Jai Kapoor v. Belair Insurance Company Inc., 2026 CanLII 10371

Licence Appeal Tribunal

Citation: Kapoor v. Belair Insurance Company Inc., 2026 ONLAT 24-006274/AABS

Licence Appeal Tribunal File Number: 24-006274/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:

Jai Kapoor

Applicant

and

Belair Insurance Company Inc.

Respondent

DECISION

ADJUDICATOR: Roderick Walker

APPEARANCES:

For the Applicant: Iqra Akram, Counsel

For the Respondent: Mark Esteireiro, Paralegal

HEARD: By Way of Written Submissions

OVERVIEW

1Jai Kapoor, the applicant, was involved in an automobile accident on December 4, 2021, 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, Belair Insurance Company Inc. 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 $1,297.25 for Physiotherapy treatment, proposed by Platinum Physiotherapy in a treatment plan/OCF-18 (“plan”) dated August 8, 2023?

ii. Is the applicant entitled to $678.24 ($2,922.45 less $2,244.21 approved) for Educational Training and In Home Exercising Equipment in a plan dated June 21, 2024?

iii. Is the applicant entitled to the assessments proposed by Alliance Diagnostics and Treatment Inc, as follows:

(a) $2,550.00 for an Orthopaedic Assessment, in a treatment plan dated June 21, 2024; and

(b) $1,440.19 ($2,750.00 less $1,309.81 approved) for an Occupational Therapy in Home Assessment, in a treatment plan dated June 21, 2024?

iv. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

3The applicant is not entitled to any of the amounts in the disputed plans.

4The applicant is not entitled to any interest.

5The application is dismissed.

ANALYSIS

6I find that the applicant has not demonstrated, on a balance of probabilities, that the disputed treatment plans are reasonable and necessary.

7To receive payment for a treatment and assessment plan under s. 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 the treatment plan, how the goals would be met to a reasonable degree, and that the overall costs of achieving them are reasonable and necessary.

8It is well established that applicants to the Tribunal are obligated to make their own case, and as part of this obligation, applicant’s must adduce all evidence which they need or intend to rely on.

The applicant is not entitled to physiotherapy treatment, the unapproved balance for Educational Training and In Home Exercising Equipment, an Orthopaedic Assessment or an Occupational Therapy in Home Assessment (Issues i-iv).

9I find that the applicant has failed to demonstrate, on a balance of probabilities, that the disputed treatment plans for the above benefits are reasonable and necessary.

10The treatment plan dated August 8, 2023, for $1,297.25 proposed physiotherapy services, including documentation support, head and neck muscle mobilization, and a full-body assessment. The goals were pain reduction, improved range of motion, and return to normal activities. The respondent denied the plan on August 18, 2023, citing Dr. Sandhu’s expectation that improvement would occur with an in-home] exercise program. As significant time had passed the respondent requested an Insurer’s Examination to determine current status and whether ongoing physiotherapy remained reasonable and necessary.

11The June 21, 2024, treatment plan proposed the amount of $2,922.45 (Issue ii) for educational training and in home exercise equipment, and the respondent denied $678.24 in goods and services. Goals included teaching task modification strategies and proper use of assistive devices. The insurer partially approved $2,244.21 and denied $678.24, citing section 25 of the Schedule and Professional Services Guideline limits. The respondent states that only one hour for form completion is covered unless extra time is justified. Also, administrative costs, planning, and provider travel are not payable, as they are considered part of the approved hourly rate. The respondent states that expenses outside approved recommendations will not be reimbursed.

12The treatment plan dated June 21, 2024, was for an Orthopaedic Assessment, in the amount of $2,550.00 (Issue 3i). The goals of the treatment plan are to properly evaluate the current status of the applicant's injuries and impairments and to determine the appropriate course of management for his injuries and impairments. The respondent denied the complete plan and stated that the Orthopaedic Assessment being proposed by Dr. T. Getahun is covered by OHIP.

13The June 21, 2024, treatment plan proposed an in-home Occupational Therapy assessment (Issue 3ii) The goals for the plan are to evaluate the applicant’s injuries, support return to normal activities, and determine appropriate care. The respondent partially approved $1,309.81 and denied $1,440.19, citing the lack of detailed breakdown and guideline limits. Instead, they approved 12 hours at $99.75–$119.92 per hour, in line with the Professional Services Guideline (PSG) and s. 25(5) of the Schedule, which caps assessments at $2,000. The respondent stated that additional payment requires a detailed report and time breakdown. The respondent further stated that only one hour will be paid for completing the OCF-18 form unless extra time is justified. Documentation and administrative costs are considered part of clinical care and cannot be billed separately.

14The applicant argues that the cost of documentation preparation, administration costs, planning and provider travel costs are reasonable and necessary. The applicant states that these expenses are necessary from his treatment plan and the other travel costs for a provider for his assessments should be covered. He submits that expenses necessary for ensuring the safe treatment of an insured person are reasonable and necessary, and they are in line with the overall objective of the Schedule. As for the transportation expenses, the applicant states that insured persons must frequently travel to attend treatment, even if each trip do not exceed 50 kilometres, and that the cumulative distance should be considered.

15The respondent submits that the unapproved balance of the disputed treatment plans and the other treatment plans are not reasonable and necessary. The respondent did not totally approve the costs associated with cost of documentation support, administration costs, planning and provider travel costs because it is in excess of the Financial Services Commission of Ontario’s Professional Services Guideline (PSG) and are not covered under the Schedule, and they are not reasonable and necessary expenses.

Conclusions and Reasoning

16In respect to Issue i, the respondent relies on its Insurer's Examination Report of May 27, 2022, Dr. Sandhu anticipated that with adherence to an exercise program, the applicant would experience further symptomatic improvement over the coming 8-12 weeks. The respondent stated that 15 months had passed since the accident, and an insurer's examination was being requested to determine the applicant’s current status and if ongoing physiotherapy treatment is considered reasonable.

17I find that this clearly states the respondent’s position and clear reasons as to why they are not approving this plan. The respondent’s assessor indicates that 15 months is too long for symptoms acting up and an examination is needed to determine the need for extra treatment to be reasonable and necessary. The applicant did not attend the insurer’s examination.

18I find that the plan at Issue 3i for the Orthopaedic Assessment is not reasonable and necessary I find the applicant in his submissions did not point or direct me to corroborating evidence of a referral from a medical doctor requesting an Orthopaedic Assessment.

19I also find that the unapproved balance for an Occupational Therapy in Home Assessment (Issue 3ii) is not reasonable and necessary.

20Sections 14 and 15 of the Schedule require insurers to pay only for medical expenses that are reasonable and necessary due to the accident. The Professional Services Guideline sets maximum allowable fees. I find that the respondent’s denial letter dated September 30, 2024, states that the OCF-18’s form lacked a detailed breakdown of services, and only partial approval was granted, being 12 hours at $99.75–$119.92 per hour. To approve more time, the respondent requested a report and detailed breakdown of components and time spent.

21Finally, I find that the applicant has not met his burden of proving that the unapproved balance for Occupational Therapy in Home Assessment for Issue 2 is reasonable and necessary. The respondent does not dispute the need for the assessment. With respect to the billing transparency, the disputed sum of $1,440.19 lacks a detailed time and task breakdown. The PSG and the Schedule require itemized billing for assessment time, travel, file review, report writing, and form completion. I find the respondent’s request for such detailed breakdown is a reasonable request. The respondent’s approval of 12 hours at PSG rates ($99.75–$119.92/hour) is consistent with the PSG and provides adequate scope for the assessment, provided the provider substantiates the time spent. The limiting payment to one hour for completing the OCF‑18 is consistent with PSG guidelines unless complexity justifies additional time. I find that documentation and administrative tasks are part of clinical care and cannot be billed separately under the PSG. Accordingly, I find that the disputed amount sum for $1,440.19 is not reasonable and necessary without a breakdown of such amounts , the applicant is not entitled to the disputed amount.

All of the denial letters dated, July 8, 2024, August 18, 2023, September 28, 2023, and September 30, 2024, for physiotherapy treatment, educational training, orthopedic assessment and occupational in-house assessment and Document , Mobilization and Assessment comply with s. 38(8) of the Schedule

22I find that the respondent’s denial letters dated July 8, 2024, August 18, 2023, and September 30, 2024, denying the physiotherapy, educational training, orthopedic assessment and occupational in-house assessment comply with s. 38(8) of the Schedule.

23The applicant submits that the denial letters for the three treatment plans fail to comply with s. 38(8), as the respondent does not give medical/relevant reasons for the denials.

24In the denial letter from the respondent dated, August 18, 2023, the respondent denied the treatment plan for Mobilization, muscles of head and neck. The respondent states, “ As per section 38(8) of the Statutory Accident Benefits Schedule, we are unable to approve the goods and services and the amount of $1297.25 is denied for the following medical and other reasons: In his Insurer's Examination Report of May 27, 2022, Dr. Sandhu anticipated with adherence to an exercise program, you would experience further symptomatic improvement over the coming 8 - 12 weeks. It's now been almost 15 months and an insurer's Examination is being requested to determine your current status and is ongoing physiotherapy treatment is considered reasonable. Based on the above and Sections 38 (10) and Section 44 of the Statutory Accident Benefits Schedule, we have arranged an independent medical examination with a qualified Health Practitioner. This examination will help us to determine if the requested goods and services are reasonable and necessary. The examination will be in person and your attendance is required.”

25I find that this denial letter states clearly that the medical reasons for the denial and gives directions for the applicant to attend an issuer’s examination to ascertain more information about the applicant’s injuries. I find that the letter is compliant to s. 38(8) of the Schedule.

26In the denial letter dated, July 8, 2024, the respondent states the reasons for not paying for the Orthopaedic Assessment and documentation preparation because the Orthopaedic Assessment being proposed by Dr. T. Getahun is covered by OHIP. The respondent states, “Please provide us with documentation to show that you have requested your family doctor refer you to an Orthopaedic Surgeon and your request was denied for any other injuries, and the reason for the denial. If your family doctor refused to refer you because your symptoms did not warrant a referral, the services proposed are not reasonable and necessary.”

27I find this denial clearly states the reasons for the denial of the orthopaedic assessment as there is no evidence from the applicant that he was denied by an Ontario doctor for an assessment. I find that the letter complies with s. 38(8) of the Schedule.

28In the denial letter dated, September 30, 2024, the respondent states the reasons for nonpayment of the Preparation Fee and the partially approved rate for Attendant Care and Documentation Fee. The respondent in the denial letter explains the approved amounts and the amounts that are denied. The respondent states, “Please note, expenses for goods and services which are administered outside of the Insurer approved amounts cannot be considered. If there are any further medical documents that have not been previously received, to support this submission, please have your health care provider submit the new information to the undersigned for consideration.”

29I find that this denial letter states clearly that the reasons for the denial and gives directions for the applicant that the amounts are outside of the PSG and if there is further medical information to send it to the respondent for review. I find that the letter is compliant to s. 38(8) of the Schedule.

30In the denial letter dated, September 28, 2023, the respondent states that , “ Dr. C. Sandhu opinion that you are likely achieved maximum therapeutic benefit from a facility-based treatment given the nature of your injuries, length of time since the accident and quantity of treatment received to date and your focus of his rehabilitation program should now be on an active independent exercise program.”

31I find that this denial letter states clearly that the reasons for the denial and advises the applicant that he has benefited fully from the treatment given. I find that the letter is compliant to s. 38(8) of the Schedule.

32I agree with the respondent that the July 8, 2023, August 8, 2023,September 28, 2023, and September 30, 2024, are compliant with the Schedule. The letters offer a principled rationale for the denials, in language that is adequate to allow an unsophisticated person to understand the reason for the denial and to make an informed decision in response. Also, it states the right to appeal for the applicant if he disagrees with the insurer.

33As I have found that all of the denial letters are compliant with s. 38(8) of the Schedule, the applicant has not established that they are payable pursuant to s. 38(11).

Interest

34Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since no benefits are payable, no interest is awarded.

ORDER

35I find on the totality of the evidence, that:

i. The applicant is not entitled to the treatment plans in dispute.

ii. The applicant is not entitled to any interest.

iii. The application is dismissed.