Licence Appeal Tribunal File Number: 24-008170/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:
Khushmeet Kaur
Applicant
and
Aviva General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Amar Mohammed
APPEARANCES:
For the Applicant:
Bianca Marinescu, Paralegal
For the Respondent:
Brittanny K Tinslay, Counsel
HEARD:
By Way of Written Submissions
OVERVIEW
1Khushmeet Kaur, the applicant, was involved in an automobile accident on October 16, 2022, 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. Is the applicant entitled to the services and examinations/assessments proposed by Mackenzie Medical Rehabilitation Centre, in treatment plans/OCF-18s (“plans”) as follows:
i. $2,023.03 for physiotherapy services, submitted May 30, 2023;
ii. $1,524.84 for chiropractic services, submitted June 15, 2023; and
iii. $1,487.44 for chiropractic services, submitted July 10, 2023?
ii. Is the applicant entitled to interest on any overdue payment of benefits?
3The applicant withdrew the following issues as listed in the Case Conference Report and Order:
i. $2,144.72 ($4,339.71 less $2,194.99) for psychological services, dated January 8, 2024; and
ii. $2,486.00 for a chronic pain assessment, dated January 24, 2024.
RESULT
4The applicant is entitled to the plan proposing $2,023.03 for physiotherapy services, submitted May 30, 2023.
5The applicant is entitled to the plan proposing $1,524.84 for chiropractic services, submitted June 15, 2023.
6The applicant is not entitled to the plan proposing $1,487.44 for chiropractic services, submitted July 10, 2023.
7The applicant is entitled to interest pursuant to s. 51 of the Schedule.
ANALYSIS
Is the applicant entitled to the three plans in dispute?
8I find that the applicant is entitled to the plan proposing $2,023.03 for physiotherapy services and the plan proposing $1,524.84 for chiropractic services. However, the applicant is not entitled to the plan proposing $1,487.44 for chiropractic services, submitted July 10, 2023.
9To 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.
10For all three plans in dispute, the goals of treatment are as follows: pain reduction, increased range of motion, increase in strength, return to activities of normal living, and return to modified work activities. The respondent does not dispute that these goals are reasonable except for one. However, the respondent argues that since the applicant was already on modified duties prior to the accident, and returned to work after the accident, the goal of returning to modified work is not a reasonable one. Since there is no dispute relating to the goals being necessary, an analysis is not necessary on this specific point. However, for clarity, I note that in my view, one goal (returning to modified duties) having been previously achieved does not invalidate the entire treatment plan. The stated goals should not be read as an all or nothing proposition. In these circumstances, there are other goals stated and the parties agree the remaining goals are reasonable.
11As to how the goals would be met to a reasonable degree, the applicant does not refer to any evidence and simply makes submissions that physiotherapy treatment has been beneficial in temporarily reducing the overall intensity of the applicant’s symptoms but she continues to experience pain. Further, that treatment has provided short term pain relief and increased the applicant’s ability to participate in daily activities. The respondent argues that these submissions are not supported by evidence.
12The applicant did not provide the plans in dispute in her evidence brief, but the respondent has included them in its brief avoiding delay of the hearing on its merits. The respondent refers me to Part 9(b) of the plans recording outcome evaluations of prior treatment arguing there is no benefit from treatment recorded. I find that the plans proposing $2,023.03 for physiotherapy services, submitted May 30, 2023, and $1,524.84 for chiropractic services, submitted June 15, 2023 record the same range of motion ranges which describe limitations in function. Whereas the plan proposing $1,487.44 for chiropractic services, submitted July 10, 2023, records a clear improvement in range of motion as follows:
i. In May and June 2023, C/S AROM is limited to extension 30/75, lateral flexion 30/45. L/S AROM is limited to flexion 60/90, extension 10/30, lateral flexion 25/35.
ii. In July 2023, C/S AROM: flexion 55/60, extension 65/75, rotation 70/80 bilaterally, lateral bending 30/45 bilaterally. L/S AROM is limited to flexion 60/90, extension 20/30, lateral flexion 25/35 and rotation 25/30.
13The applicant relies on the decision of this Tribunal in 16-003921 v Certas Home and Auto Insurance Co., 2018 CanLII 141005 (ON LAT) stating that “it is well accepted that relief of pain is itself a legitimate goal for treatment, even if the pain relief is not designed to promote pain recovery or lead to lasting improvement”. I am not persuaded by this reference because the applicant has not referred me to evidence of pain relief from treatment. Further, I note that the respondent has accepted the goals of treatment as reasonable except for one as reviewed above.
14The applicant further relies on the decision made by this Tribunal in 17-002624 v Aviva Insurance Canada, 2018 CanLII 13183 (ON LAT). The Tribunal opined that the applicant demonstrated significant improvement with incurred treatments and therefore they were reasonable and necessary. I am persuaded by this reference in this case because the applicant’s outcomes have been evaluated in the three plans in dispute supporting the claim that she benefits from treatment.
15Accordingly, I find that the applicant is entitled to the plans proposing $2,023.03 for physiotherapy services, submitted May 30, 2023, and $1,524.84 for chiropractic services, submitted June 15, 2023.
16However, I agree with the respondent that the plan proposing $1,487.44 for chiropractic services, submitted July 10, 2023, is duplicative of the plan submitted June 15, 2023, submitted within a short time frame. The applicant did not address this, and I am not persuaded that a duplicative plan is reasonable and necessary before the prior plan is incurred and outcomes are further tracked and reviewed.
17I find, on a balance of probabilities, that the applicant is entitled to the plans proposing $2,023.03 for physiotherapy services, submitted May 30, 2023, and $1,524.84 for chiropractic services, submitted June 15, 2023. However, the applicant is not entitled to the plan proposing $1,487.44 for chiropractic services, submitted July 10, 2023.
Interest
18The applicant is entitled to interest which applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule.
ORDER
19For the reasons above, I make the following orders:
i. the applicant is entitled to the plan proposing $2,023.03 for physiotherapy services, submitted May 30, 2023.
ii. the applicant is entitled to the plan proposing $1,524.84 for chiropractic services, submitted June 15, 2023.
iii. the applicant is not entitled to the plan proposing $1,487.44 for chiropractic services, submitted July 10, 2023.
iv. The applicant is entitled to interest pursuant to s. 51 of the Schedule.
Released: February 26, 2026
Amar Mohammed
Adjudicator