Licence Appeal Tribunal
Licence Appeal Tribunal File Number: 24-004023/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:
William Hannigan Applicant
and
TD General Insurance Company Respondent
DECISION
ADJUDICATOR: Harouna Saley Sidibé
APPEARANCES:
For the Applicant: Meral Kesebi, Counsel
For the Respondent: Benjamin Hutchinson, Counsel
HEARD: By way of written submissions
OVERVIEW
1William Paul Hannigan, the applicant, was involved in an automobile accident on October 20, 2021, 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, TD General Insurance Company, and applied to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issues in dispute are:
i. Is the applicant entitled to $4,239.55 for psychological services, proposed by Pilon Psychotherapy Services in a treatment plan/OCF-18 (treatment plan) dated September 09, 2022?
ii. Is the applicant entitled to the assessments or treatments proposed by Okell Rehabilitation Services, as follows:
- $145.20 ($3,936.20 less $3,791.00 approved) for occupational therapy services, in a treatment plan dated May 18, 2022;
- $2,299.00 for occupational therapy services, in a treatment plan dated August 17, 2022;
- $3,936.20 for occupational therapy services, in a treatment plan dated August 17, 2022; and
- $4,634.00 for occupational therapy services, in a treatment plan dated December 13, 2022?
iii. Is the applicant entitled to the treatments and services proposed by Apollo Applied Research Inc. as follows:
- $373.70 for good and services, in a treatment plan submitted August 3, 2022; and
- $3,264.57 for goods and services, in a treatment plan submitted December 13, 2022?
iv. Is the applicant entitled to the treatments and services proposed by Anchor Rehabilitation as follows:
- $6,373.52 for occupational therapy services in a treatment plan submitted May 26, 2022; and
- $6,373.52 for occupational therapy services in a treatment plan submitted June 14, 2022?
v. Is the applicant entitled to $2,145.00 for physiotherapy services, proposed by Axis Therapy and Performance in a plan dated October 19, 2022?
vi. Is the applicant entitled to $3,092.78 for occupational therapy services, proposed by Empowering Mind & Body in a plan dated July 25, 2022?
vii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
viii. Is the applicant entitled to interest on any overdue payment of benefits?
3In his reply submissions, the applicant has explicitly withdrawn his claims for: attendant care benefits of $5,013.68 per month, starting October 21, 2021, and ongoing; and psychological services of $4,239.55, proposed by Pilon Psychotherapy Services in a plan dated May 6, 2022.
RESULT
4For the reasons below, I find that:
The applicant is entitled, subject to the non-catastrophic (“CAT”) monetary limit, to plans for psychological services costing $4,239.55 (September 9, 2022), physiotherapy services for $2,145.00 (October 19, 2022), occupational therapy services for $4,634.00 (December 13, 2022) and $3,936.20 (August 17, 2022), and goods and services for $3,264.54 (December 13, 2022), plus interest.
The applicant is not entitled to the outstanding amounts of $145.20 (May 18, 2022), $2,299.00 (August 17, 2022), the plans for $6,373.52 (May 26, 2022), $6,373.52 (June 14, 2022), $3,092.78 (July 25, 2022), and $373.70 (August 3, 2022).
The applicant is not entitled to an award.
ANALYSIS
Section 18 – Monetary Limits for Medical and Rehabilitation Benefits
5Section 18(3)(a) of the Schedule provides that, for an insured person who is neither subject to the Minor Injury Guideline (“MIG”) nor catastrophically impaired, the combined amount payable for medical, rehabilitation, and attendant care benefits shall not exceed $65,000.00, plus any applicable harmonized sales tax, for any one accident.
6For accidents occurring on or after June 3, 2019, this financial limit applies to all such benefits paid in respect of the insured person. The respondent relies on this provision to assert that the applicant’s entitlement has been exhausted.
7The parties disagree on whether the non-CAT limit has been reached. The respondent relies on an Explanation of Benefits (“EOB”) dated September 9, 2022, which states that $56,958.48 in medical and rehabilitation benefits and $1,684.05 in HST had been approved as of that date. Subsequent EOBs dated October 19, 2022, December 13, 2022, and December 30, 2022, confirm that the maximum payable amount of $65,000.00 for medical, rehabilitation, and attendant care benefits has been reached and that no expenses will be paid beyond this limit.
8The applicant relies on Javier v. Aviva General Insurance Company, 2023 CanLII 58537 (ON LAT). In Javier, the Tribunal found the insurer’s denial non-compliant with s. 38(8) because the letter “does not describe the non-catastrophic limit being completely exceeded, nor is there a medical ground offered for the denial.” (See: Javier, para. 14). While the Tribunal noted that the insurer remained responsible for funding a partial amount within the $65,000 non-CAT cap, the failure to consider partial approval was not the basis for its s. 38(8) analysis. The applicant submits that the same principle applies in this case, as the respondent’s denial was improper because it lacked a proper statutory and medical basis, not merely because non-CAT funds were nearing exhaustion.
9In reply, the applicant refers to an email from the respondent dated April 21, 2025, which provided a detailed breakdown of benefits paid to date.
10The September 9, 2022, EOB confirms that the respondent approved $56,958.48 in medical and rehabilitation benefits, $1,684.05 in HST, and attendant care benefits of $3,000 per month, based on a Form 1 received January 28, 2022. The EOB also states that no further approvals would be provided until confirmation of ongoing attendant care expenses and reiterates that the $65,000.00 limit applies because the applicant has not been deemed catastrophically impaired.
11The April 21, 2025, email from the respondent’s claims litigation services indicates the following breakdown: Medical/Rehabilitation ($37,178.52), Cost of Examinations ($18,382.50), and Income Replacement Benefits ($494.35), for a total of $56,055.37.
12I place significant weight on the April 21, 2025, email because it is a contemporaneous summary prepared by the respondent and provided in response to the applicant’s request for updated figures. It reflects the respondent’s most recent accounting of benefits paid and shows that, even several years after the accident, the total remains below the $65,000.00 non-CAT cap.
13The respondent argues that additional approvals may not be captured in the email and that the non-CAT limit has since been exhausted. However, the respondent has not provided a ledger or detailed accounting to substantiate this assertion or to contradict its own April 21, 2025, summary. Where an insurer relies on exhaustion of statutory limits as a basis for denying entitlement, it bears the evidentiary burden to demonstrate that the limits have in fact been reached.
14On the evidentiary record before me, I find the non-CAT monetary limits under s. 18 have not been exhausted; the April 21, 2025, summary prepared by the respondent places total payments below $65,000.00, and the respondent has not adduced a ledger or detailed accounting that contradicts its own figures. I also addressed the applicant’s submission in Javier. The September 9, 2022, EOB references the $65,000 limit and the absence of a catastrophic designation, but it does not state that the cap was fully exhausted at the time of denial, nor does it provide a medical rationale. To the extent the respondent later relied on exhaustion alone as the basis for refusal, the record lacks a s. 38(8)-compliant notice that (i) clearly identifies complete exhaustion as of the denial date, or (ii) sets out medical reasons. On this point, Javier's reasoning is persuasive because mere proximity to the cap, or an unparticularized assertion of exhaustion, without a clear statement that the limit was fully reached or a medical basis, does not satisfy s. 38(8).
15Accordingly, on a balance of probabilities, I find the respondent has not established that the non-CAT limit was exhausted, and I will consider the applicant’s entitlement to the disputed plans. Further, even if the respondent intended to rely on exhaustion, its notices—as reflected in the EOBs—do not meet s. 38(8) on this record because they neither confirm complete exhaustion at the time of denial nor articulate medical reasons; consistent with Javier, that deficiency supports treating the plans as payable up to any remaining room under the cap.
Is the applicant entitled to the disputed treatment plans?
16To 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.
The Plan for Psychological Services ($4,239.55)
17I find that the applicant is entitled to the plan for psychological services, dated September 9, 2022, in the amount of $4,239.55, subject to the applicable non-CAT monetary limits.
18The applicant submits that the respondent’s denial letter is improper because it fails to provide any medical or other basis for determining whether the proposed benefits are reasonable and necessary, contrary to section 38(8) of the Schedule.
19The respondent states that its EOB dated September 9, 2022, denied the plan because the combined non-CAT medical, rehabilitation, and attendant care limits might have been reached if approved attendant care expenses had been incurred. It requested confirmation from the applicant to avoid exceeding the statutory limit, but did not receive it and therefore couldn't approve the plan. The applicant has since been approved up to the non-CAT limit.
20Section 38(8) of the Schedule requires that when an insurer denies a Treatment and Assessment Plan (OCF-18), the notice must set out the medical and other reasons for the denial and explain why the proposed goods and services are not reasonable and necessary. This requirement ensures that the applicant understands the insurer’s position and can respond meaningfully.
21The denial letter dated September 9, 2022, does not meet these requirements. While it states that the insurer does “not agree to pay for any of the following goods, services and/or assessments for medical reasons and all other reasons known,” it does not provide any specific medical rationale for the refusal. Instead, the letter focuses on the monetary limit and the applicant’s non-catastrophic status. These are financial considerations, not medical reasons.
22I note the Court of Appeal’s decision in Varriano v. Allstate Insurance Company of Canada, 2023 ONCA 78, which interpreted similar language in s. 37(4) of the Schedule. The Court held that an insurer need not supply “medical” reasons when its determination rests on a non-medical ground. The respondent’s stated basis was exhaustion of the non-CAT monetary limit—a permissible non-medical ground under the Schedule. Section 38(8) nonetheless requires the insurer to set out the “medical and other reasons” supporting the denial in a manner that corresponds to the ground relied upon. Where exhaustion is the ground, a compliant notice must clearly state that the non-CAT limit has already been fully reached as of the denial and identify exhaustion as the reason for non-payment. The respondent’s notices reference the $65,000 cap and non-CAT status, but they do not confirm that the limit was exceeded entirely at the time of denial. On this record, the deficiency lies in the absence of a clear, exhaustion-based explanation.
23The letter does not confirm that the non-CAT limit had been fully exhausted at the time of denial. Simply referencing the $65,000.00 cap—without clearly stating that the statutory limit was reached—does not satisfy s. 38(8)’s requirement to provide reasons corresponding to the ground relied upon. Where exhaustion is the basis, the notice must expressly identify that the limit has been completely exceeded. The absence of a clear explanation in the denial itself remains a deficiency because it leaves open whether the refusal was based on actual exhaustion or merely on proximity to the cap.
24I find that the September 9, 2022, denial letter does not comply with s. 38(8) of the Schedule. While exhaustion of the non-CAT limit can be a valid non-medical ground for refusal, the notice must clearly state that the limit was fully reached at the time of denial. The letter references the $65,000 cap and non-CAT status but does not confirm complete exhaustion. That omission creates ambiguity as to whether the refusal was based on actual exhaustion or merely on proximity to the cap. This lack of clarity renders the notice non-compliant with s. 38(8). The consequence of a deficient notice is that the treatment plan is payable up to any remaining room under the non-CAT monetary limit.
25Accordingly, on a balance of probabilities, I find that the applicant is entitled to the September 9, 2022, plan, subject to the non-CAT monetary limit.
The Plan for Physiotherapy Services ($2,145.00)
26I find that the applicant is entitled to the physiotherapy plan, subject to the applicable non-CAT monetary limits.
27The applicant argues that the respondent’s denial letter is inadequate because it offers no medical or other explanation to assess whether the proposed benefits are reasonable and necessary, contrary to section 38(8) of the Schedule.
28The respondent submits that the plan was denied because the combined non-CAT medical, rehabilitation, and attendant care limits had been reached, and the applicant is not catastrophically impaired.
29As set out above, where the insurer relies on non-CAT exhaustion as the ground for denial, s. 38(8) is satisfied only if the notice clearly confirms that the $65,000.00 limit was fully reached at the time of the denial and identifies exhaustion as the reason for non-payment. The October 19, 2022, letter references the cap and the applicant’s non-catastrophic status but does not state that the limit had been completely exceeded as of that date. That omission renders the notice non-compliant.
30Given this deficiency, s. 38(11) applies. Therefore, the plan is payable up to any remaining room under the non-CAT monetary limit. This conclusion turns on the lack of a clear exhaustion-based notice.
31Accordingly, on a balance of probabilities, I find the applicant is entitled to the physiotherapy plan dated October 19, 2022, subject to the non-CAT monetary limit.
Occupational Therapy Services
Outstanding amount of $145.20 as of May 18, 2022.
32I find that the applicant is not entitled to the outstanding amount of $145.20.
33The occupational therapy plan dated May 18, 2022, in the amount of $145.20 (representing the difference between $3,936.20 requested and $3,791.00 previously approved), is signed by Lauren Okeil, an occupational therapist. The stated goals are to increase the applicant’s functional performance and daily tolerances to complete activities of daily living and to facilitate a return to normal activities. The plan includes: 10 sessions of motor and living skills training; 10 sessions of service planning; 3 sessions for support activity documentation; 10 sessions of provider travel time; and 10 sessions for the applicant’s transportation to treatment.
34The applicant contends that the amount is reasonable and necessary because his mobility challenges, pain, and travel anxiety prevent him from managing treatment independently. The occupational therapist endorsed the coverage of home services and transportation costs. The applicant points out that the respondent previously covered certain transportation expenses and contends that this should continue due to the respondent's ongoing needs.
35Transportation costs of an insured person to attend treatment are addressed in the Schedule and in the Transportation Expense Guideline (“Guideline”). For non-catastrophic claims, transportation expenses are generally payable only where the round-trip distance to the treatment provider exceeds a prescribed threshold (typically 50 kilometres), unless the insurer elects to grant a discretionary exception.
36The respondent argues that the $145.20 transportation charges fall below the Guideline threshold, which requires travel over 50 km round-trip for non-CAT claims before transportation to treatment is payable. It acknowledges that a discretionary exception was previously granted, but emphasizes that a cutoff date was communicated. The respondent states it was not obliged to extend the exception and that the remaining charges are not payable under the Schedule or Guideline.
37The applicant agrees that the $145.20 dispute concerns mileage within the 50-kilometre round-trip limit and cites no legislative or Guideline provisions authorizing payment of these expenses as benefits outside the established framework.
38The evidence shows that, for a period, the respondent exercised discretion to cover certain transportation expenses beyond the Guideline's exact requirements, and that a precise end date for that exception was communicated (see EOBs dated March 8, 2022, and May 18, 2022). Discretionary payments, however, do not establish a continuous entitlement beyond what the insurer has outlined, nor do they extend the statutory coverage.
39While I accept that the applicant experiences pain and anxiety related to travel, those factors alone do not permit the payment of transportation costs, which are expressly outside the parameters of the Guideline.
40Accordingly, on a balance of probabilities, I find that the applicant has not satisfied his burden to prove that the disputed transportation amount of $145.20 is payable.
The balance of $2,299.00 as of August 17, 2022
41I find that the applicant is not entitled to the outstanding amount of $2,299.00.
42The occupational therapy plan dated August 17, 2022, for $2,299.00, is also signed by Ms. Okeil. The goals are to provide equipment to assist the applicant’s return to normal activities. The plan proposes: a neck massager, a heat pad, an e-bike, a gym membership, and documentation of a support activity.
43The respondent partially approved the August 8, 2022, treatment plan, approving $746.56 of $3,344.43 and denying $2,299.00 for the E-bike, pending insurer review. After reviewing the documentation and Ms. Quraishi's November 3, 2022, Insurer’s Examination (“IE”) report, the respondent noted that the other claimed items were reasonable, but that the E-bike was unnecessary because the applicant could access the community via public transit, Uber, or walking.
44The applicant states that an E-bike provides low-impact transportation, enabling him to travel farther for errands, appointments, and activities while managing pain and fatigue. It would promote independence, reduce reliance on others, and aid physical rehab through graded activity. He states that he cycled prior to the accident and believes that the E-bike would help him return to a meaningful pre-accident lifestyle.
45The occupational therapy progress reports from Provvidenza Dearcangelis, dated May 3, 2022, and November 22, 2022, document that the applicant experiences significant mobility restrictions and discomfort, which make prolonged walking and standing challenging.
46The applicant faces functional challenges, and exercise and activity are vital for his rehabilitation. However, the respondent has funded taxi services and supports to enable him to participate in treatment and community activities.
47I give greater weight to Ms. Quraishi’s opinion because it is the only detailed assessment on this issue. The applicant offered no clinical evidence or treating provider report to substantiate the need for an E-bike. Ms. Quraishi reviewed the applicant’s functional status, available supports, and transportation options, and while recognizing his limitations, reasonably concluded that an E-bike is unnecessary. She noted that less costly alternatives—such as a stationary cycle or a bike stand—are available and suitable for home rehabilitation.
48In these circumstances, on a balance of probabilities, I find that the E-bike is not reasonable and necessary. Accordingly, the disputed amount of $2,299.00 is not payable.
The plan dated August 17, 2022, ($3,936.20)
49I find that the applicant is entitled to the occupational therapy services plan dated August 17, 2022, in the amount of $3,936.20, subject to the non-CAT monetary limit.
50This plan, signed by Ms. Okeil, repeats goals similar to those in the May 18 plan, focusing on improving functional performance and daily tolerances to complete activities of daily living and return to normal activities. The proposed services include 10 sessions of motor and living skills training, 10 sessions of service planning, 3 sessions for support activity documentation, 10 sessions of provider travel time, and 10 sessions for the applicant’s transportation to treatment.
51The applicant’s main submission is that the respondent’s denial letter is deficient under section 38(8) of the Schedule because it fails to provide adequate medical or other reasons for the denial. The applicant argues that the denial is premised largely on the March 16, 2022, IE report by Ms. Quraishi, an occupational therapist, which focused primarily on attendant care needs and noted functional limitations, including clutter, an untidy bathroom, a slight limp, and complaints of knee pain. The applicant contends that this IE did not adequately consider ongoing symptoms, including headaches, back pain, and knee pain, and that the denial letter does not sufficiently explain why the proposed occupational therapy plan is not reasonable and necessary.
52The applicant submits that the respondent’s denial notice is deficient because it does not set out the medical and other reasons for the denial in a manner that allows the applicant to understand and respond meaningfully. The applicant further argues that the IE reports dated September 15 and November 10, 2022, which concluded that treatment plans for occupational therapy, rehabilitation services, yoga therapy, and assistive devices were unnecessary, are flawed because they did not include updated assessments since March 2022 and failed to consider the clinical records from the applicant’s treating doctors. The applicant submits that these deficiencies render the denials improper.
53The respondent states that the August 8, 2022, treatment plan sought $3,936.20 for occupational therapy services. An interim denial was issued on August 17, 2022, pending an insurer’s examination. The respondent obtained the applicant’s signed consent for further review on September 29, 2022, and a final denial was issued on November 10, 2022, based on a paper review IE dated November 3, 2022, by Ms. Quraishi.
54The IE report noted that similar occupational therapy plans had been approved earlier on February 11, 2022, and May 18, 2022. It found that the applicant had received sufficient occupational therapy to meet his goals, was active in the community, engaged in activities such as grocery shopping, and used assistive devices for safety and independence. Multiple healthcare professionals were involved in his care. Given the amount of treatment already provided and the time elapsed since the accident, the assessor concluded that the proposed plan was unnecessary. It is important to note that in the context of section 38(8), it is not the Tribunal’s role to assess the quality of the evidence on which the respondent based its denial but rather to assess whether the denial notice complies with the statutory requirements.
55While the applicant criticizes the reliance on paper reviews, he has not provided updated clinical evidence or a treating provider’s report specifically confirming the need for additional occupational therapy at this stage. The treating occupational therapy progress notes dated May 3, 2022, and November 22, 2022, document ongoing symptoms but do not clearly justify the necessity of additional sessions beyond those already funded to meet new or unmet rehabilitation goals. The applicant’s argument appears to be primarily about the reasonableness and necessity of the plan rather than the validity of the denial notice.
56Given the deficiencies in the respondent’s denial notice under section 38(8), section 38(11) is engaged. This provision provides that, where an insurer fails to provide a compliant notice, the treatment plan is payable up to the remaining non-catastrophic monetary limit. On this basis, regardless of the substantive reasonableness or necessity of the plan, the applicant is entitled to payment for the occupational therapy plan dated August 17, 2022, subject to the applicable non-CAT monetary limits.
The plan dated December 13, 2022, ($4,634.00)
57I find that the applicant is entitled to the occupational therapy plan, subject to the non-CAT monetary limit.
58The plan dated December 13, 2022, for $4,634.00, signed by Ms. Dearcangelis, seeks to increase functional performance and daily tolerances to enable completion of activities of daily living and return to normal activities. It includes: 10 sessions of motor and living skills training; 10 sessions of service planning; 3 sessions for support activity documentation; 10 sessions of provider travel time; and 10 sessions for the applicant’s transportation to treatment.
59The applicant contends that the respondent’s notice of denial does not comply with section 38 of the Schedule. He asserts that the EOB fails to provide sufficient medical and other reasons for the denial.
60The respondent asserts that a final denial was communicated in the EOB correspondence dated December 13, 2022. The denial was based on the position that the combined limits for non-CAT medical, rehabilitation, and attendant care had been reached and that the applicant does not meet the criteria for catastrophic impairment.
61Section 38(8) requires an insurer’s denial notice to set out the “medical and other reasons” for the refusal in a way that corresponds to the ground relied upon. Where exhaustion of the non-CAT limit is the basis, the notice must clearly state that the $65,000.00 cap was fully reached at the time of denial and identify exhaustion as the reason for non-payment. The December 13, 2022, EOB cites the cap and the applicant’s non-catastrophic status but does not confirm that the limit was fully exceeded. While Varriano clarifies that an insurer need not fabricate medical reasons when relying on a non-medical ground, a bare reference to financial limits without expressly stating full exhaustion does not meet s. 38(8)’s requirement for clarity.
62The insurer’s obligation is to provide a clear explanation in its denial notice that corresponds to the ground relied upon. Because the December 13, 2022, EOB does not expressly confirm full exhaustion, the notice is deficient even if the respondent’s position on the cap were correct.
63I therefore find that the respondent’s denial notice dated December 13, 2022, does not comply with s. 38(8). Under s. 38(11), the consequence of a non-compliant notice is that the treatment plan is payable up to any remaining room under the non-CAT monetary limit.
64Accordingly, on a balance of probabilities, I find that the applicant is entitled to the December 13, 2022, occupational therapy plan, subject to the non-CAT monetary limit.
The plan dated May 26, 2022, ($6,373.52)
65I find that the applicant is not entitled to the occupational therapy services plan dated May 26, 2022, for $6,373.52.
66The plan, signed by Provvidenza Dearcangelis, an occupational therapist, aims to implement strategies to maximize the applicant’s functional independence and quality of life, and to support a return to normal activities. It includes 18 sessions of cognition and learning skills training, 18 sessions of provider travel time, 8 brokerage services, 9 sessions for support activity documentation, and 8 stipends.
67The applicant argues that the proposed services are necessary to address his ongoing functional limitations and support his independence and community reintegration. He submits that the plan is essential due to residual impairments from his injuries and contends that the respondent’s denial disregards his ongoing symptoms and the recommendations of his healthcare providers. The applicant relies on clinical evidence and reports from treating professionals, including occupational therapists and psychologists, to support the reasonableness and necessity of the plan.
68The respondent submits that the plan was initially denied pending an insurer’s examination (IE). The respondent obtained the applicant’s consent for further documentation review and an IE report dated September 15, 2022, by Ms. Quraishi, an occupational therapist, formed the basis for the final denial communicated on September 16, 2022.
69The IE report concluded that the proposed plan was duplicative of prior approved plans, noting that the applicant had already received extensive treatment—including occupational therapy, psychological services, social work, dietitian support, neuro-optometric rehabilitation, and assistance from a rehabilitation support worker—addressing similar goals. The assessor found that the applicant had been provided with assistive devices and strategies to support independence, and therefore, the proposed plan was not reasonable or necessary. The applicant has the onus to demonstrate why additional treatment is required beyond what has already been funded, and the Tribunal must weigh the evidence accordingly.
70I have reviewed the submissions and evidence. While I acknowledge the applicant’s ongoing functional challenges and the potential role of occupational therapy, the evidence shows that the applicant has received substantial occupational therapy and related services targeting the same goals. The IE report’s findings are persuasive in concluding that the proposed plan duplicates prior services and does not address unmet rehabilitation needs. The applicant has not provided updated clinical evidence or a treating provider’s report justifying additional sessions.
71Accordingly, on a balance of probabilities, I find that the proposed occupational therapy plan dated May 26, 2022, is not reasonable and necessary.
The plan dated June 14, 2022, ($6,373.52)
72I find that the applicant is not entitled to the occupational therapy services plan.
73The applicant has not submitted any supporting documentation regarding this plan.
74The respondent submits that it cannot locate the purported treatment plan or the corresponding EOB. It asserts that the plan was listed by the applicant as an issue in dispute in error and appears to be a duplicate of the plan dated May 26, 2022, which was initially denied on June 14, 2022.
75In the alternative, the respondent argues that, if the disputed plan exists, it constitutes a duplicate funding request for the same treatment, submitted within days of the original request dated May 26, 2022.
76I have reviewed the evidence and submissions. The applicant has not provided a copy of the disputed treatment plan, an EOB, or any explanation of its contents. The respondent’s evidence indicates that the reference to a June 14, 2022, plan likely duplicates a plan dated May 26, 2022, submitted on June 1, 2022, and denied on June 14, 2022. There is no documentation establishing that a separate plan dated June 14, 2022, was submitted or denied.
77On this record, the applicant has not established, on a balance of probabilities, that a distinct treatment plan dated June 14, 2022, was submitted and denied. In the absence of a denial, there is no dispute before the Tribunal to adjudicate, and this issue must therefore be dismissed.
The plan dated July 25, 2022, ($3,092.78)
78I find that the applicant is not entitled to the occupational therapy services plan dated July 25, 2022, in the amount of $3,092.78.
79The plan, signed by Kristina Borho, an occupational therapist, proposes 12 sessions of motor and living skills therapy, 12 sessions of provider travel time, 13 sessions for support activity documentation, and 2 sessions of service planning. The goals include teaching gentle movement, breathing techniques, and meditation to help the applicant manage pain, improve flexibility and mobility, reduce stress, and enhance sleep hygiene, thereby supporting participation in normal activities.
80The applicant submits that these services are necessary to manage pain, improve flexibility, and support mental health through breathing techniques and meditation. He relies on his ongoing symptoms and the recommendations of his healthcare providers, including the yoga therapist Alexandra Korisis, who reported consistent participation and progress in yoga therapy since April 2022. The applicant emphasizes that the yoga therapy sessions are tailored to his physical and psychological needs and that the proposed plan is a continuation of this beneficial treatment.
81The respondent submits that an interim denial was issued on July 25, 2022, pending an insurer’s examination. A final denial was communicated on November 10, 2022, based on an occupational therapy paper review IE dated November 3, 2022, by Ms. Quraishi.
82The IE report notes that the applicant has been receiving yoga therapy since April 2022 through private virtual sessions, including breathing exercises, stretches, ball rolling, guided visualization, and meditation, supported by audio recordings. The assessor concluded that, given the time elapsed since the accident, the completed sessions, and the multiple providers involved in the applicant’s care (including occupational therapy, social work, psychotherapy, and medical cannabis treatment), the proposed plan is neither reasonable nor necessary as it duplicates prior services and does not introduce new goals.
83I accept that yoga therapy can support pain management and mental health. However, the evidence shows that the applicant has already received extensive yoga therapy and related services and has resources for independent practice. The IE report provides a reasoned analysis that the proposed plan duplicates prior services and does not address unmet rehabilitation needs. The applicant has not provided updated clinical evidence or a treating provider’s report explaining why additional sessions are required.
84Accordingly, on a balance of probabilities, I find that the proposed occupational therapy plan dated July 25, 2022, is not reasonable and necessary.
Goods and Services
85I find that the disputed amount of $373.70 for the August 3, 2022, invoice for medical cannabis services is not payable because it exceeds the approved limit under the prior treatment plan. Conversely, the denial of the December 13, 2022, treatment plan for goods and services totalling $3,264.57 is non-compliant with section 38(8) of the Schedule and is payable, subject to the non-CAT monetary limit.
86The applicant disputes the respondent’s denial of two separate items: (a) the August 3, 2022, invoice for medical cannabis services in the amount of $373.70, which is an invoice (OCF-21) submitted as part of a previously approved treatment plan; and (b) the December 13, 2022, treatment plan (OCF-18) for goods and services totaling $3,264.57, signed by Dr. Dave Chaudhary.
87The applicant submits that the respondent’s denial letters fail to provide adequate medical or other reasons for the refusals, contrary to the requirements of section 38(8) of the Schedule.
88Regarding the August 3, 2022, invoice, the respondent states that the applicant submitted an OCF-21 for $565.74 for medical cannabis services rendered on July 27, 2022. The EOB dated August 17, 2022, approved $192.04, representing the remaining balance under the approved treatment plan, and denied $373.70 as it exceeded the approved amount. The respondent maintains that the disputed amount is not payable because it exceeds the approved limit.
89The evidence confirms that the respondent approved and paid the remaining balance under the August 3, 2022, plan and denied the excess amount. The applicant has not demonstrated entitlement to payment beyond the approved limit. The applicant’s submissions do not challenge the partial approval but rather the denial of the excess invoice amount.
90Regarding the December 13, 2022, treatment plan, the respondent states that the denial was communicated on December 30, 2022, on the basis that the combined non-CAT monetary limits had been reached and the applicant was not catastrophically impaired.
91The EOB for the December 13, 2022, plan cites only exhaustion of the non-CAT limits and does not provide medical reasons, contrary to section 38(8). While the Court of Appeal in Varriano confirmed that an insurer is not required to fabricate medical reasons when relying solely on a non-medical ground, section 38(8) nonetheless requires sufficient detail to allow the insured to understand the basis for denial. A mere reference to monetary limits without addressing the substantive basis for denial renders the notice non-compliant.
92Accordingly, on a balance of probabilities, I find that the disputed amount for the August 3, 2022, invoice is not payable as it exceeds the approved limit. However, the denial of the December 13, 2022, treatment plan is non-compliant with section 38(8) and is payable, subject to the non-CAT monetary limit.
Interest
93Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Interest is due on any overdue payment.
Award
94The applicant seeks an award under section 10 of Regulation 664. Under 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. The Tribunal has determined that an award is justified where the delay or withholding of benefits by the insurer is unreasonable conduct, meaning “behaviour which is excessive, imprudent, stubborn, inflexible, unyielding or immoderate.” [See, for e.g., 17-006757 v. Aviva Insurance Canada, 2018 CanLII 81949 (ON LAT); and S.M. v. Unica Insurance Inc., 2020 CanLII 61460 (ON LAT Reconsideration)]. The onus is on the applicant to prove, on a balance of probabilities, that the respondent’s conduct meets this threshold.
95The applicant argues that the respondent acted adversarially in adjusting the claim and unreasonably denied or delayed benefits. He cites adjuster notes showing limited analysis of injuries and reliance on insurer exams without full medical record review. He emphasizes the insurer’s obligation to respond to treatment plans in a fair and timely manner. He claims repeated denials, especially when non-CAT limits weren’t exhausted, amount to unreasonable benefit withholding.
96The respondent claims it acted in good faith, relying on insurer examinations and Schedule provisions. It states that denials were based on technical or medical reasons. It also notes accommodations such as exceptions to transportation rules and the payment of substantial benefits. The respondent argues that disagreement with its determinations or a finding that a disputed plan is payable does not, in itself, establish unreasonable withholding or delay warranting a special award.
97In this case, I find that the respondent relied on insurer’s examinations, applicable guidelines, and its interpretation of non-CAT limits in making its decisions. Although I disagreed with the respondent’s position on non-CAT limits, I accept that its stance was based on a reasonable interpretation of its Explanation of Benefits calculations. The April 2025 email reflects a clarification of those calculations, not bad-faith conduct.
98The applicant has not identified specific instances where the respondent ignored Tribunal orders, refused to consider new evidence, or otherwise engaged in conduct that meets the threshold of unreasonable withholding or delay contemplated by section 10. In the absence of such evidence, I am not convinced that an award is warranted.
99Therefore, the request for an award is denied.
ORDER
100For the above reasons, it is ordered that:
i. The applicant is entitled, subject to the non-catastrophic (“CAT”) monetary limit, to plans for psychological services costing $4,239.55 (September 9, 2022), physiotherapy services for $2,145.00 (October 19, 2022), occupational therapy services for $4,634.00 (December 13, 2022) and $3,936.20 (August 17, 2022), and goods and services for $3,264.54 (December 13, 2022), plus interest.
ii. The applicant is not entitled to the outstanding amounts of $145.20 (May 18, 2022), $2,299.00 (August 17, 2022), the plans for $6,373.52 (May 26, 2022), $6,373.52 (June 14, 2022), $3,092.78 (July 25, 2022), and $373.70 (August 3, 2022).
iii. The applicant is not entitled to an award.
Released: January 9, 2026
Harouna Saley Sidibé Adjudicator