for the chiropractic services treatment plan.
The applicant is not entitled to payment for the neurological assessment treatment plan.
The applicant is not entitled to an award.
The application is dismissed.
Released: September 19, 2025
Nishant Nayak
Adjudicator