[CG] v. Belair Insurance Company Inc., 2026 CanLII 15074

Citation: [CG] v. Belair Insurance Company Inc., 2026 ONLAT 24-009594/AABS

Licence Appeal Tribunal File Number: 24-009594/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:

[CG] (By their litigation guardian, [CG])

Applicant

and

Belair Insurance Company Inc.

Respondent

DECISION

ADJUDICATOR: Nadia Mauro

APPEARANCES:

For the Applicant: Stacy Koumarelas, Counsel

For the Respondent: Stuart Norris, Counsel

HEARD: By way of written submissions

OVERVIEW

1[CG], the applicant, was involved in an automobile accident on September 11, 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.

2The applicant has been deemed catastrophically impaired. For this reason, his daughter, [CG], was appointed as litigation guardian.

ISSUES

3The issues in dispute are:

i. Is the applicant entitled $5,026.08 for physiotherapy services proposed by MyoHealth Rehab and Wellness Centre in a treatment plan (“OCF-18”) dated, November 10, 2022?

ii. Is the applicant entitled $3,358.12 for chiropractic services proposed by MyoHealth Rehab and Wellness Centre in an OCF-18, dated November 10, 2022?

iii. Is the applicant entitled to $17,176.00 for the cost of preparation of a Guardianship Application submitted on a claim form (OCF-6) dated November 24, 2022?

4The applicant confirmed in his submissions that issues 1, i-viii, 1 x-xx, 3 and 4, as listed on the Case Conference and Order, dated November 27, 2024, (“CCRO”) have been withdrawn. The remaining issues in dispute are as indicated above.

RESULT

5The applicant is entitled to the treatment plans for physiotherapy and chiropractic services.

6The applicant is not entitled to the expenses listed on the OCF-6, dated November 24, 2022.

PROCEDURAL ISSUES

7The respondent, in its submissions, raises issue with the applicant’s untimely filing of submissions and evidence. The respondent submits that the hearing date for this matter was scheduled for August 8, 2025, and as such, pursuant to the CCRO, dated November 27, 2024, the applicant’s deadline for submissions was July 8, 2025.

8The applicant’s submissions and evidence were filed on July 18, 2025.

9While the respondent points to the language within the CCRO that states “if party fails to comply with any Rule, direction or order with respect to disclosure, exchange, production, or inspection of documents or things, the party my not rely on the document or thing as evidence without the permission of the Tribunal”, it is not clear what relief the respondent is seeking from the Tribunal. The respondent has also not made any submissions as to how they have been prejudiced by the applicant’s untimely filing.

10Given that the respondent has not asked for any specific relief from the Tribunal and has not directed me to evidence of prejudice, I will consider the submissions and evidence provided by both parties in my decision.

ANALYSIS

The Treatment Plans

11I find that the applicant has proven, on a balance of probabilities, that the proposed treatment plans for chiropractic and physiotherapy services are reasonable and necessary.

12To 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 treatment, how the goals would be met to a reasonable degree and that the overall costs of achieving them are reasonable.

13The applicant addressed his claim for these treatment plans altogether in his submissions and relied upon the same evidence and arguments to establish that these treatment plans are reasonable and necessary.

14The OCF-18 in the amount of $5,026.08 for chiropractic services, dated November 10, 2022, was completed by chiropractor, Dr. Demetrios Stavros, and sought funding for the following:

Line	Description	Quantity	Amount	Total
1.	Assessment (examination) (initial assessment)	1	$200.00	$200.00
2.	Manipulation, multiple body sites (chiropractic treatment)	18	$45.00	$810.00
3.	Therapy, multiple body sites (manual therapy)	18	$67.68	$1,218.24
4.	Provider travel time, provider to treatment (travel time)	18	$135.36	$2,436.48
5.	Documentation support activity (completion of the OCF-18)	1	$200.00	$200.00
6.	Preparation, service (file and medical documentation review)	1	$135.36	$135.36

15The OCF-18 in the amount of $3,163.24 for physiotherapy services, dated November 10, 2022, was completed by chiropractor Dr. Demetrios Stavros, and sought funding for the following:

Line	Description	Quantity	Amount	Total
1.	Documentation support activity (completion of the OCF-18)	1	$200.00	$200.00
2.	Exercise, joints of fingers and hand NEC (assessment of patient condition)	18	$33.84	$609.12
3.	Instruction, promoting health and preventing disease	18	$33.84	$609.12
4.	Exercise, multiple body sites (exercise therapy)	18	$67.68	$1,218.24
5.	Brokerage, service (communication with others)	18	$20.30	$365.40
6.	Preparation, service (file and medical documentation review)	1	$135.36	$135.36

16The goals of the treatment plans are to increase range of motion and strength, reduce pain, and return to activities of daily living.

17The applicant submits that his physiotherapist, Mr. Zia Barmania, has provided ongoing treatment, confirms making progress with him in her most recent report dated March 27, 2024, and maintains the applicant continues to need ongoing care to prevent further deterioration. The applicant submits that despite the paper review of s. 44 orthopaedic surgeon, Dr. Jaqueline Auguste, dated February 2, 2023, the respondent has approved subsequent treatment plans, and as such, is evidence that it now considers this treatment both reasonable and necessary.

18The respondent submits that the proposed treatment plans are excessive and duplicative in nature. The respondent submits that it requested a s. 44 medical examination to determine if the proposed treatment was reasonable and necessary and the report of Dr. Auguste concluded otherwise.

19I give little weight to the s. 44 orthopaedic report of Dr. Auguste, dated February 2, 2023, for two reasons. First, this assessment was conducted by way of a paper review and as such, the applicant was not physically observed by this assessor. While I find that paper reviews can be useful to determine entitlement to benefits, in this case, I am not persuaded that Dr. Auguste’s paper reviewed opinion is reflective of the applicant’s abilities and need for the proposed physical treatment. This is because the applicant is deemed to have suffered catastrophic injuries, and the evidence supports the applicant uses a wheelchair, however, Dr. Auguste concludes that “there do not appear to be residual orthopaedic injuries preventing him from ambulating based on the documentation other than deconditioning.” Despite indicating that the deconditioning is “in all medical probability, related to his non-orthopaedic injuries” this assessor does not highlight or report any recovery of the identified injuries. What is more, Dr. Auguste specifically highlights a clinical note and record dated September 30, 2021, of Dr. Samer Hamer who states, “this patient will need rehab” and “from an orthopaedic perspective, he will continue to be non-weightbearing for a total of 6 weeks – 3 months.” Dr. Auguste does not report or highlight any medical evidence after the CNR of Dr. Hamer that would support the applicant has resumed weightbearing.

20Further to Dr. Auguste’s review of the applicant’s medical history, I find that the medical records reviewed by Dr. Auguste pre-date the proposed treatment plan by several months. Given this, I find that Dr. Auguste’s opinion is not based on contemporaneous medical records and, in my opinion, less persuasive in determining the reasonableness and necessity of the proposed plans.

21I find that the proposed services are reasonable and necessary given the reassessment report of Dr. Stavros, and subsequent physiotherapy reports of physiotherapist, Mr. Zia Barmania. Dr. Stavros’ report on January 26, 2023, indicates that the functional rehabilitation program will consist of exercises that are designed to increase muscular strength and endurance, increase active range of motion, and increase joint mobility. Mr. Barmania has reported in subsequent physical progress reports dated September 12, 2023, and March 27, 2024, that the applicant has shown significant improvement with respect to range of motion in his shoulders, wrists, hips and knees. I find that the evidence supports the goals of the treatment plans are being met by way of physical therapy, and therefore, I find the proposed plans to be reasonable and necessary.

22I also find that the plans are clearly distinct and disagree with the respondent that they are duplicative. As identified above, there are clear differences between the goods and services requested in each treatment plan. The respondent does not make submissions with respect to its assertion that the treatment plans are excessive.

23Given the foregoing, I find that the applicant has proven, on a balance of probabilities, that the proposed treatment plans for chiropractic and physiotherapy services are reasonable and necessary.

The OCF-6 for a guardianship application, dated November 24, 2022, in the amount of $17,176.00

24I find that the applicant is not entitled to the cost of preparing a guardianship application as proposed in the OCF-6, dated November 24, 2022.

25The applicant submits that an OCF-18 was submitted on November 24, 2022, in the amount of $17,176.00 for the purposes of facilitating a guardianship application in order to assist the applicant and his family in taking appropriate steps to ensure his care. The applicant submits that the respondent did not respond to the OCF-18 within the 10 days prescribed by s. 38(8) of the Schedule. The applicant further submits that an OCF-6 was submitted on January 24, 2024, with the actual cost of the guardianship in the amount of $12,315.64.

26The OCF-6 provided by the applicant is dated January 24, 2024, and itemises a “Guardianship Application” in the amount of $12,315.64.

27The applicant also evidences an OCF-18 dated November 24, 2022, in the amount of $17,176.00, that proposed:

i. Item 1: Guardianship application, in the amount of $15,000.00; and

ii. Item 2: Completion of OCF-18, in the amount of $200.00

28Although the applicant provides both an OCF-6, dated January 24, 2024, and an OCF-18, dated November 24, 2022, for a guardianship application, it is unclear what treatment plan or expense they are seeking to have adjudicated.

29In any event, despite the ambiguity between the treatment plan, expense form, and amounts being sought, even if the applicant is seeking reimbursement for the OCF-6 dated January 24, 2024, or for the proposed goods and/or services in the OCF-18 dated November 24, 2022, I find that neither the expense nor treatment plan for facilitating a “guardianship application” are recoverable under the Schedule.

30While I am not bound by Tribunal decisions, I agree with the respondent and its reliance on G.N. v The Guarantee Company of North America, 2020 CanLII 12754 (On LAT), in that legal costs associated in obtaining an order appointing a litigation guardian are not covered under the Schedule.

31The applicant submits in his reply submissions that G.N. is distinguishable from the present case because the applicant submitted the treatment plan prior to completing the “assessment”, which was never responded to by the respondent.

32I find that the applicant’s reply submissions appear to argue in favour of a capacity assessment. However, that is not the issue before me. The applicant has not directed me to a provision in the Schedule that would cover the cost of legal expenses associated with facilitating a guardianship application. Moreover, it is unclear what “assessment” the applicant is referring to. The issue before me is in relation to an OCF-6 form for a guardianship application. Even if that is an error on the CCRO, and the issue before me is meant to be the OCF-18, dated November 24, 2022, the treatment plan is for a guardianship application, not a capacity assessment. In any event, a guardianship application is not enumerated as a medical or rehabilitation benefit under s. 15 or 16 or any other provision of the Schedule.

33For completion, s. 38(8) and the consequences set out in s. 38(11) are only applicable to treatment plans completed pursuant to s. 38(1) to (4) of the Schedule. As I have indicated above, costs associated with external legal proceedings are not payable by the insurer either as a medical/rehabilitation benefit or expense.

34As such, I find that the applicant is not entitled to reimbursement for the cost of preparing a guardianship application.

ORDER

35I find that:

i. The applicant is entitled to the treatment plan for physiotherapy services, dated November 10, 2022;

ii. The applicant is entitled to the treatment plan for chiropractic services, dated November 10, 2022; and

iii. The applicant is not entitled to reimbursement for the services listed on the OCF-6, dated November 24, 2022.