Citation: Sertl v. Intact Insurance Company, 2026 ONLAT 24-002715/AABS

Licence Appeal Tribunal File Number: 24-002715/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:

Marjorie Noreen Sertl

Applicant

and

Intact Insurance Company

Respondent

DECISION

ADJUDICATOR: Kathleen Wells

APPEARANCES:

For the Applicant: Dayana Soto Santana, Paralegal

For the Respondent: Robbie Brar, Counsel

HEARD: By way of written submissions

OVERVIEW

1Marjorie Noreen Sertl, the applicant, was involved in an automobile accident on July 6, 2023, and sought benefits pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”). The applicant was denied benefits by the respondent, Intact Insurance Company, and applied to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

ISSUES

2The issues to be decided in the hearing are:

1. Is the applicant entitled to $4,006.32 for physiotherapy services proposed by 101 Physio in a treatment plan/OCF-18 (“treatment plan”) submitted July 17, 2023?
2. Is the applicant entitled to $2,359.52 for physiotherapy services proposed by 101 Physio in a treatment plan submitted January 8, 2024?
3. Is the applicant entitled to the remaining balance of $1,247.33 ($3,790.70 less $2,543.37 approved) for psychological treatment proposed by 101 Assessments in a treatment plan submitted September 14, 2023?
4. Is the applicant entitled to $2,460.00 for a communication assessment, in a treatment plan submitted November 23, 2023?
5. Is the applicant entitled to $2,460.00 for a total body assessment, in a treatment plan submitted January 19, 2024?
6. Is the applicant entitled to the remaining balance of $360.78 ($2,460.00 less $2,099.22 approved) for a psychological assessment in a treatment plan dated July 21, 2023?
7. Is the applicant entitled to $2,460.00 for an orthopaedic assessment in a treatment plan submitted November 8, 2023?
8. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

3I find that:

1. The applicant is entitled to $4,006.32 for physiotherapy services in the treatment plan dated July 17, 2023.
2. The applicant is not entitled to $2,359.52 for physiotherapy services in the treatment plan submitted January 8, 2024?
3. The applicant is not entitled to the remaining balance of $1,247.33 ($3,790.70 less $2,543.37 approved) for psychological treatment in the treatment plan submitted September 14, 2023.
4. The applicant is not entitled to $2,460.00 for a communication assessment in the treatment plan submitted November 23, 2023.
5. The applicant is not entitled to $2,460.00 for a total body assessment in a treatment plan submitted January 19, 2024.
6. The applicant is not entitled to the remaining balance of $360.78 ($2,460.00 less $2,099.22 approved) for a psychological assessment in a treatment plan dated July 21, 2023.
7. The applicant is not entitled to $2,460.00 for an orthopaedic assessment in a treatment plan submitted November 8, 2023.
8. The applicant is entitled to interest on any outstanding payments in accordance with s.51 of the Schedule.

ANALYSIS

4To 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.

5The purpose of an assessment is to determine whether a condition exists. For an insured, they bear the onus to demonstrate that there are grounds on which to believe that a condition exists that would warrant further investigation by way of an assessment.

Is the applicant entitled to $4,006.32 for physiotherapy services in a treatment plan submitted July 17, 2023?

6I find that the applicant has established on a balance of probabilities that this treatment plan for physiotherapy is reasonable and necessary.

7The treatment plan for physiotherapy services, dated July 17, 2023, was prepared by Dr. Wayne Coghlan, chiropractor, of 101 Physio. The goals of the treatment plans are: pain reduction, increased range of motion, increase in strength, and a return to activities of daily living.

8The July 17, 2023 treatment plan seeks $4,006.32 which is comprised of:

• 15 - 1 hour sessions of physical rehabilitation $1,692.15
• 7 - 30 minute sessions of therapy $203.70
• Hot/cold gel pack $25.00
• A total body assessment $215.00
• A cervical pillow $120.00
• Medistik pain relief spray $29.99
• 8 sessions of acupuncture, multiple body sites $400.00
• Transportation to treatment 1 PR 75.00 $1,125.00
• Taxes $195.48

9The applicant submits that she exacerbated a previous shoulder injury in the accident, and was referred to physiotherapy by her treating physician after the accident. The CNRs of the Springdale Medical Clinic reveal that the applicant was diagnosed with a repetitive strain injury to her left shoulder in December 2022 although she did not reference the previous injury in her post-accident CNRs.

10The respondent argues that the applicant has not met her onus to prove that the treatment plan is reasonable and necessary, and relies on the s. 44 insurer examination (“IE”) paper reviews of Dr. Mansour Alvi, orthopaedic surgeon, dated February 27, 2024.

11I find that Dr. Alvi’s February 13, 2024 IE paper review sheds little light on whether the July 17, 2023 treatment plan is reasonable and necessary, as the initial IE, which was the basis for the paper review, was conducted on November 14, 2023, four months after the treatment plan was submitted.

12The Springdale Medical Centre CNRs reveal that the applicant attended the Springdale Medical Clinic on July, 7, 2023, the day after the accident, and was diagnosed with back, neck, and shoulder strain, and was referred for physiotherapy. At the applicant’s July 20, 2023 appointment she was advised to continue with physiotherapy to address her neck and shoulder injuries.

13I assign more weight to the applicant’s family doctor’s July 20, 2023 recommendation that the applicant continue with physiotherapy, because it was based on a contemporaneous physical examination, and was made two weeks after the accident after an initial round of physiotherapy.

14As a result, I find, on a balance of probabilities, that the treatment plan dated July 17, 2023 is reasonable and necessary.

15Accordingly, the applicant is entitled to $4,006.32 for physiotherapy services in the treatment plan dated July 17, 2023.

Is the applicant entitled to $2,359.52 for physiotherapy services in a treatment plan submitted January 8, 2024?

16I find that the applicant has not established that the January 8, 2024 treatment plan is reasonable and necessary.

17The treatment plan for physiotherapy services dated January 8, 2024 was prepared by Dr. Coghlan of 101 Physio. The goals of the treatment plans are: pain reduction, increased range of motion, increase in strength, and a return to activities of daily living.

18The January 8, 2024 treatment plan seeks $2,359.52, which is comprised of:

• 14 - 1 hour sessions of physical rehabilitation $1,579.34
• 7 - 30 minute sessions of therapy $203.70
• An assessment $200.00
• 7 sessions of Acupuncture $350.00
• Taxes $26.48

19The applicant submits that the treatment plan is reasonable and necessary because the applicant is experiencing pain from her accident-related injuries. In addition to the CNRs of the Springdale Medical Clinic, the applicant relies on the CNRs of 101 Physio. The respondent argues that the applicant has not met her onus to prove that the treatment plan is reasonable and necessary, and relies on of Dr. Alvi,’s, February 13, 2024 IE paper review

20The applicant submits that she exacerbated a previous shoulder injury in the accident, and was referred to physiotherapy by her treating physician at after the accident. However, I agree with the respondent that the CNRs of the Springdale Medical Clinic do not contain any further referrals to physiotherapy or any mention of the accident after July 20, 2023. Further, the CNRs of 101 Physio shed little light on the applicant’s submissions as they are handwritten, and partly illegible, and where they are legible, they provide a record of treatment, but have a reference to “stiff and sore shoulders and neck,” without additional detail or notations of the applicant’s progress.

21The respondent submits that Dr. Alvi determined in his February 13, 2024 s. 44 IE report that the treatment plan was not reasonable and necessary. At his initial IE on November 14, 2023, Dr. Alvi conducted a detailed interview with the applicant and conducted a physical examination. Dr. Alvi diagnosed the applicant with mild myofascial strain to the cervical spine and mild myofascial strain to the bilateral shoulders and opined that the applicant’s prognosis for her accident-related injuries was good. He recommended that she transition from facility-based treatment to a home exercise regimen under the direction of her physician.

22Overall, I find that applicant has not met her onus to prove that the treatment plan is reasonable and necessary, because the applicant has not directed me to contemporaneous medical evidence or referrals to support the treatment plan.

23Accordingly, the applicant is not entitled to the treatment plan for physiotherapy services submitted January 8, 2024.

Is the applicant entitled to the remaining balance of $1,247.33 ($3,790.70 less $2,543.37 approved) for psychological treatment in a treatment plan submitted September 14, 2023?

24I find that the applicant has not established on a balance of probabilities that the balance of $1,247.33 in the treatment plan for psychological services is reasonable and necessary.

25The goals of the treatment plan prepared by Dr. Konstantinos Papazoglou, psychologist and dated September 14, 2023 are: pain reduction, reduction of depressive symptoms, and a return to activities of normal living. It sought $3,790.70, which is comprised of:

• 12 - 90-minute sessions of counselling $ 2,693. 04
• 1 - 2-hour Mental health assessment $299.22
• Documentation/support activity $598.44
• Fee for form completion $200.00

26The treatment plan was partially approved in the amount of $2,543.37, and the remaining balance of $1,247.33 was denied because the respondent approved 60 minute counselling sessions, and a one hour mental health assessment. The respondent submits that it required further information from the applicant to explain why 90 minute sessions, and the two-hour assessment were reasonable and necessary. Further, the respondent lowered the documentation/support activity fee from 4 hours to one hour.

27In her submissions, the applicant did not address the costs of the treatment plan or the length of the sessions requested. Instead, the applicant made general submissions as to whether the psychological treatment was reasonable and necessary.

28As the applicant did not provide submissions on whether she is entitled to the additional costs and longer treatment sessions and assessment, I find that the applicant has not met her onus to prove that the remaining balance of $1,247.33 in the treatment plan is reasonable and necessary.

29Accordingly, the applicant is not entitled to the remaining balance of $1,247.33 in the treatment plan for psychological services dated September 14, 2023.

Is the applicant entitled to $2,460.00 for a communication assessment, in a treatment plan submitted November 23, 2023?

30I find that the applicant has not established on a balance of probabilities that a communication assessment is warranted.

31The treatment plan for a communication assessment, dated November 23, 2023, was prepared by Isabelle Zonenberg, social worker. The goals of the treatment plan are: an assessment of the applicant’s resource management and coping mechanism needs, and seeks $2000.00 for a communication assessment, $200.00 for a fee to complete the OCF-18 form, and $260.00 in taxes.

32I note that the applicant refers to the assessment as a social work assessment, although it is set out in the Case Conference Report and Order as a communication assessment.

33However, the applicant did not make any submissions with respect to whether the treatment plan is reasonable and necessary or to explain what the assessment is for. Instead, the applicant cites two Tribunal decisions, which I find are not helpful in my analysis because neither of them refer to an assessment, and the applicant has not explained their relevance to her position. The applicant explains that the first decision, 19-012706 v TD Insurance 2021 CanLII 96939 (ON LAT), is related to a treatment plan for physical rehabilitation, and the second 18-001926 v Certas 2019 CanLII 43890 (ON LAT), refers to a MIG determination.

34As the applicant has not provided any submissions or directed me to any evidence to support her claim for the communication assessment, I find that the applicant has not met her onus to prove on a balance of probabilities that the treatment plan is reasonable and necessary.

35Accordingly, the applicant is not entitled to $2,460 for the treatment plan dated November 23, 2023.

Is the applicant entitled to $2,460.00 for a total body assessment, in a treatment plan submitted January 19, 2024?

36I find that the applicant has not established that a total body assessment is warranted.

37The applicant did not provide any submissions or direct me to any evidence with respect to a treatment plan for a total body assessment dated January 19, 2024.

38As such, I find that the applicant has not met her onus to prove that the treatment plan is reasonable and necessary. Accordingly, the applicant is not entitled to $2,460.00 for a total body assessment in a treatment plan submitted January 19, 2024.

Is the applicant entitled to the remaining balance of $360.78 ($2,460.00 less $2,099.22 approved) for a psychological assessment in a treatment plan dated July 21, 2023?

39I find that the applicant has not met her onus to demonstrate that the balance of $360.78 in the treatment plan for a psychological assessment is reasonable and necessary.

40The treatment plan was prepared by Dr. Papazoglou and seeks $2460.00 for a psychological assessment comprised of $2000.00 for the assessment, $200.00 to complete the OCF-18, and $260.00 in taxes.

41The treatment plan was partially approved in the amount of $2,099.22, which included $2,000.00 for the assessment and one hour or $149.61 for the completion of the OCF-18.

42The applicant has made no submissions and has not directed me to any evidence with respect to the cost of the treatment plan, or why the remaining $360.78 is reasonable and necessary. Instead, the applicant makes general submissions that the applicant is entitled to the treatment plan. The respondent argues that the assessment was approved, and remaining amount was not approved because of a “rate adjustment.” I find that the difference is the total of the taxes of $260.00 in addition to a $50.39 reduction of the time allotted for the completion of the OCF-18

43As a result, I find that the applicant has not met her onus to prove that the balance of $360.78 in the treatment plan is reasonable and necessary.

44Accordingly, the applicant is not entitled to the remaining balance of $360.78 in the treatment plan for a psychological assessment dated July 21, 2023.

Is the applicant entitled to $2,460.00 for an orthopaedic assessment in a treatment plan submitted November 8 2023?

45I find that the applicant has not met her onus to demonstrate that the orthopaedic assessment in a treatment plan dated November 8, 2023 is reasonable and necessary.

46The applicant submits that “as previously demonstrated by the medical evidence, the aforementioned medical professionals concur that the aforementioned orthopedic assessment would be beneficial to [the applicant] in her recovery, as evidenced by their numerous recommendations and referrals.”

47However, the applicant did not direct me to any medical evidence or evidence of recommendations or referrals, or provide the names of the medical professionals to support her claim. It is not appropriate for an adjudicator to go through the evidence and make the applicant’s case for her: Dooman v. TD Insurance, 2025 ONSC 184 at para. 50 (Div. Ct.).

48As a result, I find that the applicant did not meet her onus to prove that the treatment plan for an orthopaedic assessment is reasonable and necessary.

49Accordingly, the applicant is not entitled to $2,460.00 for an orthopaedic assessment in the treatment plan dated November 8, 2023.

Interest

50The applicant is entitled to interest on any outstanding payments pursuant to s. 51 of the Schedule.

ORDER

51I find that:

1. The applicant is entitled to $4,006.32 for physiotherapy services in the treatment plan dated July 17, 2023.
2. The applicant is not entitled to $2,359.52 for physiotherapy services in the treatment plan submitted January 8, 2024?
3. The applicant is not entitled to the remaining balance of $1,247.33 ($3,790.70 less $2,543.37 approved) for psychological treatment in the treatment plan submitted September 14, 2023.
4. The applicant is not entitled to $2,460.00 for a communication assessment in the treatment plan submitted November 23, 2023.
5. The applicant is not entitled to $2,460.00 for a total body assessment in a treatment plan submitted January 19, 2024.
6. The applicant is not entitled to the remaining balance of $360.78 ($2,460.00 less $2,099.22 approved) for a psychological assessment in a treatment plan dated July 21, 2023.
7. The applicant is not entitled to $2,460.00 for an orthopaedic assessment in a treatment plan submitted November 8 2023.
8. The applicant is entitled to interest on any outstanding payments in accordance with s.51 of the Schedule.