Licence Appeal Tribunal
RECONSIDERATION DECISION
Before: Tyler Moore, Vice-Chair
Licence Appeal Tribunal File Number: 23-014453/AABS
Case Name: Mohamed Babiker v. Security National Insurance Company
Written Submissions by:
For the Applicant: Submissions requested, but none received
For the Respondent: James Kolumbus, Counsel
OVERVIEW
1On November 14, 2025, the respondent requested reconsideration of the Tribunal’s decision dated October 23, 2025 (“decision”).
2The Tribunal found that the applicant was barred from bringing an application for an income replacement benefit (“IRB”), pursuant to s. 55 of the Statutory Accident Benefits Schedule – Effective September 1, 2010 (including amendments effective June 1, 2016) (“Schedule”), and that he remains in the Minor Injury Guideline (“MIG”). However, based on s. 38 (11) non-compliance, the Tribunal found that the applicant was entitled to $2,859.16 for physiotherapy services, $8,117.72 for chiropractic services, $4,373.10 for a chronic pain assessment, and interest.
3The grounds for a request for reconsideration are found in Rule 18.2 of the Licence Appeal Tribunal Rules, 2023 (“Rules”). To grant a request for reconsideration, the Tribunal must be satisfied that one or more of the following criteria are met:
a) The Tribunal acted outside its jurisdiction or committed a material breach of procedural fairness;
b) The Tribunal made an error of law or fact such that the Tribunal would likely have reached a different result had the error not been made; or
c) There is evidence that was not before the Tribunal when rendering its decision, could not have been obtained previously by the party now seeking to introduce it, and would likely have affected the result.
4The respondent seeks reconsideration pursuant to Rule 18.2(b). The respondent seeks an order overturning the Tribunal’s decision that any of the treatment plans in dispute are payable based on s. 38(11) non-compliance with interest.
5On November 19, 2025, the Tribunal e-mailed a Reconsideration Order to the parties. The order invited the applicant to provide responding submissions by December 15, 2025. The applicant has not filed any reconsideration submissions with the Tribunal to date. I am satisfied that the applicant had notice of the respondent’s request for reconsideration and of his ability to provide submissions. For that reason, I will proceed with the reconsideration decision without the applicant’s submissions, pursuant to s. 7(2) of the Statutory Powers Procedure Act, R.S.O 1990, c. S. 22.
RESULT
6The respondent’s request for reconsideration is denied.
ANALYSIS
7The test for reconsideration under Rule 18.2 involves a high threshold. The reconsideration process is not an opportunity for a party to re-litigate its position where it disagrees with the Tribunal’s decision, or with the weight assigned to the evidence. The requestor must show how or why the decision falls into one of the categories in Rule 18.2.
Did the Tribunal make an error of law or fact such that the Tribunal would likely have reached a different result had the error not been made?
8I find that the respondent has not established grounds for reconsideration under Rule 18.2(b).
9The respondent submits that the Tribunal erred in finding that the denial letters related to the proposed treatment plans in the amount of $2,859.16 ($4,141.35 less $1,282.19 approved) for physiotherapy services, $8,117.72 for chronic pain services, and $4,473.10 for a chronic pain assessment were non-compliant with s. 38(8) of the Schedule.
10Sections 38(8) and 38(11) of the Schedule set out strict notice requirements for insurers responding to treatment plans and specific consequences if they fail to comply. Section 38(8) requires an insurer to inform an insured person within ten business days after it receives an OCF-18 which goods, services, assessments, and/or examinations it agrees to pay for, and which it does not, as well as the medical and other reasons why it considered any of the goods and services to not be reasonable and necessary.
11If an insurer fails to comply with its obligations under s. 38(8), the following consequences set out in s. 38(11) of the Schedule are triggered:
The insurer is prohibited from taking the position that the insured person has an impairment to which the Minor Injury Guideline applies.
The insurer shall pay for all goods, services, assessments, and examinations described in the treatment and assessment plan that relate to the period starting on the 11th business day after the day the insurer received the application and ending on the day the insurer gives a notice described in subsection (8).
Physiotherapy Services Treatment Plan
12The respondent submits that:
a) The denial dated December 3, 2021 was sent within the required timeline, it identified the benefit being addressed, it referred to the MIG and the section of the Schedule that the respondent was relying on.
b) In the recent reconsideration decision of Plourde v. Intact Insurance Company, 2025 ONLAT 23-009183/AABS-R (“Plourde”), the Tribunal held that a denial letter that only referred to the applicant suffering a minor injury in an accident was still compliant with s. 38(8) of the Schedule, even if the applicant was subsequently removed from the MIG. In the present case, the denial provided more information, and the applicant remains in the MIG.
c) The reconsideration decision of 17-006781 v. Aviva Insurance Canada, 2019 CanLII 76856 (ON LAT) (“D.M.”) is similar to this case and should be followed. In that decision, the Tribunal initially found that a denial letter was non-compliant, but upon reconsideration, it found that denial was compliant with s. 38(8). The Tribunal held that it made a significant error of fact in finding that the denial did not meet the requirements of s. 38(8) of the Schedule
13I agree with the respondent that the timeline of the denial was compliant with s. 38(8) of the Schedule. However, the decision at issue turned on the Tribunal’s finding that the respondent did not provide compliant reasons for the denial.
14At paragraph 44 of the decision, the Tribunal found that the notice was non-compliant with s. 38(8) of the Schedule because it:
…“does [not] direct the applicant to a definition of the MIG or a minor injury in the Schedule. Additionally, the denial does not identify the applicant’s injuries or indicate that the respondent requires any further information about the applicant’s injuries.”
15As a result, the Tribunal found that the denial “lacked the specificity required by s. 38(8)”.
16Medical reasons for a denial should engage the specific details about the insured’s condition forming the basis for the decision and be adequate to allow an unsophisticated person to understand them and make an informed decision in response. I find that the Tribunal considered these factors in making its finding.
17I also find that s. 38(8) compliance involves a discretionary, fact-based analysis on the part of the Tribunal. Tribunal decisions, such as Plourde and D.M. that were cited by the respondent, are not binding, especially under such fact-specific circumstances.
18I find that the respondent is attempting to re-argue its position because it disagrees with the Tribunal’s decision. The respondent has not identified an error of law or fact that the Tribunal made in arriving at its decision that would meet the high threshold needed to grant reconsideration under Rule 18.2(b).
Chronic Pain Services Treatment Plan
19The respondent submits that:
a) The denial letter dated February 21, 2023, was sent within the required timeline.
b) The denial provided sufficient information such that an unsophisticated person could make an informed decision on whether to dispute the decision, and it identified the treatment plan in question.
c) The denial referred to the respondent’s letter to the applicant dated October 27, 2022, addressing the insurer’s examination reports of Dr. Belfon, general practitioner, and Dr. Syed, psychologist, which found no evidence of accident-related psychological impairment and concluded that the applicant’s injuries fell within the MIG.
d) The denial referred to the MIG and concluded that there was no objective evidence of psychological impairment as a result of the accident.
e) The Tribunal noted at paragraph 54 of the decision that it was confused about the denial as “it refers to a psychological condition while the treatment plan is for chiropractic services.” According to the respondent, the treatment plan was improperly listed as “chiropractic services”, and the Tribunal made a serious error in fact in believing that the plan was for chiropractic services. Had the Tribunal known that it was for chronic pain services, then it would have concluded that the denial was compliant because the lack of psychological impairments speaks directly to chronic pain services.
20I find that the case conference report and order and the parties’ hearing submissions refer to the disputed treatment plan as “chiropractic services” not “chronic pain services”. There was no request to amend how the disputed plan is referred to, or what specific services it entails, until the respondent first raised the issue on reconsideration. This does not constitute information that would have been previously unavailable or that could not have been raised on first instance.
21I further disagree with the respondent’s argument that the Tribunal would have come to a different conclusion had it known the proposed treatment plan was for chronic pain services (because the lack of psychological impairment speaks directly to chronic pain services).
22It is well established that there is a bidirectional link between physical pain and mental health in chronic pain. As a result, “chronic pain services” could be proposed and delivered in the form of psychological treatment, physical treatment, or some combination of both. The absence of accident-related psychological impairment, however, does not automatically negate a finding of chronic pain or the need for chronic pain services.
23The proposed services are also for physical treatment. The denial, however, refers to the fact that “the present psychological examination found no objective evidence to substantiate Mr. Babiker’s subjective self-report of psychological impairment related to the subject motor vehicle accident.” I find that this does not address the physical treatment being proposed, and I agree with the Tribunal that this could cause confusion for an unsophisticated person, leading to a finding of s. 38(8) non-compliance.
24For these reasons, I find that the respondent has not shown that the Tribunal made an error of fact or law such that it would likely have reached a different result had the error not been made.
Chronic Pain Assessment Treatment Plan
25The respondent submits that:
a) The denial, dated February 17, 2023, identified the proposed assessment, referred to the October 27, 2022 letter noted above, advised the applicant that their injuries fall under the MIG, and it advised that the previous insurer’s examinations found no objective evidence to substantiate the applicant’s self-reported psychological impairment.
b) The Tribunal erred at paragraph 58 of the decision by concluding that, because the wording in the denial was the same as in the February 21, 2023 denial of chronic pain services, the February 17, 2023 denial must also be non-compliant. According to the respondent, the denial should be considered independently for each issue in dispute.
c) The Tribunal questioned why a lack of psychological impairment was noted in the February 21, 2023 denial, but the issue at hand in the February 17, 2023 denial is a chronic pain assessment for which any psychological impairment is clearly relevant to a determination as to whether the proposed assessment is reasonable and necessary.
26I agree that the February 17, 2023 is compliant with the timeline set out in s. 38(8) of the Schedule. I find that the denial does not, however, reference the section of the Schedule that applies, or reference the applicant’s accident-related injuries. As in the February 21, 2023 denial, the February 17, 2023 denial references the same October 21, 2022 s. 44 assessment finding that “the present psychological examination found no objective evidence to substantiate Mr. Babiker’s subjective self-report of psychological impairment related to the subject motor vehicle accident.” There is no reference to the s. 44 physical examination assessment findings of Dr. Belfon, which I find are relevant when the proposed chronic pain assessment is a physical assessment, to be conducted by an orthopedic surgeon. I find that this would be confusing for an unsophisticated person in deciding whether to dispute the denial.
27The respondent relies on its assertion that, to determine whether a chronic pain assessment is reasonable and necessary, psychological impairments are relevant. I agree that this general finding can be a relevant factor in determining if a chronic pain assessment is reasonable and necessary. However, the proposed chronic pain assessment is to be conducted by an orthopedic surgeon and chiropractor, not a psychiatrist or psychologist. I find that this argument appears to be a request for a re-weighing of arguments and evidence from the hearing.
28At paragraph 58 of the decision, the Tribunal found that the wording in the denial “was identical to the February 21, 2023 notice which…was not compliant with s. 38(8), because it lacked the specificity required for an unsophisticated person to decide whether to dispute the denial.” I accept that the Tribunal did not find that the February 17, 2023 denial was non-compliant simply because it was identical to the February 21, 2023 denial, even though the wording used by the respondent in both denials is almost identical. The Tribunal found, once again, that the denial lacked the specificity required. I find that the Tribunal provided independent reasons for why it found that the February 17, 2023 denial was non-compliant with s. 38(8).
29The respondent submits further that even if there was inadequate notice, the applicant has not proven his claim because the remaining treatment plan balances are beyond the $3,500.00 MIG limits, which the Tribunal found the applicant was subject to.
30I find that once a breach of s. 38(8) has been established, the remedy under s. 38(11) is triggered: the insurer “shall pay”. Therefore, while the respondent may argue that the applicant has not established the reasonable and necessary nature of the plans for which the denials are in question, this has little bearing on s. 38(11) of the Schedule. I find that the Tribunal correctly identified that the applicant is entitled to the proposed treatment plan, pending proof that he has incurred the plan in accordance with s. 38(11).
31For these reasons, I find that the respondent has not shown that the Tribunal made an error of law or fact such that it would likely have reached a different result had the error not been made.
CONCLUSION & ORDER
32The applicant’s request for reconsideration is denied.
Tyler Moore Vice-Chair
Released: February 10, 2026