Licence Appeal Tribunal File Number: 24-011104/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:
Lynda Ciavaglia
Applicant
And
Co-operators General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Rebecca Hines
APPEARANCES:
For the Applicant:
Teena Belland, Counsel
For the Respondent:
David Raposo, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Lynda Ciavaglia, the applicant, was involved in an automobile accident on November 18, 2012, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (the “Schedule”). The applicant was denied benefits by the respondent, Co-operators General Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
2The applicant sustained serious physical, cognitive and psychological impairments as a result of the accident and was deemed to be catastrophically impaired by the respondent in September 2016.
ISSUES
3The issues in dispute are:
Is the applicant entitled to $1,911.03 for massage therapy services, proposed by Fleming Fitness in a treatment plan/OCF-18 (“plan”) submitted August 19, 2022?
Is the applicant entitled to $983.16 ($3,695.68 less $2,712.52 approved) for case management services, proposed by Stephanie Drouin in a plan submitted November 14, 2022?
Is the applicant entitled to $4,676.88 ($5,596.40 less $919.52 approved) approved) for case management services, proposed by Heather MacGregor in a plan submitted August 22, 2024?
Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
4After reviewing both parties’ submissions and evidence I find the applicant is not entitled to the OCF-18s in dispute or interest.
ANALYSIS
5To receive payment for an OCF-18 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.
OCF-18 for Massage Therapy
6The applicant is not entitled to the OCF-18 for massage therapy in the amount of $1,911.03.
7The applicant argues that the OCF-18 for massage therapy is reasonable and necessary because she sustained objective physical impairments as a result of the accident. For example, she still suffers from ongoing pain in her neck, back, hips and glutes. She submits that this was the first OCF-18 submitted for this type of treatment and the goal was to decrease muscle tension and pain and help improve joint mobility and flexibility to restore function. In support of her position, she relies on the progress report of Samuel Laviolette, kinesiologist dated June 27, 2022, which noted that the applicant required continued treatment to ensure ongoing improvement in her health. She maintains that the respondent denied the OCF-18 relying on the outdated IE of Dr. Perera, physiatrist dated August 9, 2018, who opined that the applicant had reached maximum medical recovery from facility based passive treatment.
8The respondent submits that the OCF-18 is not reasonable and necessary because the applicant has achieved maximum medical recovery from passive treatment. To date, it has approved 13 OCF-18s for physiotherapy, physical rehabilitation, aqua therapy, and a chronic pain program. It argues that the applicant has not submitted any evidence to support that the OCF-18 for massage therapy is reasonable and necessary. It relies on the above noted IE report of Dr. Perera who concluded that passive treatment would have no benefit, and that the applicant should engage in active therapy for general health management and to improve core muscle strength. It also relies on the more recent physiatry IE report of Dr. Khan who determined that while an OCF-18 for physiotherapy may lead to temporary pain relief, the potential benefit is outweighed by the applicant’s dependence on facility staff. The doctor concluded that the applicant received adequate facility-based treatment and recommended that she engage in a self-directed exercise program.
9I find that the applicant has not proven that the OCF-18 for massage therapy is reasonable and necessary for the following reasons.
10First, although I acknowledge that the applicant suffers from ongoing pain, I find the progress report of Mr. Laviollette does not support that the OCF-18 for massage therapy is reasonable and necessary. I find that this report establishes that the applicant was receiving significant benefit from the active treatment that she was receiving from this therapist. For example, the report notes that the past kinesiology treatment has resulted in an increase in her activity tolerance, strength and endurance and has helped stabilize her mood and energy levels. She now goes for long bike rides and walks with friends. I find the report of Mr. Laviollette demonstrates that the applicant was improving with active therapy, which I find consistent with Dr. Perera’s opinion that she should engage in this type of treatment.
11Second, the applicant did not submit the OCF-18 for massage therapy as evidence for this hearing. Nor did her submissions address the breakdown of the cost of the OCF-18, duration of treatment or indicate who was recommending it and why. While I agree with the applicant that pain reduction is a reasonable objective of treatment, without evidence relating to the breakdown of the cost of the OCF-18, I have no way of determining whether the cost is reasonable and necessary.
12I conclude that the applicant has not met her onus in proving on a balance of probabilities that the OCF-18 for massage therapy in the amount of $1,911.03 is reasonable and necessary.
OCF-18s for Case Management Services
13The applicant is not entitled to the partially denied portions of either OCF-18 for case management services.
14The applicant argues that the goals of the OCF-18s for case management services was to locate, coordinate and advocate for necessary goods and services to address her impairments and maximize her function. The applicant submits that the first OCF-18 noted that she struggles with daily pain and participates in interventions aimed at building her physical strength to maximize her recovery. It also indicated that case management services were being recommended to assist the applicant with coordinating services because she presented as overwhelmed and required a high degree of follow-up to respond to and complete documentation. The applicant relies on the case management report of Heather MacGregor dated January 21, 2025, in support of her position that the OCF-18s for case management are reasonable and necessary. She also relies on updated insurer examination occupational therapy and psychiatry reports which she submits support that she still has functional limitations as a result of her impairments which require case management services.
15The respondent submits that the only treatment the applicant was receiving at the time these OCF-18s were submitted was kinesiology treatment. It maintains that it partially approved the OCF-18s because less coordination from a case manager would be required when the applicant was attending limited treatment. It also asserts that it had previously approved five treatment plans for case management services.
16I find that the applicant has not proven that the balance of either OCF-18 for case management services is reasonable and necessary for the following reasons.
17First, the applicant did not submit either OCF-18 for case management services as evidence for this hearing. Consequently, I have no evidence regarding the breakdown of the cost of the OCF-18s or any information for how many sessions were recommended or the cost of same or whether additional fees were listed on the OCF-18s.
18Second, the applicant’s submissions did not provide clarity on why the denied amounts are reasonable and necessary. For example, her submissions state that the respondent approved three one-hour sessions. However, what I find unclear is how many sessions were recommended in the first place and what was the cost breakdown of same. The applicant’s submissions did not address why the denied portions of the OCF-18s are reasonable and necessary. The applicant’s submissions also indicate that case management services for the total cost of $3695 ($2712.52 partially approved) and $5596.40 ($919.52 partially approved) is reasonable under the circumstances, but she does not explain why. Further, she indicates that the case manager’s rate of 2.5-hour sessions of $299.80 had been previously approved by the respondent (including travel time) which justifies that the disputed OCF-18s should be approved. I find the fact that the respondent previously approved certain amounts insufficient to justify that the denied portions of the disputed OCF-18s are reasonable and necessary.
19Finally, I find Ms. MacGregor’s case management report unhelpful because it does not provide any information regarding the breakdown for case management services outlined in the OCF-18s or explain why additional or longer sessions are required.
20For the above reasons, I find I do not have sufficient evidence or submissions before me to make a finding that the denied portions of the OCF-18s are reasonable and necessary.
Interest
21Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. The applicant is not entitled to interest as I have not determined that any benefits are overdue.
ORDER
22For the above-noted reasons, I order as follows:
The applicant is not entitled to the OCF-18s in dispute or interest.
This application is dismissed.
Released: March 10, 2026
__________________________
Rebecca Hines
Adjudicator