Sarpong v. Belair Insurance Company Inc., 2026 CanLII 18349

Citation: Sarpong vs. Belair Insurance Company Inc., 2026 ONLAT 24-009186/AABS

Licence Appeal Tribunal File Number: 24-009186/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:

Richard Sarpong

Applicant

and

Belair Insurance Company Inc.

Respondent

DECISION

ADJUDICATOR:

Brian Norris

APPEARANCES:

For the Applicant:

Richard Sarpong, Applicant

For the Respondent:

Gurpreet Singh, Counsel

Farzana Merchant, Counsel

HEARD: by Videoconference:

December 1, 2025

OVERVIEW

1Richard Sarpong (“the Applicant”) was involved in an automobile accident on September 15, 2019, and sought benefits from Belair Insurance Company Inc. (“the Respondent”) 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 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. Has the Applicant sustained a catastrophic impairment as defined by the Schedule?

ii. Is the Applicant entitled to income replacement benefits (“IRBs”) in the amount of $238.49 per week for the period from December 9, 2021, to date and ongoing?

iii. Is the Applicant entitled to a medical benefit in the amount of $2,460.00 for a functional abilities evaluation, proposed by Complete Rehab in a treatment plan/OCF-18 (“plan”) dated August 3, 2023?

iv. Is the Applicant entitled to a medical benefit in the amount of $2,460.00 for a work site analysis, proposed by Complete Rehab in a plan dated August 3, 2023?

v. Is the Applicant entitled to a medical benefit in the amount of $6,708.17 for psychological treatment and driving anxiety treatment, proposed by Chinguacousy Physio & Foot Clinic in a plan dated December 18, 2023?

vi. Is the Applicant entitled to a medical benefit in the amount of $2,144.94, less $1,703.91 approved by the Respondent, for psychological treatment, proposed by Chinguacousy Physio & Foot Clinic in a plan dated September 8, 2023?

vii. Is the Applicant entitled to a medical benefit in the amount of $3,010.88, less $2,910.63 approved by the Respondent, for physiotherapy services, proposed by Chinguacousy Physio & Foot Clinic in a plan dated June 7, 2024?

viii. Is the Applicant entitled to interest on any overdue payment of benefits?

ix. Is the respondent liable to pay an award under section 10 of Regulation 664 because it unreasonably withheld or delayed payments to the Applicant?

RESULT

3The Applicant has not sustained a catastrophic impairment as a result of the accident.

4The Applicant is not entitled to IRBs as claimed.

5The functional abilities evaluation and worksite assessment plans are not reasonable and necessary as a result of the accident.

6The psychological treatment and driver’s anxiety plan, dated December 18, 2023, is not in dispute because it was approved by the Respondent.

7The Applicant is entitled to a medical benefit in the amount of $50.39 relating to the psychological treatment plan, dated September 8, 2023.

8The Applicant is entitled to an additional medical benefit in the amount of $100.25 relating to the psychological treatment plan, dated June 7, 2024.

9The Applicant is entitled to interest pursuant to section 51 of the Schedule in relation to the psychological treatment and drivers anxiety plan, dated December 18, 2023, the additional $50.39 related to the psychological treatment plan, dated September 8, 2023, and the $100.25 form fee related to the physiotherapy plan, dated June 7, 2024.

10No award is payable.

BACKGROUND

11On September 9, 2019, less than a week before the subject accident, the Applicant was struck on the left shoulder by the mirror of a vehicle while inline skating. He sought no medical attention at the time of the accident and was able to skate home after it. The Applicant met with his family physician, Dr. S. Shahzad, the following day and reported that he got hit by a hit-and-run driver the day prior as a pedestrian. He reported being hit on his back, and falling to a bent knee, and then he was hit on his left shoulder by the car mirror.

12The Applicant was examined by Dr. Shahzad due to complaints of pain in the left shoulder, left arm, left thigh, and right wrist, as well as headaches. On examination, Dr. Shahzad noted that the Applicant was tender in the areas of complaint, but all range of motion (“ROM”) was normal, and no visible swelling was noted. The Applicant was then referred for an x-ray of the left shoulder, which was normal.

13On September 15, 2019, the Applicant was involved in the subject accident when he was struck by a vehicle while walking. He was struck on the left side, and this time fell on his right side. He reports that he attempted to go to a walk-in clinic following his second accident, but the clinic was closed. Instead, the Applicant opted to see his family physician the following day.

14The Applicant was involved in an altercation with police at the scene of the second accident. The Applicant testified that the other driver denied to police that the Applicant was hit, and the Applicant felt disrespected by the police. The Applicant testified that he was then assaulted by the police officer, which led him to file a complaint with the former Office of the Independent Police Review Director.

15Regarding his complaint, the Applicant testified that he did an informal resolution with respect to the incident with the police. Records of the complaint are not before me. The Applicant did not provide the details of the assault in his testimony. The most robust account of any injuries stemming from the incident is in the catastrophic impairment assessment report, dated October 28, 2024. In that report, the Applicant stated that his right wrist was twisted in the incident, and he was kicked in his leg.

16The Applicant met with Dr. Shahzad the following day, on September 16, 2019, and reported that he was hit by the mirror of a car on his left side, and he fell to his right side, causing an injury to his right shoulder and wrist, which continued to be painful. There is also a separate note from that visit stating that the Applicant complained of left wrist and thigh pain. On examination, the Applicant had painful adduction and restricted flexion in his right shoulder, his left knee had restricted ROM, left wrist flexion was painful and restricted, as well as inside and outside medial and lateral rotation. His right wrist had normal ROM. Dr. Shahzad characterized these as myofascial injuries and advised the Applicant to engage in physiotherapy.

17Imaging was ordered for the Applicant following the accidents. Right knee x-rays on October 9, 2019 revealed no significant pathology, the right shoulder ultrasound imaging on October 16, 2019 revealed supraspinatus tendinosis with no evidence of a tendon tear, and the right knee ultrasound of October 16, 2019 revealed calcification in keeping with patellar calcific tendinosis, normal ligaments, and a mild degree of bursitis.

18The Applicant’s current complaints, listed by Dr. Friedlander in the October 28, 2024 report, include bilateral knee pain, bilateral shoulder pain, headaches, symptoms of post-concussion syndrome, neck pain radiating into the shoulder blades, low back pain, bilateral wrist pain, heart palpitations, gait issues, a lack of libido, psychological symptoms, and non-restorative sleep. When assessed by Dr. Friedlander, the Applicant ranked his overall pain as marked and constant.

ANALYSIS

19An analysis of the evidence in this case is difficult because the Applicant’s claim is with respect to his second accident, which occurred on September 15, 2019. However, the catastrophic impairment reports he relies on combine the accidents and the Applicant’s injuries together and make no distinction between the two accidents and the injuries related to each incident.

20The Applicant reports similar injuries between the two accidents. As noted, the Applicant reported to Dr. Shahzad that he injured his left shoulder, left arm, and left thigh, as well as right wrist pain, and that he got a headache following the first accident, on September 9, 2019. Following the second accident, on September 15, 2019, the Applicant reported primarily right shoulder and wrist pain, with left wrist and left knee pain.

21Further muddying the analysis is the fact that the Applicant sustained two subsequent assaults. First, the Applicant was assaulted by police following the second accident, as previously discussed.

22The second assault occurred in December 2022 or January 2023, nearly three years after the Applicant’s return to work in early 2020. The Applicant was involved in an altercation at work in January 2023, in which he was assaulted by a manager at the company. The Applicant has not worked at that place of employment since that incident and testified that he could not return to work in that environment and that the incident with the manager caused psychological symptoms such as anxiety and depression.

23There is little information regarding the assault at the workplace, or the Applicant’s employment status before and after the accident. The Applicant has not produced his employment records from his employer where he was assaulted, despite agreeing to do so prior to the hearing. Little other employment information was provided, such as a record of employment, which is in the Applicant’s possession, which would provide information on the end of his employment such as whether he was terminated, resigned, or left for illness or injury.

24The Applicant received standard Canadian Emergency Response Benefits (“CERB”), as well as the Canadian Recovery Caregiving Benefit (“CRCB”) after the accident. CERB was payable to individuals who stopped working because of reasons related to the pandemic or were eligible for employment insurance regular or sickness benefits or have exhausted their employment insurance benefits. CRCB is payable to individuals who were unable to work because they had to care for their child or family member who needed supervised care.

25The Applicant’s receipt of the CRCB complicates his claim because it suggests that he can work, but is not working because of the pandemic, or that he can work as a caregiver, or that he will seek benefits that he may not be entitled to. He testified that he was not providing care for anyone during the period and felt that the benefit was for people who needed care. I note that eligibility for CRCB is outlined in the application process, and the Applicant has not paid back the CRCB funds he received to-date.

26At the hearing, the Applicant was vague in directing me to the evidence that supports his claim. He directed me to the catastrophic impairment assessment reports he obtained while he had counsel, the clinical notes and records (“CNRs”) of Dr. Staab, his past treating psychiatrist, his prescription records, several insurer’s examinations (“IEs”), and some documents from his former employers. However, the Applicant was unable to provide direction as to why his reports should be preferred over that of the Respondent. Likewise, he never directed me to any errors in the IE reports, other than to criticize Dr. M. Angel, neurologist, for allegedly asking him to sign the consent form after the assessment took place.

27I reviewed all the reports referenced by the Applicant and placed the most weight on the reports that corroborate the Applicant’s self-reports with as much objective evidence as possible. I did this in light of the difficulty in distinguishing what injuries are related to the subject accident, what injuries are related to the assaults and any impact the assaults may have had on the Applicant and his mental and behavioural wellbeing, and the fact that the Applicant applied for and received CERB and CRCB, which requires that the person receiving the benefits is not working due to the pandemic or because they are caring for someone during the pandemic.

Catastrophic impairment

28The Applicant claims to have sustained a catastrophic impairment under: (i) Criterion 6, whole person impairment (“WPI”); (ii) Criterion 7, combined mental and physical impairments; and (iii) Criterion 8, mental and behavioural impairments. The Applicant holds the onus in demonstrating that his impairments meet the criteria for a catastrophic impairment.

29The Applicant’s claims are rooted in the catastrophic impairment report by Dr. Friedlander, anesthesiologist, dated October 28, 2024, and the associated assessments. In the catastrophic impairment report, Dr. Friedlander concluded that the Applicant sustained a 66% physical impairment pursuant to criterion 6, based solely on physical impairments. Under criterion 7, based on a combination of physical and mental and behavioral impairments, Dr. Friedlander assigned a combined WPI of 76%. Pursuant to criterion 8, Dr. Friedlander found that the Applicant met the test for a catastrophic mental and behavioural impairment because he suffered from marked impairments in all four domains of functioning.

30The Respondent disagrees and submits that the Applicant does not meet the criteria for a catastrophic impairment in any criteria. It relies on the catastrophic impairment report of Dr. D. Mula, physician, dated February 5, 2024, and the associated assessments. Dr. Mula concluded that the Applicant suffered a 36% WPI under criterion 7, and one marked mental and behavioural impairment, and no extreme impairment. Dr. Mula did not opine on whether the Applicant is catastrophically impaired pursuant to criterion 6.

31I must note that I discount Dr. Friedlander’s assessment of the Applicant’s impairments in general, because Dr. Friedlander does not differentiate where the Applicant’s impairments arise from and does not address the subsequent assaults. As I previously noted, the Applicant was involved in two separate accidents, and his claim for a catastrophic impairment arises from the accident dated September 15, 2019. Dr. Friedlander’s assessment notes both the September 9 and September 15, 2019 accidents. Further, Dr. Friedlander refers to the police assault but does not comment on whether it resulted in any of the impairments currently exhibited by the Applicant. Similarly, Dr. Friedlander does not adequately address the workplace assault the Applicant was involved in and instead states that the Applicant stopped working due to performance issues, which is based solely on the Applicant’s self-reports, which are demonstrated to be inaccurate at times. Dr. Friedlander’s omission of any meaningful discussion of the workplace assault, which precipitated the end of the Applicant’s employment after nearly three years of uninterrupted employment, suggests that important information was not fully considered by Dr. Friedlander, or that it was overlooked.

The Applicant has not sustained a catastrophic impairment under criteria 6 and 7

32I find that the Applicant has not met his onus to demonstrate on a balance of probabilities that he sustained a catastrophic impairment under criteria 6 and 7, as a result of the subject accident.

33To qualify for a catastrophic impairment under criterion 6, the Applicant must demonstrate that he has a physical impairment or a combination of physical impairments that, in accordance with the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993 (“the AMA Guides”), results in a WPI of 55% or more. To qualify for a catastrophic impairment under criterion 7, the Applicant must demonstrate that he has a combination of physical and psychological impairment ratings from medical professionals that meet the 55% WPI threshold.

34For the following reasons, I find that Dr. Friedlander overstated the Applicant’s impairments related to headaches, bilateral knee impairments, and sexual function, by 7%, 18%, and 5% respectively. When I adjust Dr. Friedlander’s overstated impairment ratings with my findings, the Applicant is left with a 41% WPI under criterion 6, and a 46% WPI under criterion 7, which fall below the 55% threshold for both criteria. Once I have corrected the overstated impairment ratings for headaches, knee impairments, and sexual function, the Applicant’s impairment rating results in a WPI of less than 55%, it becomes unnecessary to assess the other areas of impairment noted in Dr. Friedlander’s report.

Headaches

35I find that an impairment rating of 3% should be attributed to headaches. Overall, the Applicant has provided limited objective evidence supporting a finding that he suffers from accident-related headaches. For the following reasons, I apply the rating attributed by Dr. M. Angel, neurologist, in the IE dated February 5, 2024.

36I place great weight on the CNRs from Dr. Shahzad and Chinguacousy Physio and Foot clinic (“Chinguacousy”), which indicate that the Applicant does not suffer from accident-related headaches. The Applicant reported suffering from a headache immediately following the first accident but did not report suffering from a headache following the second accident. The CNRs from Dr. Shahzad do not include any issues related to headaches, aside from reporting that he had a single headache following the first accident. The Applicant also denied having a headache to Dr. Shahzad during a visit on November 5, 2021, when he was being assessed for a sore throat, which is inconsistent with a finding of impairment due to persistent headaches. CNRs from Chinguacousy, where the Applicant sought treatment following the subject accident, do not include any reports from the Applicant that he hit his head or suffered from headaches or other concussion-related symptoms. The Applicant’s initial complaints at Chinguacousy where related to pain in the low back, right knee, right thigh, right shoulder, and pain with neck movements. The fact that the Applicant never reported chronic headaches, or occipital headaches to Dr. Shahzad, or his treatment providers at Chinguacousy, indicates that the Applicant does not suffer from an impairment due to headaches, or that it is unrelated to the accident.

37I give less weight to the report of Dr. Friedlander, because it is an outlier when assessing the Applicant’s impairment for headaches. Dr. Friedlander attributed a 22% WPI related to headaches and determined that the Applicant suffered from bilateral greater occipital neuralgias, as well as bilateral lower occipital neuralgias, and bilateral great auricular neuralgias. Dr. Friedlander never highlighted any historical headache complaints in the CNRs reviewed as part of the assessment. Dr. Friedlander’s finding is based partly on the Applicant’s report that he suffered a headache from the first accident, and it was exacerbated by the second accident, which is not reflected in the other medical records. On assessment, Dr. Friedlander reported that the Applicant’s neurological examination showed intact cranial nerve function. Dr. Friedlander observed pain complaints with tenderness and guarding over the greater and lesser occipital and greater auricular nerves bilaterally upon palpitation of the vertebral column. Testing did not reproduce the Applicant’s headache, and no radiculopathy was reported. Overall, the assignment of 22% WPI for headaches is inconsistent with the balance of the Applicant’s medical records. Accordingly, I reject Dr. Friedlander’s attribution of 22% WPI for headaches.

38I accept the assignment of 3% given by Dr. Angel, neurologist, in the catastrophic impairment IE dated February 5, 2024. Dr. Angel assigned a WPI of 3% for headaches because it could not be ruled out that the Applicant suffered from them. The Applicant reported mostly neck and back pain, and he only mentioned headaches much later in the examination. According to Dr. Angel, the Applicant’s description of his pain was, for the most part, non-specific, vague, and did not resemble a symptom of complex suggestive of a primary neurological impairment. On examination, Dr. Angel found normal neck ROM and was unable to disclose any evidence of a primary peripheral or peripheral nervous system injury.

39I will not discount Dr. Angel’s report on account of the Applicant’s submissions regarding consent for the assessment. The Applicant asked that I discount Dr. Angel’s report because, he submits, his consent for the assessment was obtained after the assessment took place, not before as stated in the report. The Applicant stated that he raised the issue of the consent with his prior counsel a week following the assessment but is unsure if any action was taken. I have chosen not to discount the report because the issue was not raised previously with the Respondent and, more importantly, the Applicant does not deny that he consented to the assessment, or that he revoked his consent.

40Considering Dr. Angel’s impairment assignment, I find on a balance of probabilities that a WPI of 3% for headaches is accurate.

Impairment	Applicant’s WPI% (Criterion 6)	Applicant’s WPI% (Criterion 7)	Respondent’s WPI% (Criterion 7)	Tribunal’s Finding (Criterion 6)	Tribunal’s Finding (Criterion 7)
Bilateral greater occipital neuralgias (Headache)	10%	10%	3%	3%	3%
Lower occipital neuralgias	6%	6%	0%	0%	0%
Greater auricular neuralgias	6%	6%	0%	0%	0%

Knees

41I assign a 4% WPI for the Applicant’s knee impairments based on table 41 of the AMA Guides. Table 41 of the AMA Guides provides impairment ratings based on the ROM exhibited on examination. Knee flexion that less than 110° amounts to a mild impairment with a WPI of 4%.

42With respect to the Applicant’s knee impairments, I prefer the assessment and findings of Dr. Yee over Dr. Friedlander because Dr. Yee’s conclusion is more consistent with the balance of the Applicant’s medical records. Dr. Yee found that palpation revealed tenderness predominantly anteriorly, but nonspecific to patellofemoral region. There was no pain with any compression test and no significant hypermobility observed. Objective testing showed his right knee ROM was 0°-115° on the right, and 0°-125° on the left, negative McMurray’s test, and normal straight leg raises.

43I find Dr. Yee’s assignment of 0% WPI for the Applicant’s knees may be accurate and is consistent with Table 41 of the AMA guides, but I assign a WPI of 4% considering the Applicant’s ongoing complaints of right knee dysfunction. Table 41 states that knee flexion must be less than 110° to apply an impairment rating. In Dr. Yee’s assessment, the Applicant’s ROM is beyond that threshold, there is no deformity in the knees, and no crepitus observed upon examination, thus the allocation of 0% was given. I have chosen to increase that rating to 4% to factor in observations made by other healthcare professionals, as I will outline further.

44I reject Dr. Friedlander’s impairment rating because it is anomalous to the other information in the Applicant’s medical records. Dr. Friedlander recorded that the Applicant’s right knee flexion was 40° and his extension was -50°, and his left knee flexion was 60° and his extension was -10°, correlating to a 14% WPI for the right knee and 8% WPI for the left knee. The negative extension recorded by Dr. Friedlander indicates that the Applicant’s knees hyperextend significantly, which is not recorded by any other healthcare provider. Similarly, the knee flexion recorded by Dr. Friedlander is extreme and would likely impede the Applicant from performing many tasks, such as traversing stairs. I reject Dr. Friedlander’s impairment rating because the knee flexion indicated in the report is not recorded by any other healthcare provider, particularly with respect to the Applicant’s left knee. Such impairments would significantly impede, if not totally preclude the Applicant from accessing his bedroom in the basement, where he resides and where several assessments took place.

45There are several examples in the Applicant’s medical records which demonstrate that his bilateral knee ROM is within functional limits, or mildly reduced at most, which equate to an impairment rating of 4%, at most. In the January 27, 2021 report by occupational therapist (“OT”) A. Amezquita, from Chinguacousy, it was noted that the Applicant exhibited functional ROM in the knees bilaterally, and was observed to negotiate stairs with a reciprocal pattern. This would result in an impairment rating of 0%. In the April 13, 2021 report by A. Phillips, OT, the Applicant’s bilateral knee flexion and extension were found to be within normal functional limits, despite noted right knee pain reported with flexion. OT Phillips’ findings would result in no impairment rating. Dr. A. Belfon, physician, in an IE report dated November 29, 2021, found left knee ROM ranging from 0°- 130°. The Applicant’s right knee ROM was up to 50°, but the Applicant would not let Dr. Belfon passively flex the knee further and demonstrated extension up to 90° when sitting up from the examination table. This suggests that the Applicant was self-limited and that his right knee ROM was greater than he exhibited. Dr. Belfon’s findings would result in a 4% WPI at most, because the Applicant does not exceed the less than 80% threshold for a moderate impairment. In a December 2, 2021 routine physical examination with Dr. Shahzad, it was noted that the Applicant had no swollen joints, no joint pain, all joint ROM was good, and was found to have a normal physical examination. This would result in a 0% WPI.

46Other examples of the Applicant’s knee ROM continue to show at most, a moderate impairment equating to an 8% WPI. Dr. E. Silver, physician, in an IE report dated September 21, 2023, found bilateral flexion limited at 90° without provocation of pain on the left, but patellar pain on the right. In the same assessment, bilateral knee extension was full and pain free. Overall, Dr. Silver found the Applicant to be “quite self-limited in ROM and orthopaedic testing”. The ROM exhibited on this examination would result in, at most, an 8% WPI, without consideration for the Applicant’s self-limiting behaviour. The November 14, 2024 in-home OT assessment report by T. Rubin, OT found right knee flexion was moderately restricted between 1/3 and 2/3 of normal range, which I equate to be between 45° and 90°. Left knee flexion was within functional limits, as was bilateral knee extension. To me, this equates to at most an 8% WPI, noting that the Applicant’s right knee ROM is recorded here to be less than 80°. I would not assign a severe impairment rating of 14% to the right knee based on this observation because the Applicant was able to do a half squat during this assessment and is not impaired from using the stairs to access his bedroom, located in the basement of his familial home. Similarly, I would not assign an 8% WPI in light of the self-limiting behaviour exhibited on examination with Dr. Silver.

47Like Dr. Yee, and Dr. Shahzad, OT P. Nair concluded that the Applicant’s knee ROM was within functional limits. In the February 5, 2024 IE report, OT Nair found that the Applicant’s knee flexion was up to 140° bilaterally, and extension was 0° bilaterally. OT Nair’s observation correlates to a 0% WPI.

48Overall, the average rating based on my above analysis can be rounded up to a 4% WPI, representing a mild impairment in the right knee. I would not award any impairment rating for the Applicant’s left knee based on the above information. Accordingly, my impairment rating for the knees is 4%.

Impairment	Applicant’s WPI% (Criterion 6)	Applicant’s WPI% (Criterion 7)	Respondent’s WPI% (Criterion 7)	Tribunal’s Finding (Criterion 6)	Tribunal’s Finding (Criterion 7)
Left knee	8%	8%	0%	0%	0%
Right knee	14%	14%	0%	4%	4%

Sexual Function

49I reject Dr. Friedlander’s assignment of a 5% impairment rating for sexual functioning and assign a 0% WPI for the Applicant’s sexual function impairments because the Applicant does not have a physical impairment that precludes his ability to engage in intimacy.

50The AMA Guides state that awareness and capability of having an orgasm are the criteria for evaluating permanent impairment of sexual functioning that may result from a spinal cord or other neurologic system disorders. The patient’s previous sexual function should be considered in the evaluation. To achieve a 5% WPI score in sexual function, the Applicant must demonstrate that a physical symptom is impacting his sexual function, and that sexual function is possible but with difficulty of erection or ejaculation, or a lack of awareness excitement, or lubrication. There is no such evidence before me.

51I find that Dr. Friedlander neglected to connect the Applicant’s reported lack of libido to a physical impairment, and never inquired about the Applicant’s pre-accident sexual function, as required by the AMA Guides. Neither Dr. Friedlander, nor any of the Applicant’s other treating or examining health care providers have diagnosed the Applicant with a spinal or neurologic system injury that would impact the Applicant’s sexual function.

52At most, the Applicant’s reported lack of libido would fall under a mental and behavioral impairment, which is captured in the assignment of a 30% WPI rating for mental and behavioural impairments. Sexual function was a factor when assessing the Applicant’s mental and behavioural impairments, which I address in greater detail below. Accounting for an impairment rating related to sexual function as a result of a physical condition as well as a psychiatric condition results in an inflated impairment rating.

53Having found no connection between the Applicants’ reported lack of libido and a physical impairment, as well as finding that the reports of sexual dysfunction are captured in the mental and behavioural impairment ratings, I find that a 0% WPI rating is correct.

54When my findings are factored into Dr. Friedland’s WPI rating under criteria 6 and 7, it equates to no more than a 36% WPI under criterion 6, and a 46% WPI under criterion 7, which fall below the 55% threshold for both criteria. As a result, I do not need to assess the other areas of impairment and conclude that the Applicant has not sustained a catastrophic impairment pursuant to criteria 6 and 7 as a result of the accident.

Criterion 8

55The Applicant submits that he sustained a catastrophic impairment pursuant to section 3.1(1)8 of the Schedule (“criterion 8”). He relies on the report by Dr. S. Shahmalak, psychiatrist, dated December 12, 2024.

56To qualify for a catastrophic impairment pursuant to criterion 8, the Applicant must demonstrate that he sustained an impairment in accordance with the AMA guides, which results in a class 4 impairment (“marked impairment”) in three or more areas of function that precludes useful functioning or a class 5 impairment (“extreme impairment”) in one or more areas of function that precludes useful functioning, due to a mental or behavioural disorder. The parties agree that the Applicant does not suffer from an extreme impairment in any area of function.

57The assessment pursuant to criterion 8 excludes consideration for any physical impairments and is based solely on mental and behavioural disorders. Pursuant to criterion 8, mental and behavioural impairments are measured in four areas: 1) Activities of Daily Living (“ADLs”); 2) Social Functioning (“SF”); 3) Concentration Persistence and Pace (“CPP”); and 4) Adaptation in Work or Work-like Settings (“adaptation”).

58According to the AMA guides, the impairment rankings are as follows.

Area or aspect of functioning	Class 1: No Impairment	Class 2: Mild Impairment	Class 3: Moderate Impairment	Class 4: Marked Impairment	Class 5: Extreme Impairment
ADLs	No impairment is noted	Impairment levels are compatible with most useful functioning	Impairment levels are compatible with some, but not all, useful functioning	Impairment levels significantly impede useful functioning	Impairment levels preclude useful functioning
Social Functioning
Concentration Persistence and Pace
Adaptation in work and work-like settings

59The AMA Guides note that a marked impairment in two or more spheres would be likely to preclude performing complex tasks without special support or assistance, such as that provided in a sheltered environment. An individual who was impaired in all four categories of functioning, as the Applicant claims, would be limited in his ability to carry out many, but not all complex tasks. Mild and moderate limitations reduce overall performance but do not preclude performance.

60The onus is on the Applicant to demonstrate that he suffers from a class 4 marked impairment in three of the four domains or a class 5 extreme impairment in one domain.

61Overall, I find that the Applicant does not suffer from a mental and behavioural impairment that limits his ability to carry out many, but not all, complex tasks. When assessing the Applicant’s case from a high level, I find that he can carry out complex tasks outside of a sheltered environment that is not akin to a person suffering from four marked mental and behavioural impairments. The Applicant demonstrated an ability to participate in the hearing and the Tribunal’s process as a self-represented party. This included filing motions, reviewing evidence, and introducing evidence that he felt was relevant but had never been disclosed. This demonstrates a level of function and cognition which is not compatible with a finding of marked impairments in all domains of function.

Activities of daily living (“ADLs”)

62I find that the Applicant has not demonstrated on a balance of probabilities that he suffers from a marked impairment in the sphere of ADLs.

63According to the AMA guides, ADLs include: self-care and personal hygiene, such as bathing, grooming, dressing, eating, and toileting; Communications such as hearing, speaking, reading, writing, and using a keyboard; Physical activity such as standing, sitting, walking, stooping, squatting, kneeling, reaching, bending, twisting, carrying, lifting, pushing, pulling, climbing and exercise; Sensory functions such as hearing, seeing, feeling, tasting, and smelling; Hand functions such as grasping, holding, pinching, percussive movements, sensory discrimination; Travel, such as riding, driving, or travelling by plane, train or automobile. Sexual function such as participation in desired sexual activity; Sleep and having a restful sleep; and Social and recreational activities such as sports and hobbies.

64I find that Dr. Shahmalak overstates the Applicant’s impairment in the sphere of ADLs, with respect to his mental and behavioural impairments. Dr. Shahmalak found that the Applicant’s mental and behavioural impairments significantly impede the Applicant’s useful functioning in ADLs. However, the evidence does not indicate that the Applicant’s functioning in ADLs is significantly impeded. By all reports, the Applicant remains independent with personal hygiene, but for reports of occasional reminders to bathe. He has demonstrated effective communications throughout the hearing, and with the various assessors who evaluated him during his claims process, most of which characterized the Applicant as pleasant and cooperative. The Applicant walks independently, with a normal gait, and without the use of a mobility aide as reported by Dr. Shahmalak. During Dr. Shahmalak’s assessment, the Applicant was noted to sit comfortably on an examination table for up to 50 minutes. The Applicant has participated in physical rehabilitation, suggesting that he is capable of exercising. Though he reports having stopped driving, the evidence demonstrates that the Applicant drove following the accident, including when he returned to work as a driver in 2020, which included travel as far as 1.5 hours from his origin. He can travel as a passenger, as evidenced by his attendance at various assessments in which he was brought by taxi. He reports no difference in his sexual relationships pre-accident versus post-accident, aside from a decreased desire.

65I find that Dr. Shahmalak considered the Applicant’s physical impairments when assessing ADLs. For example, Dr. Shahmalak notes that pain and anergia limits the Applicant’s walking to only short distances however, the Applicant testified that pain is impairing his ability to walk and complete tasks such as dressing, reaching, lifting, and standing.

66I find that Dr. Shahmalak’s opinion should be discounted because he attributes cognitive difficulties to the Applicant without assessing cognition. Dr. Shahmalak states that the Applicant’s parents handle his bill payments, and that the Applicant misses medication doses due to cognitive difficulties. Yet, Dr. Shahmalak never conducted formal cognitive testing of the Applicant and stated that the Applicant’s “recollection of approximate events, timeframes, and dates from his short-term and long-term memory seemed to be fair” and that he “responded to questions and commands, indicating that he is able to process, comprehend, interpret, and respond to information within the context of the assessment”. I do not accept Dr. Shahmalak’s findings on the Applicant’s cognition, considering no formal testing was done, and the above comments, which suggest a reasonable level of cognition.

67I find that the CNRs from Dr. R. Staab, psychiatrist, support a finding of a moderate impairment in the sphere of ADLs. The Applicant was referred to Dr. Staab by Dr. Shahzad, starting in December 2022. Dr. Staab assessed the Applicant and diagnosed him with Major Depressive Disorder, Generalized Anxiety Disorder, Post-Traumatic Stress Disorder, and Chronic Pain. Dr. Staab noted that the Applicant reported reduced socializing, and panic attacks about once a month. However, during the course of care from December 2022 to October 2023, Dr. Staab noted that the Applicant has goals of improving his mental health and coping skills, has been trying to do some regular chores around the house, has been engaging in physiotherapy, practices breathing exercise, and takes daily walks. By October 2023, Dr. Staab discharged the Applicant, noting some ongoing struggles, but that he has been “well stabilized so far and has made some good improvement in the last year”.

68I find Dr. Jwely’s February 5, 2024 report and conclusion of a moderate impairment in ADLs as a result of the accident to be consistent with the Applicant’s medical records. Dr. Jwely was overall suspicious of the Applicant’s claim that there is a direct link between the Applicant’s psychological state and the accident, given the absence of psychological or psychiatric intervention immediately following the accident and the onset of the Applicant’s psychological symptoms. Further, Dr. Jwely noted that the reported symptoms and their severity, particularly given the time elapsed since the accident, do not align with typical patterns of psychiatric response to trauma, and that the discrepancy points to a possibility that the Applicant’s current psychological state might be influenced by factors other than the subject accident. Dr. Jwely concluded that the Applicant demonstrated an ability to perform self-care, personal hygiene, and engage in some level of social and recreational activities such as using the meditation app and walking short distances, and that he remained able to initiate and participate in these activities independently. It was noted that the Applicant arrived at the assessment by taxi, indicating that he continues to be able to travel in a vehicle. Dr. Jwely noted that the Applicant’s self-reported independence in personal ADLs and participation in light household duties, despite pain and low motivation, suggested a moderate level of functioning.

69I find that a rating of a moderate mental and behavioural impairment in ADLs is consistent with the information in Dr. Shahzad’s CNRs. Dr. Shahzad monitored and treated the Applicant’s mental and behavioural impairments following the accident. The CNRs include complaints of nightmares during the months following the accident, as well as depression, anxiety and overall chronic body pain. Dr. Shahzad prescribed psychotropic medication and made referrals for counselling, including an 8-week group program in 2021, and one-on-one telephone counselling with Dr. Staab. The impairments relayed to Dr. Shahzad are consistent with a moderate mental and behavioural impairment.

70I find that Dr. Shahzad’s CNRs are not indicative of a marked impairment in the sphere of ADLs. Dr. Shahzad’s CNRs demonstrate that the Applicant is independent with his ADLs, is a capable communicator, and can access his community. The CNRs confirm that the Applicant returned to work and maintained that employment for nearly three years. These reports are not consistent with a marked impairment in the sphere of ADLs.

71Overall, I accept that the Applicant suffers from mental and behavioural impairments in the sphere of ADLs however, those impairments do not rise to a level that they significantly impede useful functioning. At most, from a mental and behavioural perspective, I find that the Applicant has impaired sleep due to initial insomnia and middle insomnia attributed to nightmares (and pain), impaired participation in leisure activities, and amotivation to perform household tasks. To me, these findings demonstrate that the Applicant suffers a moderate impairment in the sphere of ADLs because his impairments have some impact on him, but do not serve to significantly impede his useful functioning.

Social Functioning

72I find that the Applicant suffers from a moderate impairment in the sphere of SF.

73SF refers to one’s capacity to interact appropriately and communicate effectively with other individuals. This includes the ability to get along with family, friends, neighbours, and other people in the community.

74I place weight on the fact that the Applicant returned to work for a period of more than 2.5 years following the accident, which suggests that he has reasonable capacity in interacting appropriately with others. There is no information before me to suggest that the Applicant was unable to interact appropriately or communicate effectively with others during his tenure at work following the accident. I acknowledge the workplace incident that precipitated the end of the Applicant’s employment as a driver and find it to be consistent with impairment levels that are compatible with some but not all useful functioning. This is because the workplace altercation is a single incident over the period of more than 2.5 years. In addition, the Applicant found new employment as a driver following the workplace incident. This demonstrates that he was capable of navigating the hiring process, and there is no indication that his termination was as a result of an inability to communicate or interact appropriately. To me, this post-accident behaviour is consistent with a moderate impairment in SF.

75I find that Dr. Shahmalak’s conclusion of a marked impairment in the sphere of SF is an overstatement of the Applicant’s mental and behavioural impairments. Dr. Shahmalak noted that the Applicant reported that he isolates himself, lost all his friends, and currently has minimal interaction with his family due to his irritability. While this demonstrates some impairment in the Applicant’s ability to get along with others, it does not demonstrate that he is unable to interact appropriately or communicate effectively with others. This is reflected in the collateral interview questionnaire, completed by the Applicant’s father. The Applicant’s father noted that the Applicant was irritable but never characterized him as being unable to communicate appropriately or as being argumentative. This level of impairment, being irritable and self-isolating, but maintaining the ability to communicate appropriately with others, is more consistent with a moderate impairment than a marked impairment because the Applicant’s impairment levels are compatible with some, but not all, useful functioning.

76The Applicant exhibits SF that is compatible with some but not all useful functioning, contrary to Dr. Shahmalak’s conclusion. The Applicant has demonstrated that he has the social functioning to maintain employment for a period of over two years. Following that, he was then capable of navigating the hiring process and obtained new employment. By all accounts of the healthcare providers who have met with the Applicant, he behaves appropriately during his many medical assessments and appointments. In fact, I have been unable to find a report from an assessor who characterized the Applicant’s social presentation negatively. He participated meaningfully in the dispute resolution process at the Tribunal, including filing motions to include evidence and obtain accommodations. This behaviour was appropriate to the situation and included no outbursts or altercations with Tribunal staff or members. To me, this is indicative of a person who has mental and behavioural impairment levels that are compatible with some, but not all, useful functioning.

77I find Dr. Jwely’s conclusion that the Applicant sustained a moderate impairment in the sphere of SF to be accurate. Dr. Jwely highlighted that the Applicant’s capability to reside with his family and partake in therapeutic sessions suggest a level of social engagement, even if diminished from his pre-accident levels. Dr. Jwely noted that the Applicant elicited high scores on psychometric testing, suggestive of considerable difficulties in cognition, understanding, and communication, but found that his interactions with medical professionals and his level of social engagement weighed more than the numerical values in the psychometric testing.

78I find the CNRs of Dr. Shahzad and Dr. Staab are not indicative of a marked impairment in the sphere of SF. The CNRs by Dr. Shahzad and Dr. Staab do not characterize the Applicant as exhibiting anti-social behaviour, communicating inappropriately, or engaging in confrontational behaviour. Dr. Shahzad’s CNRs demonstrate that the Applicant suffers from a depressed mood and anxiety, but there are no notes indicating that the Applicant is unable to communicate or interact appropriately due to his mental and behavioural impairments.

79Dr. Staab’s CNRs are not indicative of a person with a marked impairment in SF. Dr. Staab provided therapy for the Applicant over the course of approximately one year. The notes in the CNRs from Dr. Staab describe a person with depressed mood and anxiety, but do not portray the Applicant in a manner that suggests he suffers mental and behavioural impairments that significantly impede him in the sphere of SF. In fact, Dr. Staab concluded that the Applicant was stable after about six therapy sessions and concluded that he could be discharged back to Dr. Shahzad for monitoring.

80Overall, I find that the Applicant suffers, at most, a moderate impairment in the sphere of SF. Having concluded that the Applicant suffers not more than a moderate impairment in the spheres of SF and ADLs, and not having sustained an extreme impairment in any sphere, it follows that the Applicant has not met his onus to demonstrate that he suffers a catastrophic impairment as a result of the accident.

IRBs

81I find that the Applicant has not met his onus to demonstrate on a balance of probabilities that he is entitled to IRBs.

82To qualify for IRBs as claimed, the Applicant must demonstrate that he suffers a complete inability to engage in any employment or self-employment for which he is reasonably suited by education, training, or experience, pursuant to section 6(2)(b) of the Schedule.

83The Applicant submits that he is unable to maintain employment as a result of the accident. He did not address the test for entitlement to IRBs. Instead, the Applicant highlights his need for breaks, difficulty following conversations, and inability to handle stressful situations as reasons why he should be entitled to IRBs. The Respondent submits that the Applicant has not provided evidence that he meets the test for IRBs and notes that the Applicant returned to work for a significant period that overlaps with his claim for IRBs.

84The Applicant was employed as a package handler at the time of the accident. His role involved working in a warehouse, scanning and sorting packages, and loading packages as heavy as 80 pounds onto a conveyor belt. He returned to work in early 2020, with the same employer, but as a delivery driver instead of a package handler. As a delivery driver, the Applicant reports that he was only responsible for driving a vehicle between warehouses. Indeed, the Applicant’s return to work at his pre-accident employment, as well as his temporary employment thereafter, occurred during the period he claims entitlement to IRBs.

85I draw an adverse inference on the Applicant’s failure to produce his employment records from his pre-and post accident employers. This questions the veracity of the Applicant’s claims regarding his inability to work because the Applicant has demonstrated that he can be an inaccurate historian and his inability to work is inconsistent with most of the other evidence. The employment files would likely provide information regarding the Applicant’s return to work in 2020, his performance following his return to work, the incident when he drove himself to the hospital in Peterborough while on a delivery, and the assault at work in December 2022 or January 2023. The employment records could corroborate the Applicant’s claims that he was struggling at work due to physical demands. The records would indicate whether any accommodations were sought by the Applicant. The employment records would also clarify the reasons why the Applicant’s employment ended. Having failed to produce this evidence, I infer that it is unfavorable to the Applicant.

86I find that the minimal employment records provided do not indicate that the Applicant suffers a complete inability to engage in suitable employment. The Applicant provided a document, dated August 18, 2021, that appears to have a comment from a manager, stating that the Applicant takes 7 hours or more to complete a 6-hour route, and asks if the Applicant is experiencing any difficulties which would explain the delay. There is no other relevant information within this document. This document pre-dates the Applicant’s end of employment by nearly a year and a half and there is no evidence of any subsequent employment issues before me. However, I conclude that taking 7 hours to complete a 6-hour route is not indicative of a complete inability to engage in suitable employment because it shows that he can complete the essential tasks of his employment but takes more time to complete them.

87The termination letter from his second post-accident employer, dated February 24, 2023, does not indicate a complete inability to engage in suitable employment. The letter does not address the Applicant’s performance or ability to complete the tasks of employment. The letter advises that the Applicant’s services are no longer required, and he was terminated during his probationary period. If anything, this letter confirms that the Applicant will be untruthful when advancing his claims – he testified that he quit his employment, and reported the same to various assessors, when this letter unequivocally states that his employment was terminated.

88The Applicant’s receipt of CERB and CRCB indicate an ability to work. As discussed previously, the Applicant claimed and received CERB and CRCB during the pandemic. These benefits are for people whose employment is affected by the pandemic, and for those providing care for people during the pandemic. Having received these benefits, and never paid them back, suggests the Applicant could work but is not working due to pandemic-related issues.

89A factor when considering whether the Applicant suffers from a complete inability to engage in any suitable employment or self-employment is the fact that he returned to work and maintained that employment for nearly three years. The Applicant returned to work in early 2020, as confirmed by his request for clearance to return to work, as well as his report to Dr. E. Silver, in the September 21, 2023 IE report. The Applicant maintained that employment from early 2020 until December 2022, or January 2023, a period of nearly three years. There is evidence of only one performance issue during that period of nearly three years, which to me indicates that the Applicant does not suffer a complete inability to engage in suitable employment or self-employment.

90I find the September 21, 2023 IE report by Dr. Silver to be a reasonably accurate account of the Applicant’s physical functioning following the accident. Dr. Silver noted that the applicant exhibited ROM deficits during formal testing, and refused to do tests, such as bilateral rotation, due to a fear of pain. However, informal observation demonstrated that the Applicant exhibited bilateral rotation of greater than 30° and flexion greater than exhibited during formal testing. Overall, Dr. Silver found that the Applicant walked with a normal gait, demonstrated an ability to sit on the examination table for 50 minutes with no obvious signs of pain, exhibited non-specific pain complaints, and found a significant non-organic component to the Applicant’s pain presentation. Dr. Silver’s assessment and conclusion is consistent with my overall impression that the Applicant’s physical impairments are overstated, as discussed previously in the catastrophic impairment section of this decision.

91As with the catastrophic impairment reports, Dr. Friedlander’s IRB report, dated October 28, 2024, and Dr. Shahmalak’s IRB report, dated December 12, 2024, hold less weight because they do not differentiate between the two accidents, and both rely too heavily on the Applicant’s self-reports, which have been demonstrated to be inaccurate. For example, Dr. Friedlander mistakenly notes that it took the Applicant a year to return to work following the accident, but the period was closer to six months. In another example, it states that the Applicant returned to work with modifications, and repeatedly received letters regarding his poor performance at work, but there is no evidence to support this. In fact, the performance document dated August 18, 2021 states that the Applicant was taking 7 hours to complete a 6-hour route, and asks whether the Applicant is experiencing any difficulties. To me, the document suggests that the Applicant had no accommodation when he returned to work because there is no indication that the Applicant’s medical status is a contributing factor to any performance issue. Overall, I cannot accept Dr. Friedlander’s conclusion that the Applicant’s physical and mental and behavioural impairments substantially interfere with his vocational activities, nor that he has diminished ability to carry out tasks of employment, because the report is based on inaccurate reporting and non-organic physical restrictions.

92I further find that Dr. Shahmalak’s conclusion is, in part, inconsistent with the body of the December 12, 2024 report, diminishing the overall persuasiveness of the opinion. Dr. Shahmalak concluded that the Applicant, in both the catastrophic impairment assessment and the IRB assessment, did not demonstrate the capacity to maintain work-appropriate engagement and emotional demeanour. Yet, the Applicant completed all the psychometric testing in the assessment, required no breaks, never had any outbursts, and was pleasant during the interview with Dr. Shahmalak. The only relevant anti-social behaviour noted was that the Applicant reported that people were irritated with his slow cognition and that he acknowledged experiencing emotional dysregulation towards family, friends, and members of the community, but no examples were provided.

93Overall, I find that the Friedlander and Shahmalak reports are outweighed by the objective information discussed above. The objective evidence does not indicate a complete inability to engage in suitable employment. Accordingly, I find that the Applicant has not met his onus to demonstrate entitlement to IRBs.

Functional abilities evaluation and worksite assessment plans dated August 3, 2023

94I find that the Applicant has not demonstrated on a balance of probabilities that the functional abilities evaluation and worksite assessment plans are reasonable and necessary as a result of the accident.

95Like the other plans subject to this hearing, the Applicant never tendered any submissions on why these plans are reasonable and necessary as a result of the accident, nor did he direct me to any evidence to support his claim for entitlement to these plans. Given that the Applicant holds the onus to demonstrate entitlement to the benefits claimed, these facts alone are sufficient for me to dismiss the Applicant’s claims. Nevertheless, I reviewed the plans in light of the evidence presented and my conclusions are as follows.

96With respect to the functional abilities evaluation and worksite assessment, the largest factor I consider is that the Applicant demonstrated the functional ability to return to work as a driver for a period of over 2.5 years, until his employment stopped following the altercation with his manager. It is unreasonable to assess the Applicant’s function and worksite considering his return to work for such a prolonged period without any evidence of an accommodation. I find his return to work during this post-accident period demonstrates a level of function compatible with real-world employment such that these assessments are not reasonable and necessary.

97I find that the Applicant does not exhibit the physical dysfunction to warrant assessing his function and worksite. I highlight that the Applicant returned to work as a driver and reiterate my previous findings that the Applicant’s knee and headache impairments are minor or unrelated to the accident, and ROM throughout his body was within normal limits for the most part. While the Applicant exhibits psychological dysfunction, the work site analysis and functional abilities evaluation seek to assess the Applicant from a physical perspective without consideration for his mental and behavioral impairments.

98Accordingly, I find that the Applicant has not met his onus to demonstrate on a balance of probabilities that these assessments are reasonable and necessary as a result of the accident.

Psychological and driver’s anxiety treatment plan dated December 18, 2023

99I find that this plan is not in dispute because it was approved by the Respondent.

100The Respondent approved funding for this plan in full following the paper review IE report by Dr. Jwely, dated February 6, 2024. Accordingly, the Applicant is entitled to the goods and services proposed in this plan, if not already consumed. This plan is subject to interest pursuant to section 51 of the Schedule.

Psychological plan dated September 8, 2023

101I find that the Applicant is entitled to an additional medical benefit in the amount of $50.39 in relation to this plan.

102The unapproved portion of this plan relates to a preparation fee of $299.22, additional travel time for the OT of $149.61 proposed and $58.19 approved, and a form fee of $200.00 proposed but $149.61 approved.

103I find that the Applicant is not entitled to the preparation fee of $299.22. The Professional Services Guideline (“the PSG”) provides that insurers are not liable to pay any administration or other expenses, charges and surcharges, that have the result of increasing the effective hourly rates, or the maximum fees payable for completing forms, beyond what is permitted under it. To me, the preparation fee is one such charge or surcharge that has the result of increasing the effective hourly rate of the service provider. Accordingly, the Applicant is not entitled to that benefit.

104I find that the Applicant is not entitled to the transportation expenses claimed. Insured persons are permitted to claim all reasonable and necessary expenses, including travel time for the service provider to and from their home. In making such a claim, the Applicant remains obligated to demonstrate that the transportation expense is reasonable and necessary. Here, the Applicant made no such submissions. Nevertheless, I have considered whether his reported vehicular anxiety warrants in-home treatment and concluded that the anxiety does not rise to such a level. Recall, the Applicant returned to work following the accident as a delivery driver, suggesting that he can drive. Additionally, the Applicant demonstrated an ability to travel in a vehicle when he attended various assessments in-person, for which he was taken to by taxi. By taking a taxi to several assessments, the Applicant has demonstrated that he can travel to attend at in-clinic appointments.

105I find that the Applicant is entitled to a medical benefit in the amount of $200.00, less $149.61 approved by the Respondent, for the form fee related to this plan. The Applicant claims entitlement to a fee of $200.00. The Respondent contends that the Applicant’s service provider is entitled to a fee equivalent to 1 hour of the provider’s time. The PSG provides that insurers are not liable to pay for any expenses related to the completion of forms that exceed the maximum fees. The PSG notes maximum fee of $200.00 for completing a plan, including any assessment or examination necessary for the purpose of that review and approval by the health practitioner. Here, the form fee of $200.00 is consistent with the PSG. This is because the PSG does not state that form fees must be billed at the lesser of the service provider’s hourly rate, or the $200.00 maximum fee for completing a form. The plan proposes a fee of $200.00 for completing the plan and all the necessary examinations for the purpose of the review, which is in accordance with the PSG. Accordingly, I find that the Applicant is entitled to the amount of $50.39, being the denied portion of the form fee related to this plan.

Physiotherapy plan, dated June 7, 2024

106I find that the Applicant is entitled to the unapproved portion of this plan.

107The unapproved portion of this plan totals $100.25 and it relates to the fee for completing the form. For the reasons noted previously regarding the form fee outline in the PSG, I find that the Applicant is entitled to a medical benefit in the amount of $200.00 for the completion of the treatment plan. Accordingly, I find that the Applicant is entitled to the unapproved portion of this plan totalling $100.25.

Interest

108Interest applies on the payment of any overdue benefits pursuant to section 51 of the Schedule.

109Having found that the Applicant is entitled to the full amount of the psychological and drivers anxiety plan, dated December 18, 2023, an additional $50.39 related to the psychological treatment plan, dated September 8, 2023, the $100.25 form fee related the physiotherapy plan, dated June 7, 2024, it follows that interest is also payable on those amounts owed.

Award

110At the case conference, the Applicant sought an award under section 10 of Regulation 664. However, at the hearing he made no submissions on the issue of whether he is entitled to an award.

111Under section 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.

112I find that the Applicant is not entitled to an award. This is based on my findings that the Applicant has not demonstrated that he sustained a catastrophic impairment, is not entitled to IRBs, and is only partially entitled to the treatment plans in dispute. It cannot be said that the Respondent unreasonably withheld or delayed the payment of benefits when the Applicant is not entitled to the benefits. While I found that some of the adjusting on the Applicant’s claims for treatment plans was incorrect, there is no evidence indicating that the denials were unreasonable.

CONCLUSION AND ORDER

113The Applicant has not sustained a catastrophic impairment as a result of the accident.

114The Applicant is not entitled to IRBs as claimed.

115The functional abilities evaluation and worksite assessment plans are not reasonable and necessary as a result of the accident.

116The psychological treatment and driver’s anxiety plan, dated December 18, 2023 is not in dispute because it was approved by the Respondent.

117The Applicant is entitled to an additional medical benefit in the amount of $50.39 relating to the psychological treatment plan, dated September 8, 2023.

118The Applicant is entitled to an additional medical benefit in the amount of $100.25 relating to the psychological treatment plan, dated June 7, 2024.

119Since the Applicant is entitled to the psychological treatment and drivers anxiety plan, dated December 18, 2023, an additional $50.39 related to the psychological treatment plan, dated September 8, 2023, and the $100.25 form fee related to the physiotherapy plan, dated June 7, 2024, it follows that interest is also payable on those amounts owed.

120No award is payable.