Licence Appeal Tribunal
Licence Appeal Tribunal File Number: 24-012110/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:
Brenda Rollins
Applicant
and
Definity Insurance Company
Respondent
DECISION
ADJUDICATOR:
Amar Mohammed
APPEARANCES:
For the Applicant:
Brenda Rollins, Applicant Rebbecca Phillips, Counsel
For the Respondent:
Nicholas Maida, Counsel
HEARD:
By Way of Written Submissions
OVERVIEW
1Brenda Rollins, the applicant, was involved in an automobile accident on October 28, 2020, 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, Definity 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 $1,964.88 for an occupational therapy assessment, proposed by Rehab First Inc., in a treatment plan/OCF-18 ("plan") submitted on August 27, 2024, and denied on September 11, 2024?
ii. Is the applicant entitled to interest on any overdue payment of benefits?
3The applicant withdrew the issue of a disputed plan in the amount of $1,437.78 for physiotherapy treatment, proposed by Fit for Life Physiotherapy.
RESULT
4The applicant is not entitled to the disputed occupational therapy assessment, or to interest.
ANALYSIS
The applicant entitled to $1,964.88 for an occupational therapy assessment
5I find that the applicant is not entitled to this occupational therapy 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.
7Notably, the purpose of an assessment is to determine whether a condition exists. For an insured, they bear the onus to demonstrate that there are grounds to suggest that some condition exists that would warrant investigation by way of an assessment.
8The applicant argues the assessment is reasonable and necessary because she has functional impairments resulting from the accident. The applicant identified the goals of the assessment being to increase safety and participation in normal activities of daily living, to assess her level of functioning and independence with activities of normal living and home environment, and to provide recommendations to address any functional barriers that would be identified.
9The respondent argues that neither the applicant's treating physician nor physiotherapist recommended the proposed assessment. The respondent notes that this disputed assessment is proposed by a clinic that has not been involved in her care. Further, that the medical records of her treatment providers note improvement in her functional limitations and less frequent treatment. The respondent also submits that the applicant had already undergone two occupational therapy assessments in 2021. In this context, the respondent argues the proposed assessment is duplicative and therefore not reasonable and necessary.
10The respondent does not strongly oppose that the applicant may have functional limitations as a result of the accident that can be investigated by an occupational therapy assessment. However, the respondent refers me to Shaikh v Security National Insurance Company, 2024 CanLII 38454 (ON LAT) ("Shaikh"), at para 17. In Shaikh, the Tribunal held that a proposed occupational therapy assessment was not reasonable and necessary because the insured underwent a more comprehensive occupational therapy assessment three years prior. The respondent submits that the assessment in dispute would be duplicative of the assessment she underwent in 2021. The respondent refers me to an Occupational Therapy Assessment Report of Ms. Emily Warren dated June 16, 2021 and to an Independent Occupational Therapy Evaluation Report of Ms. Tovit Rubin dated October 14, 2021. The respondent argues the 2021 occupational therapy assessments were more comprehensive than the proposed assessment because they addressed occupational therapy needs and also attendant care needs.
11I am persuaded by the respondent that the applicant's argument based on ongoing symptoms as a result of the accident does not establish multiple occupational therapy assessments are reasonable and necessary. In my view, in the case of reassessments, the applicant should lead submissions or evidence addressing how the disputed assessment would gather information that is not already known or that there are grounds to suggest that some condition exists that would warrant another investigation via further assessment. The applicant did not provide reply submissions for consideration. I find that the applicant has not established that a further occupational therapy assessment is reasonable and necessary.
12On a balance of probabilities, I find that the applicant is not entitled to this occupational therapy assessment.
Interest
13The applicant is not entitled to interest because it applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. There are no overdue benefits on this application.
ORDER
14For the reasons above, I make the following orders:
i. The applicant is not entitled to the disputed occupational therapy assessment, or to interest.
Released: March 24, 2026
Amar Mohammed
Adjudicator