Licence Appeal Tribunal File Number: 24-011956/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:
Ali Nazari Nafouti
Applicant
and
Definity Insurance Company
Respondent
DECISION
ADJUDICATOR:
Sarah Guergis
APPEARANCES:
For the Applicant:
Carlos Ortiz, Paralegal
For the Respondent:
Sue Yingxue Li, Counsel
HEARD: In Writing
OVERVIEW
1Ali Nazari Nafouti, the Applicant, was involved in an automobile accident on September 5, 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 the assessment/treatment plan/OCF-18’s (“plan”) proposed by Doctor’s Rehabilitation Clinic, as follows:
a) $3,700.25 for Chiropractic Services, in a plan dated April 5, 2021; and
b) $3,840.00 for Chiropractic Services, in a plan dated August 9, 2021;
c) $2,200.00 for a Psychological Assessment, in a plan dated March 3, 2021?
ii. Is the Respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the Applicant?
iii. Is the Applicant entitled to interest on any overdue payment of benefits?
3The application included issues related to OCF-6 expenses and the Minor Injury Guideline. The Respondent submits that it paid the OCF-6’s and removed the Applicant from the Minor injury Guideline in May 2025, as indicated in paragraph 2 of its written submissions. The Applicant did not provide any reply submissions disputing this.
4Accordingly, the updated issues in dispute are reflected above.
RESULT
5I find that the Applicant is not entitled to the treatment plans in dispute.
6I find that the Applicant is not entitled to interest or an award.
ANALYSIS
Failure to Dispute Denial Within 2-Year Limitation Period
7The Respondent submits that the OCF-18’s in dispute are statute-barred, as the Applicant has failed to dispute the denials of the OCF-18s within the two-year limitation period provided by s. 56 of the Schedule.
8The Applicant does not address these issues in their written submissions. Nor did they provide reply submissions.
9This defence will be taken into consideration in my analysis.
Late Submissions/abandoned application.
10The Respondent submits that the Applicant has abandoned his application and, thus, the application should be dismissed as he has failed to file any submissions.
11However, this is false, as the Applicant filed their written submissions on August 15, 2025; roughly one week late.
12The notice of written hearing was sent on January 21, 2025, which stated the hearing will be held on Friday, September 5, 2025. The Case Conference Report and Order (CCRO) ordered the Applicant to submit their written submissions 30 calendar days prior to the scheduled hearing, which would be August 6, 2025, pursuant to Tribunal Rule 14.
13While I acknowledge that the Applicant’s written submissions were filed roughly one week late, breaching Tribunal Rule 14.2(g), I was not pointed to evidence of how this prejudiced the Respondent. The Respondent still had roughly 3 weeks to review and consider the Applicant’s submissions and filed its submissions on time. Nor was I pointed to evidence which would establish the Applicant’s abandonment of the application.
14I find that it would be far more prejudicial to the Applicant to dismiss their application due to late filing of submissions than it would be prejudicial to the Respondent to proceed with the hearing due to the short delay.
15The Applicant’s filed submissions will be considered.
Is the Applicant entitled to the plans proposed by Doctor’s Rehabilitation Clinic for chiropractic services in the amounts of $3,700.25 in a plan dated April 5, 2021, and $3,840.00 in a plan dated August 9, 2021?
16I find the Applicant is not entitled to these plans.
17To 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.
18The Applicant submits that treatment goals of these plans include pain reduction, increased range of motion, strength improvement, return to normal activities, and modified work.
19The Applicant did not specifically address why these plans in dispute are reasonable or necessary but directs the Tribunal to the treatment plan in dispute. The Applicant also details evidence of their chronic pain but does not specifically note how the chronic pain medical evidence connects to this treatment plan’s reasonableness or necessity.
20The Respondent submits that the OCF-18 in the amount of $3,700.25, submitted by Doctor’s Rehab Clinic on April 5, 2021, for chiropractic services, was denied by letter dated April 20, 2021, on the basis that, according to the medical records provided, this OCF-18 was not reasonable and necessary. Further, that an insurer’s examination was not required.
21The Respondent further submits that the OCF-18 in the amount of $3,840, submitted by Doctor’s Rehab Clinic on August 9, 2021, for chiropractic services, was denied by letter dated August 23, 2021, on the basis that, according to the medical records provided, this OCF-18 was not reasonable or necessary.
22The Respondent relies on an Insurer’s Examination Report by Dr. Hashmat Khan, MD, dated July 26, 2024. Dr. Khan concluded that it was more likely than not that the Applicant had reached maximum medical recovery. From a musculoskeletal perspective, there were no external factors preventing the Applicant from achieving maximal recovery. Further, that from a musculoskeletal perspective, the Applicant sustained a minor injury as defined under the Schedule.
23The Respondent further relies on an insurer’s examination report from Dr. Khan dated October 21, 2021. Dr. Khan concluded that from a musculoskeletal perspective, the Applicant sustained a minor injury as defined under the Schedule, and there were no external factors preventing the Applicant from achieving maximal recovery.
24I do not find the Respondent’s evidence holds significant weight, as, the Applicant has already been removed from the MIG, which seems to be the focus of these s.44 assessments.
25As it is the Applicant’s onus to establish that the treatment plans in dispute are reasonable and necessary, I do not find they have met their onus. I was not pointed to evidence which would establish why these specific plans in dispute are reasonable or necessary, how the goals would be met to a reasonable degree and that the overall costs of achieving them are reasonable. The Applicant’s own self reporting does not establish the treatment plans reasonableness or necessity. It is also well established that an OCF-18 alone is not sufficient to establish that a treatment plan is reasonable and necessary.
26Therefore, on a balance of probabilities, I find these plans are not payable.
Is the Applicant entitled to $2,200.00 for a Psychological Assessment, in a plan dated March 3, 2021?
27I find the Applicant is not entitled to this plan.
28The 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.
29The Applicant submits that the accident caused significant physical and psychological impairments, including chronic pain, depression, anxiety, sleep disturbances, memory issues, and difficulty focusing.
30The Applicant did not specifically point me to their reasoning as to why this plan is reasonable or necessary but instead directs the Tribunal to the plan itself, a psychological assessment by Dr. Shirin Jazayeri.
31Dr. Jazayeri concluded that the Applicant’s impairments are severe and should not fall under the MIG. She recommended a full psychological assessment, including psychometric testing and a clinical interview, to determine his diagnosis and treatment needs. She stated that the goal of treatment is to address his physical and psychological barriers to recovery and help him return to pre-accident functioning.
32The Respondent submits that this plan was denied because it is not reasonable or necessary.
33The Respondent relies on an Insurer’s Examination Report of Dr. Nicole Azizli, psychologist, dated July 26, 2024. Dr. Azizil concluded that the present psychological assessment found no objective evidence to substantiate the Applicant’s subjective self-report of psychological impairment related to the index accident.
34Dr. Azizl further noted that the psychological assessment in dispute is from 2021 and is outdated, and the Applicant stated that he is not interested in pursuing any mental health treatment at this time, as he believes that his primary issues with respect to the accident are physical in nature, therefore, the OCF-18 is not reasonable or necessary.
35As the Applicant did point me to the reasonableness or necessity of this plan, I find he has not met his onus. The Applicant has not pointed me to other medical evidence which may establish the reasonableness and necessity of this specific plan.
36The Applicant did identify the goals of treatment as addressing his physical and psychological barriers to recovery and help him return to pre-accident function. However, they did not explain how the goals would be met to a reasonable degree and that the overall costs of achieving them are reasonable. It is also well established that an OCF-18 alone is not sufficient to establish that a treatment plan is reasonable and necessary.
37I acknowledge that Dr. Azizli removed the Applicant from the MIG due to psychological injuries. However, the Applicant does not direct me to evidence or reasoning which would establish the reasonableness and necessity of this specific plan. Therefore, I find the Applicant has not met their onus.
38Therefore, on a balance of probabilities, I find the Applicant is not entitled to this plan.
Interest
39As the Applicant is not entitled to the benefits in dispute, no interest is owing.
Award
40As no benefits have been withheld or delayed, I find that an award is not payable.
ORDER
41I find that the Applicant is not entitled to the treatment plans in dispute.
42I find that the Applicant is not entitled to interest or an award.
Released: March 26, 2026
Sarah Guergis
Adjudicator