Licence Appeal Tribunal File Number: 24-008764/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:
Ida Greco
Applicant
and
Unifund Assurance Company
Respondent
DECISION
ADJUDICATOR:
Christin Carmichael Greb
APPEARANCES:
For the Applicant:
Michael Rotondo, Counsel
For the Respondent:
Hue Nguyen, Counsel
HEARD:
By Way of Written Submissions
OVERVIEW
1Ida Greco, the applicant, was involved in an automobile accident on June 15, 2023, 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, Unifund 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 $133.25 ($1,198.04 less $1,064.79 approved) for chiropractic services, proposed by Mackenzie Medical Rehabilitation Centre, in a treatment plan/OCF-18 (“plan”) dated August 25, 2023?
ii. Is the applicant entitled to $133.25 ($1,198.04 less $1,064.79 approved) for chiropractic services, proposed by Mackenzie Medical Rehabilitation Centre, in a plan dated October 10, 2023?
iii. Is the applicant entitled to $3,860.00 for an MRI, proposed by Princeton Hill Medical Assessments, in a plan dated September 5, 2023?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
v. Is the respondent liable to pay an award under s.10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
RESULT
3I find that:
i. The applicant is not entitled to the remaining balance of $133.25 for chiropractic services, in a plan dated August 25, 2023.
ii. The applicant is not entitled to the remaining balance of $133.25 for chiropractic services, in plan dated October 10, 2023.
iii. The applicant is not entitled to $3,860.00 for an MRI, in a plan dated September 5, 2023.
iv. The applicant is not entitled to an award.
v. No interest is owing.
vi. The application is dismissed.
4The application submitted by the applicant contained 6 issues in dispute: income replacement benefits, three treatment plans, an award, and interest. A three-day videoconference hearing was ordered. On April 17, 2025, the applicant filed a Notice of Motion to convert the format of the hearing from videoconference to written and to update the issues in dispute, as the parties had resolved the income replacement benefits and reached a partial resolution of two of the treatment plans in dispute. The applicant’s motion was granted.
5The applicant subsequently received payment for the income replacement benefits with interest, so this issue is no longer in dispute.
ANALYSIS
6To 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, how the goals would be met to a reasonable degreed, and that the overall costs of achieving them are reasonable.
Is the applicant entitled to the remaining amounts of the treatment plans for chiropractic services dated August 25, 2023, and October 10, 2023?
7The applicant has not met the onus to prove that the remaining amounts of the chiropractic treatment plans are reasonable and necessary.
8The applicant submits that the treatment plans were initially denied under the Minor Injury Guideline (MIG) and that the respondent gave notice of two s.44 assessments but omitted the reasons and purpose for the assessments. The applicant also argues that the s.44 assessment report of Dr. Alex Luczak, Psychiatrist, confirmed the exacerbation of a pre-existing psychiatric condition and concluded the MIG did not apply, however the treatment plans were denied based on the s.44 assessment report of Dr. Abdul Khan, Physiatrist, who concluded the applicant’s injuries were soft tissue in nature and therefore the treatment plans are not reasonable and necessary. The applicant submits that these decisions show the respondent is contradicting its initial sole reliance on the MIG.
9The respondent subsequently partially approved the treatment plans, leaving $133.25 outstanding based on an hourly rate of $99.75 vs. $200.00 and the cost of gloves for $33.00. The applicant submits that the respondent had not previously raised a quantum dispute on the treatment plans and that the hourly rate for a chiropractor is $112.81, not $99.75. The applicant also submits that the respondent had not denied costs for PPE items in other treatment plans.
10The respondent submits that the treatment plans were partially approved upon receipt of further medical documentation provided by the applicant. The respondent also submits that although the applicant was removed from the MIG, it was based on a pre-existing psychological impairment.
11The Financial Services Commission of Ontario’s Professional Services Guideline (Guideline) sets the hourly rates for professional services covered by the Schedule. The respondent argues that the hourly rate of the provider listed in the treatment plan was lowered to $99.75 from $200.00 based on the rates prescribed in the Guideline and the direction in the Guideline that administration costs, overhead and related costs, fees, expenses, charges, and surcharges are not to be charged to the insurer. The respondent goes on to submit that additional fees for preparation of session notes and review of medical files and records are attempts to increase the provider’s effective hourly rate beyond that permitted by the Guideline.
12I find that the provider named in the treatment plans is listed as a physiotherapist, not a chiropractor, and the adjusted hourly rate of $99.75 is the correct rate based on the Guideline.
13In the absence of any evidence from the applicant on this issue or an explanation as to why gloves are payable under the Schedule aside from “they had been approved in other treatment plans,” I agree with the respondent and find that the costs of gloves are not payable.
14Accordingly, I find that the applicant has not proven on a balance of probabilities that the unapproved balance for these treatment plans is reasonable and necessary.
S. 38(8)
15I find the denial letters are compliant with s. 38(8) of the Schedule.
16Section 38(8) requires an insurer to inform an insured person, within 10 business days after it receives the treatment plan, of the medical and other reasons why it considered the goods and services not to be reasonable and necessary if it denies a plan. Pursuant to s. 38(11), if an insurer fails to comply with its obligations under s. 38(8), it must pay for the goods and services that relate to the period starting on the 11^th^ business day after the insurer received the application and ending on the day the insurer gives a notice described in s. 38(8) and it is prohibited from taking the position that the insured person has an impairment to which the MIG applies.
17The applicant submits that the respondent failed to meet the requirements set out under section 38(8) of the Schedule by relying on the MIG to first deny funding and then deny the treatment plans as not reasonable and necessary once the applicant was removed from the MIG.
18I find the respondent’s denial notices for the OCF-18’s dated August 25, 2023, and October 10, 2023, were compliant with s. 38(8) because a s. 44 examination was scheduled to address the applicant’s injuries and to indicate if the Minor Injury Guidelines are applicable, as stated in the denial letter.
19I find that standing within the MIG is a medical reason because it indicates that the applicant’s impairments are minor, which is a medical definition in the Schedule. Therefore, I find that the denial letters are compliant with s.38(8) of the Schedule.
20I find on a balance of probabilities that the outstanding amounts of the treatment plans are not payable pursuant to s. 38(11) of the Schedule.
Is the applicant entitled to $3,860.00 for an MRI, in a plan dated September 5, 2023?
21The applicant has not met the onus to prove that the treatment plan is reasonable and necessary.
22The applicant submits that the respondent advised the treatment plan was denied under the MIG, and that no s.44 assessment was requested. The applicant goes on to argue that once she was removed from the MIG, the treatment plan remained denied and that the denial breached s.38(8) of the Schedule by failing to provide claim-specific reasons.
23The respondent submits that the treatment plan was not considered to be reasonable and necessary. The respondent also submits that MRIs are covered by OHIP and could have been completed without expense to the applicant.
24The applicant responds that according to s. 47(2) of the Schedule, the medical good or service must be “reasonably available” through OHIP, which the applicant states require a consideration of wait times existing through the public health care system. The applicant subsequently obtained an MRI through OHIP on December 27, 2024, which she argues was an unreasonable delay of over a year.
25The applicant points to a statement in Capildeo Bissoon v. The Co-operators General Insurance Company, 2023 CanLII 42675 (ON LAT), which states “due to wait times that exist within the public system,” and uses this statement to show an unreasonable delay of the MRI and that it should have been approved by the respondent. Decisions of the Tribunal are not binding on me, and upon review, I find that the decision in Capildeo Bisson is distinguishable. The adjudicator in Capildeo Bisson was specifically pointing to a physiatry assessment and went on to state “as well as the added pressure that was placed on this system at the time in question in 2020 and 2021, when the province was dealing with the COVID-19 pandemic.” In my view, the timeframe for receiving an MRI is not the same as a Physiatry Assessment. Moreover, in Capildeo Bissoon, the adjudicator relies on pandemic-related delays to support its conclusion, a factor that does not exist here.
26The applicant provides no further evidence, other than removal from the MIG, that the MRI was reasonable and necessary. The applicant was able to obtain an MRI through OHIP, which was reasonably available and in line with s.47(2) of the Schedule.
27I find that the applicant has not proven on a balance of probabilities that the treatment plan for an MRI is reasonable and necessary.
S. 38(8)
28The applicant further submits that the respondent failed to meet the requirements set out under section 38(8) of the Schedule by failing to provide claim-specific reasons with respect to the MRI.
29I find the respondent’s denial notice of September 26, 2023, was compliant with s. 38(8) because the notice states that the denial was based on the Minor Injury Guideline and there is a lack of documentation on file that would support removal from the MIG. I find on a balance of probabilities that the treatment plan is not payable pursuant to s. 38(8) of the Schedule.
Interest
30Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Having found no benefits payable, it follows that no interest is payable.
Award
31The applicant sought an award under s.10 of Reg 664. Under s.10, the Tribunal may grant an award of up to 50 percent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits.
32I find that the applicant is not entitled to an award because she has not met her onus on a balance of probabilities that the benefits have been unreasonably withheld or delayed.
33Accordingly, I do not find an award is payable.
ORDER
34I find that:
i. The applicant is not entitled to the remaining balance of $133.25 for chiropractic services, in a plan dated August 25, 2023.
ii. The applicant is not entitled to the remaining balance of $133.25 for chiropractic services, in plan dated October 10, 2023.
iii. The applicant is not entitled to $3,860.00 for an MRI, in a plan dated September 5, 2023.
iv. The applicant is not entitled to an award.
v. As no payments are owing, no interest is due.
vi. The application is dismissed.
Released: March 3, 2026
Christin Carmichael Greb
Adjudicator