RECONSIDERATION DECISION
Before: Melanie Malach, Adjudicator
Licence Appeal Tribunal File Number: 24-003040/AABS
Case Name: Salad H Mohamoud v. Jevco Insurance Company
Written Submissions by:
For the Applicant: Julia Logoutova, Paralegal
For the Respondent: Asal Karimi, Counsel
OVERVIEW
1On January 9, 2026, the respondent requested reconsideration of the Tribunal’s decision dated December 19, 2025 (“decision”).
2The Tribunal found that the applicant’s injuries are minor as defined in s. 3 of the Statutory Accident Benefits Schedule – Effective September 1, 2010 (including amendments effective June 1, 2026) (“Schedule”), and therefore the applicant is subject to treatment within the Minor Injury Guideline (“MIG”). However, based on s. 38(8) non-compliance, the Tribunal found that the applicant was entitled to $2,300.00 for a neurological assessment proposed in the treatment plan, dated May 3, 2023.
3The grounds for a request for reconsideration are found in Rule 18.2 of the Licence Appeal Tribunal Rules, 2023 (“Rules”). To grant a request for reconsideration, the Tribunal must be satisfied that one or more of the following criteria are met:
a) The Tribunal acted outside its jurisdiction or committed a material breach of procedural fairness;
b) The Tribunal made an error of law or fact such that the Tribunal would likely have reached a different result had the error not been made; or
c) There is evidence that was not before the Tribunal when rendering its decision, could not have been obtained previously by the party now seeking to introduce it, and would likely have affected the result.
4The respondent seeks reconsideration pursuant to Rule 18.2(b). The respondent seeks an order to vary the decision to find the applicant is not entitled to payment of the treatment plan, dated May 3, 2023, due to s. 38(8) of the Schedule.
RESULT
5The respondent’s request for reconsideration is granted. Specifically, the respondent has shown that the Tribunal erred in its Order that the treatment plan dated May 3, 2023 is payable due to non-compliance with s. 38(8) of the Schedule.
6Pursuant to Rule 18.4, I am varying the decision to find that the applicant is not entitled to payment of this treatment plan.
ANALYSIS
7The test for reconsideration under Rule 18.2 involves a high threshold. The reconsideration process is not an opportunity for a party to re-litigate its position where it disagrees with the Tribunal’s decision, or with the weight assigned to the evidence. The requestor must show how or why the decision falls into one of the categories in Rule 18.2.
8I find the respondent has established an error of fact or law that triggers Rule 18.2(b).
Rule 18.2(b) – Error of Fact or Law
9The respondent submits that the Tribunal erred in finding that the denial letter related to the treatment plan, dated May 3, 2023, was non-compliant with s. 38(8) of the Schedule. The respondent argues that the Tribunal mistakenly referred to the treatment plan in dispute as a neurological assessment, when the treatment plan was for an orthopedic assessment. Had this error not occurred, the respondent argues that the Tribunal would likely have reached the conclusion that the denial letter complied with s. 38(8) of the Schedule.
10Sections 38(8) and 38(11) of the Schedule set out strict notice requirements for insurers responding to treatment plans and specific consequences if they fail to comply. Section 38(8) requires an insurer to inform an insured person within ten business days after it receives a treatment plan which goods, services, assessments, and/or examinations it agrees to pay for, and which it does not, as well as the medical and other reasons why it considered any of the goods and services to not be reasonable and necessary.
11If an insurer fails to comply with its obligations under s. 38(8), the following consequences set out in s. 38(11) of the Schedule are triggered:
The insurer is prohibited from taking the position that the insured person has an impairment to which the Minor Injury Guideline applies.
The insurer shall pay for all goods, services, assessments, and examinations described in the treatment and assessment plan that related to the period starting on the 11th business day after the day the insurer received the application and ending on the day the insurer gives a notice described in subsection (8).
12The respondent submits that the Tribunal correctly outlined the requirements of s. 38 of the Schedule in paragraph 18 of the decision. However, the Tribunal made factual errors in paragraphs 16, 17, 18 and 19, by concluding that the respondent’s notice was insufficient because it relied on an Insurer’s Examination (“IE”) report by Dr. Irina Safir, which evaluated physical rehabilitation, to justify the denial of a neurological assessment.
13The respondent submits that the treatment plan in dispute is for an orthopedic assessment, not a neurological assessment. The respondent argues that its denial letter dated June 2, 2023 indicated that the treatment plan in dispute recommended services that were substantially similar to those in a previously submitted treatment plan dated March 29, 2023. The previous treatment plan had been reviewed and found not reasonable and necessary based on the IE completed by Dr. Safir. The respondent directed the applicant to the correspondence providing this information on April 24, 2023, and it included Dr. Safir’s report with the denial letter. Therefore, the respondent claims its reliance on Dr. Safir’s report to deny the treatment plan is justified.
14The applicant submits that, although the Tribunal mistakenly references the treatment plan as a request for a neurological assessment, this error does not change the fact that the respondent’s denial letter is based on the report of Dr. Safir who addressed the need for physical rehabilitation, and not the assessment with an orthopedic surgeon. The applicant argues that the Tribunal did not err in finding that the respondent’s reliance on an IE report focused solely on physical therapy is not sufficient to justify the denial of an assessment, be it neurological or orthopedic, and that each treatment plan must be evaluated on its own merits when it involves a different modality or medical discipline. The applicant requests that the Order be varied to read “orthopedic assessment” instead of “neurological assessment”. In the alternative the applicant seeks a new written hearing of the issue.
15There is no dispute between the parties that the Tribunal erred in finding that the treatment plan in dispute was for a neurological assessment. Both parties agree that the treatment plan in dispute is for an orthopedic assessment, not a neurological assessment. The analysis before me is whether the Tribunal would likely have reached a different decision had this error not been made.
16I agree with the respondent that the Tribunal would likely have come to a different conclusion had it correctly found that the proposed treatment plan was for an orthopedic assessment.
17At paragraphs [17] and [18] of the decision, the Tribunal stated:
[17] The proposed treatment plan is for a neurological assessment, not physical rehabilitation. Therefore, the respondent’s reliance on an IE focused solely on physical therapy is not sufficient to justify the denial of a neurological assessment. Each treatment plan must be evaluated on its own merits particularly when it involves a different modality or medical discipline.
[18] I find under s. 38 of the Schedule, the insurer is required to provide clear and specific reasons for denying a treatment plan. A general reference to a prior IE that does not address the proposed treatment is not adequate to meet this requirement. The respondent’s notice fails to explain why a neurological assessment is not reasonable or necessary in light of the applicant’s injuries.
18I find that the Tribunal, in determining the sufficiency of the respondent’s denial letters in respect to the other treatment plans in dispute, accepted that the respondent denied the treatment plans for other physical assessments, specifically the Functional Abilities Evaluation (“FAE”), based on Dr. Safir’s IE report. At paragraphs [31] and [32], the Tribunal found:
[31] On June 2, 2023, the applicant was advised that based on the enclosed s. 44 IE (Paper Review) Report of Dr. Safir dated May 18, 2023, the applicant’s injuries were deemed to fall within the MIG, and the proposed treatment plan was not considered reasonable and necessary.
[32] The respondent’s denial is based on the findings of Dr. Safir’s IE, which concluded that the applicant’s injuries do not warrant treatment beyond the MIG. The report did not identify any clinical findings that would support a diagnosis or impairment outside the MIG threshold. The applicant did not submit additional medical documentation to rebut the MIG classification or to demonstrate that the proposed treatment plan was reasonable and necessary in light of the injuries sustained. The respondent complied with procedural requirements under s. 38 and s. 44 of the Schedule by providing timely notice of the denial, enclosing the relevant IE report, and offering a clear rationale for the denial based on medical opinion. There is no indication that the respondent failed to meet its obligations under the Schedule in relation to this treatment plan.
19I therefore find that, had the Tribunal evaluated the correct treatment plan in dispute, namely, a plan that recommended an orthopedic assessment, it would have reached the same conclusion as it did with respect to the treatment plan for a FAE and the denial letter dated June 2, 2023. I note that both the denial letters for the FAE assessment and the orthopedic assessment were written on the same date, and both relied upon Dr. Safir’s IE report. I find the Tribunal’s conclusion that the denial of the treatment plan is “supported by the findings of the s. 44 IE and complies with the procedural requirements under the Schedule” would likely apply consistently to the denial of the treatment plan for the orthopedic assessment. I find that both assessments were to address the applicant’s physical impairments, and the report of Dr. Safir directly assessed the applicant’s physical injuries and found him to be in the MIG.
20I do not accept the applicant’s submission that the treatment plan had to be assessed specifically by an orthopedic specialist, as Dr. Safir, who is a general practitioner, is qualified to assess physical impairments.
21I find that the Tribunal incorrectly ordered that the applicant is entitled to the proposed treatment plan due to the respondent’s non-compliance with the Schedule.
22For these reasons, I find that the respondent has shown that the Tribunal made an error of law or fact such that it would likely have reached a different result had the error not been made.
Rule 18.4 – Varying the Decision
23Since the respondent has established grounds for reconsideration for the treatment plan dated May 3, 2023, I must now determine what the appropriate remedy is under Rule 18.4. I find the appropriate remedy is to vary the decision. Considering this issue was extensively argued in the parties’ written hearing submissions, I find I can adequately assess the claim for this treatment plan within the confines of this reconsideration decision. I see no prejudice facing the parties from this arrangement, especially as it will foster a timelier resolution of the dispute.
24I confirm that the Tribunal has found that the applicant’s injuries are minor. Therefore, it is not necessary to consider the reasonableness or necessity of the treatment plan. The analysis turns to whether the respondent’s denial was compliant with s. 38(8) of the Schedule.
25I find that the June 2, 2023 denial letter was a valid denial. I find that the notice identified the treatment plan in dispute, and it specified that the reason for the denial is that the goods and services recommended in the treatment plan are substantially similar to the goods and services that were previously submitted on a treatment plan dated March 29, 2023. The respondent advises that the goods and services are denied based on the IE report of Dr. Safir dated May 18, 2023. A copy of this report was attached to the letter. I find that the respondent provided clear medical and other reasons in its notice, sufficient to allow the applicant to make an informed decision as to whether to accept or dispute the decision. I find that this was a clear and unequivocal denial.
26Having concluded that the respondent complied with its obligations outlined in s. 38(8) of the Schedule, I find that the applicant has not met his burden of proving that the treatment plan for an orthopedic assessment, dated May 3, 2023, is payable.
CONCLUSION & ORDER
27The respondent’s request for reconsideration is granted.
28Pursuant to Rule 18.4, the decision is varied at paragraph [39]. This paragraph shall now read:
On the totality of the evidence, I find that:
i. The applicant’s injuries are minor as defined in s. 3 of the Schedule and therefore the applicant is subject to treatment within the MIG.
ii. The treatment plans are not payable.
Melane Malach Adjudicator
Released: March 18, 2026