Licence Appeal Tribunal File Number: 24-009038/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:
Irina Motskin
Applicant
and
Aviva General Insurance Company
Respondent
AMENDED DECISION
ADJUDICATOR:
Jeff Chatterton
APPEARANCES:
For the Applicant:
Bianca Marinescu, Counsel
For the Respondent:
Justin Chan, Counsel
Dominik Gora, Counsel
HEARD: In Writing
OVERVIEW
1Irina Motskin, the applicant, was involved in an automobile accident on April 5, 2022, 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, Aviva 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:
Is the applicant entitled to $2,502.32 for chiropractic services, proposed by Polyclinic Rehabilitation Institute Inc. in a treatment plan/OCF-18 (“plan”) submitted October 23, 2023?
Is the applicant entitled to $1,534.52 for chiropractic services, proposed by Polyclinic Rehabilitation Institute Inc. in a plan submitted March 27, 2024?
Is the applicant entitled to $2,486.00 for a chronic pain assessment, proposed by Polyclinic Rehabilitation Institute Inc. in a plan submitted March 27, 2023?
Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant is not entitled to the treatment plans in dispute or interest.
ANALYSIS
Is the applicant entitled to chiropractic services?
4The applicant has not met her onus to establish entitlement to the treatment plans for chiropractic services which are in dispute (issues 1 and 2).
5The first plan, dated October 23, 2023, recommends 12 sessions of therapy, 12 more sessions of massage therapy, and an assessment, all to assist with pain reduction and increased range of motion, with a stated goal of increased strength and a return to the activities of normal living. The second treatment plan, dated March 27, 2024, has similar stated goals of pain reduction and increased range of motion, and recommends 6 counts of therapy, 6 counts of acupuncture, and another assessment.
6To receive payment for a treatment and assessment plan under s. 15 and 16 of the Schedule, the applicant bears the burden of demonstrating on a balance of probabilities that the benefit is reasonable and necessary as a result of the accident. To do so, the applicant should identify the goals of treatment, how the goals would be met to a reasonable degree and that the overall costs of achieving them are reasonable.
7The applicant argues that although she has been removed from the MIG for psychological reasons, she is out of the MIG regardless and is not subject to the $3,500 treatment limit. Furthermore, she argues that she is entitled to the plans as she receives short-term pain relief from the chiropractic treatments in question, and the Tribunal has long established that pain relief is a valid goal when it comes to determining whether a proposed treatment plan is reasonable and necessary.
8The respondent argues the treatment goals are not reasonable. It argues the respondent was not making complaints of pain, and that the Clinical Notes and Records from the applicant’s primary care physician do not show reports of pain.
9While I am alive to the applicant’s position that pain relief is a valid goal, I have not been led to supportive corroborating medical evidence to indicate that the applicant was suffering from accident-related pain contemporaneous to the treatment plans in question. Neither have I been led to supportive corroborating evidence which indicates that chiropractic services will help relieve the applicant’s pain, or that chiropractic services are recommended, other than by Chiropractor Dr. Bob Grossman, who is the author of the treatment plan.
10While the applicant has made a submission regarding pain relief in her written arguments, submissions are not evidence. In the applicant’s reply submission, she notes that she reported her accident-related concerns to her family physician and various medical practitioners on numerous occasions. She submits that she cannot be expected to make a causation connection and it is too burdensome to expect a claimant to know what legal tests must be satisfied when reporting pain complaints to their treating practitioners.
11Again, while the applicant may have submitted that her accident-related pain complaints have been reported to various medical practitioners on numerous occasions, submissions are not evidence, and I have not been led to evidence of these complaints in the medical evidence before me.
12For these reasons, I find the applicant has not, on the balance of probabilities, met her onus to establish entitlement to the chiropractic treatment plans in question.
Is the applicant entitled to a Chronic Pain Assessment?
13The applicant has not met her onus to establish entitlement to a Chronic Pain Assessment.
14The 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.
15To support her claim, the applicant argues she has made repeated complaints of pain to various medical professionals. Further, she points to the AMA Guides and argues she meets at least 3 of the 6 criteria for chronic pain. She does not stipulate which three conditions she has met. The applicant continues to work full time as a nurse, but is unable to work in the Intensive Care Unit. Finally, the applicant points to the fact she has already been diagnosed with Adjustment Disorder with Mixed Anxiety and Depressed Mood, and Major Depressive Disorder.
16The respondent argues the applicant does not meet the AMA Guides, and argues that the applicant has not presented evidence which indicates she has a pain condition which merits further investigation. The respondent points to the fact the applicant is working full time, and has resumed the majority of her self-care activities. The respondent points to the lack of evidence regarding physical deconditioning, social withdrawal, or dependency on pharmaceuticals, as well as the fact that there is no evidence that a Chronic Pain Assessment was recommended by a primary care physician or other treatment provider.
17I agree with the respondent. Although I am alive to the fact the applicant may be in some pain or discomfort, and has been diagnosed with a psychological disorder which involves social withdrawal, I have not been presented with evidence supporting that she has a pain condition that warrants further investigation.
18For these reasons, I find the applicant has not, on the balance of probabilities, met her onus to establish entitlement to a Chronic Pain Assessment.
Interest
19Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no benefits are overdue, no interest is payable.
ORDER
20The application is dismissed.
i. The applicant is not entitled to the treatment plans in dispute.
ii. No interest is payable.
Released: March 24, 2026
__________________________
Jeff Chatterton
Adjudicator