Licence Appeal Tribunal File Number: 24-004869/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:
Yousif Nour
Applicant
and
Security National Insurance Company
Respondent
DECISION
ADJUDICATOR:
John Mazzilli
APPEARANCES:
For the Applicant:
Jason Katz, Counsel
For the Respondent:
Alanna Pink, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Yousif Nour, (the “applicant”), was involved in an automobile accident on October 30, 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 Security National Insurance Company (the “respondent”) 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 $1,920.53 for psychological services, proposed by E Clinic United Healing in a treatment plan/OCF-18 (“plan”) submitted February 13, 2024?
ii. Is the applicant entitled to $2,095.32 for physiotherapy services, proposed by Physiotherapy Advanced Health & Wellness Centre in a plan submitted March 5, 2024?
RESULT
3The applicant is not entitled to the disputed treatment plans. As no benefits are owing interest is not owing.
4The application is dismissed.
ANALYSIS
5To receive payment for a treatment and assessment plan under sections 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.
$1,920.53 for psychological services dated February 13, 2024
6I find that the applicant is not entitled to $1,920.53 for psychological services.
7The Case Conference Report and Order dated September 4, 2024, lists issue i. above as an issue in dispute, however the applicant did not provide the Tribunal with any submissions or evidence to support the treatment plan. Accordingly, follows that the applicant has not met his onus to prove entitlement to the treatment plan.
8I find that the applicant is not entitled to $1,920.52 for psychological services because it is not reasonable and necessary.
$2,095.32 for physiotherapy services dated March 5, 2024
9I find on a balance of probabilities that the applicant is not entitled to $2,095.32 because it is not reasonable and necessary.
10The applicant submits that as a result of the accident he sustained physical injuries such a right knee fracture, right ankle sprain and lower back strain, dental trauma. The applicant submits that his symptomology improved with physiotherapy and message treatments in late 2022, however he continues to experience flare ups at times such as when the physical demands associated with his usual activities of daily living increase. The applicant submits that the plan is reasonable and necessary and relies on a physiotherapy re-assessment conducted on March 4, 2024, and an OCF-18 completed by Bahaa Mansour, physiotherapist dated March 4, 2024.
11The respondent argues that the treatment plan is not reasonable and necessary, and that the applicant sustained an avulsion fracture to his right knee that did not require surgery. It argues that as early as January 2021 the applicant reported walking, jogging for at least twenty minutes and able to complete squats. It argues that the applicant’s physical injuries have resolved, and that the applicant has achieved maximum medical recovery. The respondent relies on the report of Dr. Rusen, orthopaedic surgeon dated February 23, 2021, and the report of Dr. Soric, physiatrist dated June 25, 2024.
12I find that the disputed plan is not reasonable