Licence Appeal Tribunal File Number: 24-008672/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:
Samuel Agyapong
Applicant
and
Aviva General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Mary Henein Thorn
APPEARANCES:
For the Applicant:
Rita M. Gratsias, Counsel
For the Respondent:
Geoffrey Keating, Counsel
Interpreter:
Alberta Cheetham (Twi language), Day 1
Emmanuel Mensah (Twi language), Day 2
Court Reporter:
Guido Riccioni
Heard by Videoconference:
May 20, 21 and 22, 2025
OVERVIEW
1Samuel Agyapong (“applicant”) was involved in an automobile accident on September 26, 2016, 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 General 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:
i. Has the applicant sustained a catastrophic impairment (Criterion 8) as defined by the Schedule?
ii. Is the applicant entitled to $4,856.14 for prescriptions, submitted on a claim form (“OCF-6”) dated October 3, 2016?
iii. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3I find the applicant has not satisfied the onus of proving that he sustained a CAT impairment as a result of the accident;
4The applicant is not entitled to payment for the OCF-6 for prescriptions; and
5The applicant is not entitled to interest.
PROCEDURAL ISSUES
Res Judicata
6Generally, res judicata is a legal principle preventing matters that have been previously decided to be heard again. While some exceptions exist, there are three essential criteria for the principle to apply: first, there must be an earlier decision on the issue; second, there must be a final judgment on the merits; and third, the same parties must be involved. The purpose of the principle is to provide finality and to promote consistency in decisions. I find on the evidence that res judicata does not apply to the facts of this hearing. The respondent submits the Tribunal’s earlier decision conclusively determined that the applicant’s lower extremity neurological symptoms and pain are not a result of the accident. Accordingly, the respondent argues that res judicata applies in this matter, and any evidence related to the applicant’s lower extremity should not be considered.
7The applicant disagrees with the respondent and submits the Tribunal’s decision is being re-considered, and, as such, is relevant to this hearing. Causation was not before the Tribunal as an issue in dispute at the previous hearing, therefore res judicata does not apply.
8I find the respondent’s argument hinges on issue estoppel (the same question, final decision, and same parties; pursuant to Danyluk v. Ainsworth Technologies Inc., 2001 SCC 44. However, in the previous hearing, the adjudicator conducted a thorough analysis of the evidence before her and determined, on a balance of probabilities, the applicant’s lower extremity neurological symptoms and pain are not as a result of the accident pertaining to the specific issues in dispute before her.
9The question before me is a different question in this hearing. I am asked to make a determination about whether the applicant suffered a catastrophic impairment for which the lower extremity symptoms may form only a part of the applicant’s overall symptoms. I find that is a different question, therefore I find the rules of res judicata do not apply.
Applicant’s representatives
10Rita M. Gratsias, Counsel, and Kwaku Bona, Paralegal, identifed themselves as the applicant’s representatives. I questioned Mr. Bona’s ability to represent the applicant at the hearing given that he is a Paralegal and given that one of the issues in dispute is catastrophic impairment.
11Mr. Bona advised me that he was currently a student-at-law, and he can call himself a lawyer. As such, he asserted he is able to represent the applicant in this matter. It is his submission that, since he is well on his way to being a lawyer, the Law Society of Ontario’s (“LSO”) By-laws do not apply in this case. In fact, he has represented the applicant in other cases which appeared before the Tribunal.
12Before making a ruling, I asked Mr. Bona to provide me with the authority that allows a law student to act as counsel for someone who may be catastrophically impaired. I was not provided with any legal authority.
13Since Mr. Bona’s status appears as a Paralegal in the LSO’s Directory, I declined to allow him to represent the applicant in this matter. I rely on LSO By-Law 4, which prohibits paralegals from representing a party in a statutory accident benefits claim where an individual is or appears to be catastrophic impaired. Counsel Rita M. Gratsias proceeded to represent the applciant for the duration of the hearing.
Surveillance report, video, and photographs
14The respondent’s surveillance is accepted into evidence.
15At the start of the hearing, the applicant brought a motion to exclude the surveillance material. The applicant submits that the respondent conducted surveillance of him on June 17, 18, 19 and 26 of 2022, but he was not provided with this material until April 3, 2025. Due to the proximity to the hearing, he submits he did not have an opportunity to present the surveillance material to his experts for review in preparation for the hearing. The applicant submits that this amounts to a trial by ambush, and to allow it would be prejudicial and procedurally unfair.
16The applicant further submits that the Case Conference Report and Order (dated November 12, 2024) ordered the respondent to exchange any surveillance material it intends to rely on at the hearing within 30 days of the case conference. The respondent failed to comply with the order, therefore it should not be admitted.
17In its defence, the respondent submits that surveillance is not an expert opinion that needs a rebuttal. Rather, it shows the applicant’s day-to-day activities to which he should already be aware of. Further, the test for whether or not evidence should be excluded is based on relevancy to the issues in dispute. For example, documents that would be relied upon at the hearing and not provided to an assessor for an opinion are still admissible and relevant to the hearing. If the surveillance is excluded, it will prejudice the respondent.
18The surveillance will not be entered into evidence. Pursuant to Rule 9.3 of the Licence Appeal Tribunal Rules, 2023, (“Rules”) the respondent did not serve the surveillance file within the production exchange timelines in contravention to the Case Conference Report and Order (“CCRO”). It also is in contravention of Rule 9.4.3, the respondent did not exchange the surveillance evidence with the applicant 21 days prior to the hearing even though it had it in its possession for over two years.
19By allowing the surveillance file into evidence, it will prejudice the applicant. I agree with the applicant, he should have been presented an opportunity to allow his experts to review, analyze and respond to the surveillance. The respondent did not provide a reason for not exchanging the surveillance file within the timeframes of the CCRO and the Tribunal Rules. In the absence of a valid reason, I am denying the request to include the surveillance evidence as an exhibit.
ANALYSIS
Catastrophic Impairment under Criterion 8
20The applicant has not established he suffers a catastrophic impairment as defined under Criterion 8 in the Schedule.
21The applicant seeks a determination of catastrophic impairment (“CAT”) under Criterion 8 as defined by the Schedule. He takes the position he meets the definition of CAT under Criterion 8, because he now suffers a marked impairment due to a mental or behavioural disorder as a result of the injuries he sustained in the subject accident.
22Criterion 8 refers to impairments due to a mental or behavioural disorder resulting from the accident. These impairments are rated according to how seriously they affect a person’s useful daily functioning. The American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993 (“AMA Guides”) set out the four spheres of functioning and the levels of impairment as represented in the chart below:
| Area or Aspect of Functioning | Class 1: NO Impairment | Class 2: MILD Impairment | Class 3: MODERATE Impairment | Class 4: MARKED Impairment | Class 5: EXTREME Impairment |
|---|---|---|---|---|---|
| Activities of Daily Living | No impairment is noted | Impairment levels are compatible with most useful functioning | Impairment levels are compatible with some, but not all useful functioning | Impairment levels significantly impede useful functioning | Impairment levels preclude useful functioning |
| Social Functioning | |||||
| Concentration, Persistence and Pace | |||||
| Adaption |
23The test to determine whether the applicant has sustained a catastrophic impairment is a legal one and not a medical one. See: Liu v. 1226071 Ontario Inc. (Canadian Zhorong Trading Ltd.), 2009 ONCA 571 at paras. 29-30.
24An insured person is catastrophically impaired under Criterion 8 if they prove on a balance of probabilities that an accident causes them to sustain three or more marked (Class 4) impairments or one extreme (Class 5) impairment in the areas of function due to mental or behavioural disorders.
25The applicant testified that the physical injuries he sustained at the time of the accident were to his head, neck, hand, shoulder, and to his lower extremities which include his leg and back. He also suffers psychological impairments, which include a diagnosis of an Adjustment Disorder with Mixed Anxiety and Depressed Mood, and Somatic Symptom Disorder With Predominant Pain, nightmares, and sleeplessness.
26The applicant relies on the opinions of Dr. Emily Gavett-Liu, Psychiatrist, and Dr. Tajedin Getahun, Orthopaedic Surgeon. Dr. Gavett-Liu authored a report, dated September 25, 2023, and Dr. Getahun completed an OCF-19 form, dated October 26, 2023, for a CAT impairment based on Criterion 8. He also provided an executive summary, dated August 12, 2023. Together, they opined the applicant suffers 3 marked impairments in the spheres of: activities of daily living, social functioning, and adaption based on his psychological impairments. Dr. Gavett-Liu diagnosed him with Somatic Symptom Disorder, Specific Phobia Situational Type (vehicular) and Major Depressive Disorder, with anxious distress. They also found the applicant has a moderate impairment in the sphere of concentration, persistence, and pace.
27The respondent argues the applicant has not met his onus to prove that he has sustained a CAT impairment as a result of the subject accident, and he should not be found catastrophic under Criterion 8. It relies on the opinions of Dr. Mohamed Khaled, Physician, in a report dated June 3, 2021, and Dr. Jodi Grenier, Psychiatrist, in a report dated April 13, 2021. They found the applicant suffers a moderate impairment in the sphere of activities of daily living and adaption, and a mild impairment in the sphere of social functioning.
28Both parties agree that the applicant’s impairment in the sphere of concentration, persistence and pace is below the level of a marked impairment. I accept the applicant has not sustained a marked or extreme impairment in this sphere.
29Therefore, in order to be deemed catastrophically impaired, the applicant must show that he has a marked impairment in the three remaining spheres, i.e., activities of daily living, social functioning, and adaptation, as a result of the accident. Neither party states that the applicant has sustained an extreme impairment in any of the spheres.
30As noted above, when considering the evidence and making a determination, I will not consider the physical impairment of the applicant’s lower extremity neurological symptoms and pain related to his lower extremities.
Activities of Daily Living
31I find the applicant has not met his onus that he suffers a marked impairment in the sphere of activities of daily living as a result of the accident.
32The AMA Guidelines specify that this domain includes self-care, personal hygiene, communication, ambulation, travel, sexual function, and sleep. The quality of these activities is judged by their independence, appropriateness, effectiveness, and sustainability. The assessment focuses on the overall degree of restriction, not merely the number of restricted activities.
33Moderate impairments are compatible with some useful functioning. Marked impairments significantly impede useful functioning.
34The applicant testified that, prior to the accident, he had back surgery to remove a cyst located in his back in February of 2016, and pain in his right knee. However, he stated he did not have any functional limitations and was able to do everything. He traveled, attended church regularly, and enjoyed spending time with friends and family. He maintained his house inside and out, drove his children to school and to their other extracurricular activities. He was also heavily involved in a cultural group called Atwimaman Society, where he assisted other members with anything they needed.
35The applicant testified that he last worked in 2015. He worked in a warehouse where he was expected to lift objects up to 40 lbs. He stated he was laid off due to the number of medical appointments related to his surgery and the lifting demands. He was looking for a job as a professional truck driver but was unsuccessful in finding a placement.
36Post-accident, the applicant testified his ability to function, and his psychological impairments, have significantly affected his activities of daily living. He keeps to himself and no longer finds leisure activities excite him. Pre-accident, he used to be able to assist his wife with the required home maintenance, cooking, and cleaning, but now he does not due to physical and psychological issues. He has a fear of exacerbating his pain or falling and he lacks motivation. He instead relies on her to manage almost everything. As a result, his relationship with his wife is very strained. He testified that they argue all of the time, have become estranged, and, as a result, they no longer have a sexual relationship.
37The applicant submits his inability to work, the inability to contribute and be a partner to his wife have all deteriorated his self-esteem, and he feels as though he does not have a sense of purpose. He has issues sleeping due to nightmares where he feels like someone is coming to get him, or he has flashbacks of the accident. He also finds himself crying a lot, he has excessive worrying and nothing makes his mood better.
38The applicant submits he also struggles to take care of his personal needs. He can no longer go upstairs to take a shower due to a weakening of his legs and a fear of falling and injuring himself; he uses a bucket to bathe while sitting on a couch downstairs. He can easily go a week and a half without changing his clothes. Periodically he drives short distances, but, to get to his appointments, he takes an Uber because he has a fear of driving and getting into an accident. To get out of the house, he will go shopping or for aquatherapy at the community centre, but, overall, he testified, his life has become quite small and secluded.
39Dr. Gavett-Liu testified that she relied on a Catastrophic Assessment Report, dated August 8, 2023, by Allyson Weldon, Occupational Therapist. She also relied on the applicant’s pre and post accident clinical notes and records. Dr. Gavett-Liu determined the applicant’s pre-accident baseline was that of a fully functioning individual who was working at the time of the accident. He was independent in his activities of daily living, including in the areas of his self-care, homecare, social, vocational, and avocational activities. She opines post-accident, the applicant’s life has drastically changed, and he has a significant decrease in his ability to function due to his psychological impairments.
40To assist in forming her opinion, she performed a series of tests and determined the applicant is moderately depressed; his somatic symptom severity level is severe; and she found, overall, the Clinical Global Impression-Severity Scale determined he is considered severely ill. Within her evaluation, she identified psychosocial stressors contributing to his psychological impairments, including dysfunctional physical/emotional symptoms, limited meaningful daytime structure, financial strain, inability to work, social isolation and marital strain. In her report, she indicates the applicant did not remember taking any medication prior to the accident, but, post-accident, he takes medication to control his mood, sleep and for his pain.
41Based on her clinical testing, the applicant’s self-reporting, and her review of other medical documentation, she opined the applicant suffers a marked impairment in the sphere of activities of daily living.
42The respondent challenges Dr. Gavett-Liu’s assessment of the applicant on the basis that she did not allocate a score for his pre-existing condition, her pre- and post-accident baseline is substantially incorrect, and her analysis is flawed. Since she found he had little to no physical or psychological impairments prior to the accident, she attributes all of his change in functioning, and much of his psychological impairments, to the accident.
43The respondent submits Dr. Gavett-Liu did not properly review the clinical notes and records before her. She preferred the applicant’s self-reporting over some of the medical records to form her opinion, which led to an inaccurate determination of a marked impairment in this sphere. It also claims it led to an inaccurate diagnosis of Somatic Symptom Disorder, persistent and severe, Specific Phobia, and Major Depressive Disorder, with anxious distress. The respondent disagrees with her opinion that these are all related to the accident. It submits the applicant suffered from neurological and psychological issues pertaining to his lower limbs that did not resolve prior to the accident.
44The applicant testified, and it is well documented in the medical records, that he stopped working prior to the accident in 2015. The reason for the work stoppage is due to a right knee osteoarthritis diagnosis, multi-level degenerative disc disease in his lumbar spine and lumbar stenosis with radiating symptoms in his legs. He subsequently had surgery to his back.
45The applicant’s section 25 assessor Dr. Gavett-Liu acknowledged in her testimony that there was some ambiguity in the records on the applicant’s work history that she reviewed. Although she testified that she considered both scenarios when forming her opinion, I do not see that analysis in her report. Her baseline indicates the applicant was fully functional and was able to do everything, which included working. As a result, she found the applicant suffered physically and psychologically as a result of the accident, and opined he is catastrophically impaired in this domain.
46However, I find the pre-accident records of Dr. Wudom, the applicant’s family doctor show otherwise. I prefer the notes of Dr. Wudom over Dr. Gavett-Liu as Dr. Wudom has been treating the applicant for quite some time and Dr. Gavett-Liu conducted a one time interview over zoom, I find his notes more reliable. In a note dated March 16, 2016, it indicates the applicant was using a walker. Then, in a note dated August 26, 2016, approximately 1 year pre-accident, it indicates that, due to significant nerve damage as a result of his surgery, he was prescribed strong pain medication. The prescription included Hydrocodone, Hydromorphone, Lyrica, and Percocet. He also requested Oxycocet for his pain, and, just prior to the accident, he requested stronger pain medication.
47I am persuaded Dr. Gavett-Liu failed to adequately account for the applicant’s pre-existing condition and its effect on his activities of daily living. I find she did not include a comprehensive pre and post accident analysis to show how the accident materially contributed to a significant worsening of his pre-existing physical and psychological condition which materially contributed to a decline of his ability to maintain his activities in his daily living. Therefore, the baseline Dr. Gavett-Liu used to determine his change in pre- and post-accident impairments is incorrect.
48I am also not persuaded the applicant was living a full life and could do “anything” prior to the accident. His self-reporting about his pre-accident capacity is inconsistent with the medical records. Although Dr. Gavett-Liu testified she did not find a pre-accident diagnosis of a Somatic Symptom Disorder, or issues with his mental health, the family doctor’s records indicate pre-accident the applicant suffered ongoing pain which caused him to be irritated and in a depressed mood.
49In the report from Dr. Grenier, she indicated the applicant was taking Duloxetine, an antidepressant medication. She also indicated that the applicant was diagnosed with a Major Depressive Disorder by Dr. David Slyfield, a Psychiatrist the applicant was seeing pre-accident, which was not noted in Dr. Gavett-Liu’s report.
50Dr. Gavett-Liu emphasizes the escalation of the applicant’s physical symptoms and how it causes the applicant ongoing stress. She indicated his stressors stem from financial strain, his inability to work, social isolation and marital difficulty. I find her analysis fails to encompass how his pre-existing condition contributed to his inability to work, which resulted in a financial strain. Nor did she provide an analysis of how his ongoing pain contributed to his desire to isolate or created a marital strain. She also included in her report that medication can impact one’s mental state, such as worsening sexual dysfunction, fatigue and/or poor cognition, but she did not comment on how, in this particular case, the medication he is taking now may have affected the physical relationship with his wife. Therefore, I give her report less weight, and I cannot accept from her analysis that, on a balance of probabilities, her diagnosis of Somatic Symptom Disorder and Major Depressive Disorder with anxious distress is due to the accident.
51I do agree however with Dr. Gavett-Liu’s diagnosis of Specific Phobia, Situational type (vehicular). The applicant testified he only drives short distances, and, when he attends appointments, he takes an Uber to avoid driving. When reviewing the medical reports, I found there was not a previous history of driver/passenger anxiety. However, since I have determined the other two disorders are not related to the accident, I find this diagnosis alone does not significantly impede useful functioning enough to rise to the level of a marked impairment.
52The applicant has not met his burden to show he suffers a marked impairment in the sphere of activities of daily living.
53Having found that the applicant does not have a marked impairment in the sphere of activities of daily living, and there is no evidence that the applicant has a marked or extreme impairment in the sphere of concentration, persistence, and pace, this is sufficient to find that the applicant has not sustained a catastrophic impairment under Criterion 8.
54However, for completeness, I will consider the last two spheres.
Social Functioning
55I find the applicant has not shown he suffers from a marked or extreme impairment in the sphere of social functioning.
56According to the Guides, this area of social functioning refers to an individual’s capacity to interact appropriately and communicate effectively with other individuals such as family and friends, neighbours, clerks and others. It is not only the number of aspects in which social functioning is impaired that is significant, but also the overall degree of interference with a particular aspect or combination of aspects.
57Prior to the accident, the applicant testified he had an active social life with his wife. He enjoyed attending church and spending time with friends, family and Atwimaman Society members. He and his wife used to host people and entertain, but now he feels ashamed of the trajectory of his life and would rather isolate. His lack of interest socializing has created a rift between himself and his wife. The fatigue and pain limit his desire to engage in the community, and he no longer finds leisure activities excite him. He indicated to the assessors that he no longer makes or returns phone calls to his family and friends, as he is not in a mood to talk to anyone. But he did testify that his grown children and grandchildren visit, and he does engage with his grandchildren when they are there. Finally, he testified his life has become quite small and secluded, but he also testified he does try to get out as much as he can, as he goes shopping, regularly exercises at the local community centre, and he attends places like the Dollar Store and the bank.
58In her assessment, Dr. Gavett-Liu notes the changes to his social functioning as the applicant reported it to her. I find she does not factor in his pre-accident physical impairments into her analysis and their effect on his desire and ability to socialize, for example due the impairments of his lower extremities, he depends on the use of a walker, which means he is unable to dance like once used to. She also found the applicant’s affect was flat, he was anxious, irritable, and depressed. She finds he suffers a marked impairment in this sphere, and she attributes it to his physical symptom escalation, due to a mental and behavioural disorder.
59Both assessors agreed he was able to interact with the assessors in an appropriate manner. Dr. Grenier indicates in her report, and I agree, that the applicant’s ability to freely socialize in the community is impacted by his ability to be independently mobile, which is primarily due to his physical issues. He did testify that he does not like to be questioned about his physical impairments, it leaves him feeling ashamed.
60I find even though he submits he suffers from depression and anxiety, he testified he frequently goes to the store to pick up calling cards to make calls. He is also able to go to the bank, do some shopping, interact with his grandchildren and attend the community centre. He also testified that, when his mother passed away, (sometime in 2020) he was able to travel to Ghana in the absence of family and friends but with the assistance of airline staff.
61Based on the totality of the evidence, the applicant has not shown he has a marked or extreme impairment in this sphere. The applicant has demonstrated his ability to interact with store clerks to shop for calling cards and other things, he has the capacity to interact appropriately and communicate effectively with other individuals. He also testified that he plays with his grandchildren and attends the community centre for aquatics frequently. He was able to travel alone for his mothers funeral, to do so he would have been required to socially interact with the airline staff. I have taken into consideration his feeling of shame, however, I find his ability to interact appropriately and communicate effectively with other individuals is at the most a moderate social impairment pursuant to the AMA Guides and does not reach the level of a marked impairment.
62Given that he is able to have these social interactions, I am not persuaded, on a balance of probabilities, that his impairment in this sphere reaches the level of a marked impairment.
Adaption
63I find the applicant has not shown he suffers from a marked or extreme impairment in the sphere of adaption.
64The factors to consider under this domain according to the AMA Guides are:
Deterioration or decompensation in work or work like settings (also referred to as adaptation) refers to repeated failure to adapt to stressful circumstances. Under stressful circumstances an individual may withdraw from the situation or experience exacerbation signs and symptoms of a mental disorder. Stresses common to the work environment include attendance, making decisions, scheduling, completing tasks and interacting with supervisors and peers.
65Ms. Weldon noted in her report that the applicant stopped working due to the issues with his back, and that his job was far more physically demanding than mentally demanding.
66Dr. Gavett-Liu opined that the applicant has poor emotional regulation due to his dysfunctional physical symptoms and stressors, which would create difficulty in a work-like setting. She also opined that, although he was able to follow simple instructions, the applicant had difficulty with memory retrieval. Finally, she found the applicant did not demonstrate he had the capacity to maintain work-appropriate engagement and emotional regulation to hold relationships with his co-workers that would allow him to be successful in a work-like setting because of his dysfunctional physical symptoms and stressors.
67Dr. Grenier opined the applicant suffers a moderate impairment in this sphere based on the assessment of Occupational Therapist Nina Munir who observed some difficulty with concentration, focus and forgetfulness, however, she also observed inconsistencies between his reported function ability and her observation. Based on the opinion of the Occupational Therapist and Dr. Grenier’s observations during her interview and the results of her testing (current behaviour, social interaction and difficulty tolerating changes in his environment), she found he has a moderate impairment.
68I agree the applicant suffers an impairment in the area of adaption, but I do not find it reaches the level of a marked impairment. The applicant through his testimony gave several examples of his ability to make decisions, focus, and adapt to stressful situations. For example, he testified that he was able to mange the stress of travelling to Ghana without assistance from a family or friend but with some assistance from the airlines staff which requires a level of concentration, focus and the ability to interact in a professional setting. Further, the applicant also testified that he assists his wife with banking which requires the ability to focus and make decisions and he is able to follow through on the steps to book an uber.
69I prefer the opinion of Dr. Grenier over Dr. Gavett Liu as I find Dr. Gavett Liu relied heavily on the applicant’s self reporting and she did not provide a clear pre- and post-accident analysis which supports her determination. I am persuaded by the applicant’s testimony and the findings of Dr. Grenier that although the applicant does suffer an impairment in the sphere of adaption, it does reach a level of a marked impairment.
70The applicant has not demonstrated on a balance of probability he suffers a marked impairment in this sphere. I again find.
71For those reasons, I am not persuaded the applicant has shown he suffers from a marked or extreme impairment in the sphere of adaption.
Prescriptions
72The applicant has not met his burden to show that the OCF-6 for the cost of prescriptions is reasonable and necessary.
73To receive payment for a medical benefit 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.
74The applicant simply submitted these medications are reasonable and necessary, without identifying what the prescriptions are for, how the medication will meet the goals for recovery and an expert opinion that this medication is required as a cause of the accident. The respondent disagreed without giving further submissions.
75In the absence of any detailed submissions, I find the applicant has not met his burden to show these prescriptions are reasonable and necessary. Therefore, the OCF-6 is not payable.
Interest
76As no benefits are owing, no interest is payable.
ORDER
77For all the reasons set out above, I find that the applicant has not proven, on a balance of probabilities, that he sustained a catastrophic impairment under Criterion 8, in accordance with the Schedule as a result of the accident.
78The applicant is not entitled to the OCF-6 for prescriptions.
79As there are no overdue benefits payments, the applicant is not entitled to interest.
80The application is dismissed.
Released: October 2, 2025
Mary Henein Thorn
Adjudicator