Citation: Moradianjouybari v. Aviva General Insurance Company, 2026 ONLAT 24-009435/AABS

Licence Appeal Tribunal File Number: 24-009435/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:

Masoumeh Moradianjouybari

Applicant

and

Aviva General Insurance Company

Respondent

DECISION

ADJUDICATOR:

Kathleen Wells

APPEARANCES:

For the Applicant:

Carlos Ortiz, Paralegal

For the Respondent:

Hilary Doyle, Counsel

HEARD:

By way of written submissions

OVERVIEW

1Masoumeh Moradianjouybari, the applicant, was involved in an automobile accident on October 20, 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 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:

1. Is the applicant entitled to $150.00 ($3,700.25 less $3,550.25 approved) for chiropractic services, proposed by Doctors Rehabilitation Clinic in a treatment plan/OCF-18 (“treatment plan”) dated January 13, 2023?
2. Is the applicant entitled to $1,100.00 for chiropractic services, proposed by Doctors Rehabilitation Clinic in a treatment plan dated August 30, 2021?
3. Is the applicant entitled to $2,150.00 for psychological services in an OCF-21 form submitted by Counselling and Rehabilitation Services dated June 15, 2023?
4. Is the applicant entitled to $1,909.34 for chiropractic services, in an OCF-21 submitted by Doctors Rehabilitation Clinic dated February 27, 2023?
5. Is the applicant entitled to $1,400.00 for expenses for acupuncture services provided by Acupuncture Pain Clinic submitted on August 7, 2024?
6. Is the applicant entitled to $2,200.00 for a psychological assessment, proposed by Doctors Rehabilitation Clinic in a treatment plan dated August 6, 2024?
7. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
8. Is the applicant entitled to interest on any overdue payment of benefits?

3Issue # 2 above, the treatment plan for $1,100.00 for chiropractic services, was set out in the Case Conference Report and Order (“CCRO”) with a date of January 13, 2023. The treatment plan in question is dated August 30, 2021, as set out above.

4The respondent submits treatment plans set out in the CCRO as issues #3, and #4, refer to OCF-21 forms, and not treatment plans as set out in the CCRO. Both issues # 3 and #4 are identified as OCF-21 forms in the application. As such, I have referred to them as OCF-21s in the issues in dispute.

5Issue #5 above was set out in the CCRO as a treatment plan. It was added on consent at the Case Conference. However, the respondent submits that it did not receive a treatment plan, but received a statement of expenses from the applicant. I have referred to it as such in the issues in dispute above.

6With respect to Issue #6 above, the amount set out in the CCRO for the treatment plan for psychological services dated August 6, 2024, was $1,400.00. The treatment plan in question sought $2,200.00 for the assessment, and I have corrected the amount above.

RESULT

7I find that:

1. The applicant is not entitled to the treatment plans in dispute.
2. The applicant is not entitled to the OCF-21s in dispute.
3. The applicant is not entitled to $1,400.00 for expenses for acupuncture services submitted on August 7, 2024.
4. As no payments are owing, no interest is due.
5. The applicant is not entitled to an award.
6. The application is dismissed.

ANALYSIS

8To 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.

9The purpose of an assessment is to determine whether a condition exists. For an insured, they bear the onus to demonstrate that there are grounds on which to believe that a condition exists that would warrant further investigation by way of an assessment.

Is the applicant entitled to $150.00 ($3,700.25 less $3,550.25 approved) for chiropractic services in a treatment plan dated January 13, 2023?

10I find that the applicant has not established on a balance of probabilities that the remaining balance of $150.00 for chiropractic services in a treatment plan dated January 13, 2023 is reasonable and necessary.

11The treatment plan, prepared by Dr. Nouralie, chiropractor, seeks $3,700.25 for chiropractic services, including $150.00 for a reassessment.

12The applicant makes general submissions that the treatment plan is reasonable and necessary. The respondent argues that it approved $3,550.25, but denied the $150.00 reassessment fee because a reassessment is included in the $200.00 fee for completing the OCF-18 form.

13Although the applicant listed a reassessment as one of the services outlined in the treatment plan, the applicant has not made submissions or directed me to evidence with respect to whether the reassessment or its $150.00 fee is reasonable and necessary. As such, I find that she has not met his onus to prove that the remaining balance of $150.00 is reasonable and necessary.

14Accordingly, the applicant is not entitled to the remaining balance of $150.00 in the treatment plan for chiropractic services dated January 13, 2023.

Is the applicant entitled to $1,100.00 for chiropractic services in a treatment plan dated August 30, 2021?

15I find that the applicant has not established on a balance of probabilities that that the treatment plan for chiropractic services dated August 30, 2021 is reasonable and necessary.

16Neither party has submitted the treatment plan into evidence, however the respondent has provided details of the plan in its EOB, as did Dr. Michael Fung in his s. 44 insurer’s examination (“IE”) report dated November 29, 2022.

17The applicant has not made specific submissions with respect to the August 30, 2021 treatment plan, and has not directed me to any contemporaneous medical evidence in support of the treatment plan. A review of the applicant’s medical evidence reveals that she has not submitted any medical records dated between January 25, 2021 and June 30, 2022. The Clinical Notes and Records (“CNRs”) of the applicant’s family doctor, Dr. Golbarg Araghi, end seven months before the treatment plan was submitted, and eight months after the treatment plan was submitted.

18The Tribunal has long held that a treatment plan must be supported by corroborating, contemporaneous medical evidence. The applicant has not provided such evidence. As such I find that the applicant has not met her onus to prove on a balance of probabilities that the treatment plan is reasonable and necessary.

19Accordingly, the applicant is not entitled to $1,100.00 in the treatment plan for chiropractic services dated August 30, 2021.

Is the applicant entitled to $2,150.00 for psychological services in an OCF-21 Form submitted June 15, 2023?

20I find that the applicant has not established that she is entitled to the OCF-21.

21The respondent submits that it sent correspondence denying the OCF-21 with respect to services provided by Counselling and Rehabilitation Services Inc. on May 13, 2023 to the applicant in error. It informed the applicant by email dated May 9, 2025 that it had not received a treatment plan with respect to the applicant from the treatment provider in question, and requested that the applicant withdraw the issue as an issue in dispute. The applicant did not withdraw the issue.

22As the applicant has made no submissions and led no evidence with respect to the treatment plan or OCF-21 in question, I find that the applicant has not met her onus to prove on a balance of probabilities that she is entitled to $2,150.00 in a treatment plan for psychological services dated June 15, 2023.

Is the applicant entitled to $1,909.34 for chiropractic services in an OCF-21 treatment plan dated February 27, 2023?

23I find that the applicant has not established on a balance of probabilities that she is entitled to payment of the OCF-21 dated February 27, 2023.

24The applicant makes no specific submissions with respect to the OCF-21. The respondent argues that the $1,909.34 was incurred for treatment which had been approved in the treatment plan dated January 13, 2023, which was partially approved in the amount of $3,550.25, and discussed above.

25The respondent does not dispute that the applicant is entitled to the treatment plan, once properly invoiced. However, the respondent submits that the applicant has access to third party benefits, which have paid part of the applicant’s previous treatment, and the applicant did not provide information as to the amount, if any, the third party insurer would pay. It submits that, as such, the respondent does not have accurate information with respect to the amount it is obligated to pay.

26In a letter dated February 28, 2023, the respondent informed the applicant that it is not required to pay any part of the OCF-21 which would reasonably be payable by another insurer under s. 47(2) of the Schedule, and requested that the applicant submit the OCF-21 to its third party insurer.

27As the applicant has not made submissions or directed me to any evidence with respect to the OCF-21 in question, I find that the applicant has not met her onus to prove on a balance of probabilities that the payment sought on the OCF-21 is due to the applicant.

28As a result, I cannot find that the applicant is entitled to payment of the OCF-21.

Is the applicant entitled to $1,400.00 for expenses for acupuncture services provided by Acupuncture Pain Clinic submitted on August 7, 2024?

29I find that the applicant has not established on a balance of probabilities that she is entitled to $1,400.00 for acupuncture treatment.

30The applicant does not make any specific submissions with respect to the payment of $1,400.00 for acupuncture treatment.

31The respondent argues that it denied the applicant’s request for payment of $1,400.00 for acupuncture services because there was no treatment plan approved for the services, and directed me to the EOB denying payment to the applicant, dated August 29, 2024.

32Neither party has submitted a treatment plan, nor have they submitted the applicant’s request for payment into evidence.

33As the applicant has not made submissions or directed me to any evidence with respect to the acupuncture services, I find that the applicant has not met her onus to prove that she is entitled to payment for the acupuncture services.

Is the applicant entitled to $1,400.00 for a psychological assessment in a treatment plan dated August 6, 2024?

34I find that the applicant has not established on a balance of probabilities that the psychological assessment in the treatment plan dated August 6, 2024 is reasonable and necessary.

35The treatment plan, prepared by Dr. Shirin Jazayeri, psychologist, seeks $2,200.00 for a psychological assessment.

36The applicant submits that she suffers psychological symptoms as a result of the accident. She submits a January 13, 2023 s. 25 psychological assessment report prepared by Dr. Betty Kershner, psychologist, and Ms. Leila Abbaszadeh, registered psychotherapist, which recommended psychotherapy.

37The respondent argues that on October 26, 2022, it approved a previous psychological assessment for the applicant, submitted by the same provider, which was dated January 10, 2020. The applicant has not submitted a request for payment for any psychological assessment to the respondent in the intervening time.

38While the applicant appears to have had a previous psychological assessment on January 13, 2023, the applicant has not made any submissions with respect to the course of the applicant’s treatment, if any, or why a second psychological assessment is required, while payment for the first assessment remains outstanding. Further, the applicant has not provided any contemporaneous medical evidence with respect to her psychological symptoms in support of the treatment plan.

39As a result, I find that the applicant has not met her onus to prove on a balance of probabilities that the treatment plan is reasonable and necessary.

40Accordingly, the applicant is not entitled to the treatment plan for a psychological assessment.

Interest

41Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no payments are owing, no interest is due.

Award

42The applicant sought an award under s. 10 of Reg. 664. Under s. 10, the Tribunal may grant an award of up to 50 per cent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits. As the applicant has not made submissions with respect to an award, and I have found that no benefits were unreasonably delayed or withheld by the respondent, and the applicant is not entitled to an award.

ORDER

43I find that:

i. The applicant is not entitled to the treatment plans in dispute. ii. The applicant is not entitled to the OCF-21s in dispute. iii. The applicant is not entitled to $1,400.00 for expenses for acupuncture services submitted on August 7, 2024. iv. As no payments are owing, no interest is due. v. The applicant is not entitled to an award. vi. The application is dismissed.