Mai v. Co-operators General Insurance Company, 2026 CanLII 26854

RECONSIDERATION DECISION

Before: Craig Mazerolle, Vice-Chair

Licence Appeal Tribunal File Number: 24-001089/AABS

Case Name: Lianda Mai v. Co-operators General Insurance Company

Written Submissions by:

For the Applicant: Ryan Olson, Paralegal

For the Respondent: Simran Walia, Counsel

OVERVIEW

1On December 29, 2025, the respondent requested reconsideration of the Tribunal’s decision released December 15, 2025 (“decision”).

2Stemming from an accident on December 18, 2022 and a request for benefits made pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”), the parties participated in a written hearing. In the decision, the Tribunal found, in part, that the respondent did not deny a treatment plan for chiropractic services in accordance with s. 38(8) of the Schedule. As such, the applicant was found to be entitled to payment of the plan, pursuant to s. 38(11).

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 relies on Rule 18.2(b) to support its request. It is asking the Tribunal to vary the decision to find that the applicant is not owed any payment of the chiropractic services treatment plan.

5The applicant asks the Tribunal to dismiss the respondent’s request for reconsideration.

RESULT

6The respondent’s request for reconsideration is granted, in part.

7Pursuant to Rule 18.4, paragraph 28(ii) of the decision is varied to read:

The treatment plan for $4,217.20 for chiropractic services is payable, if incurred between May 4, 2023 and October 11, 2024, under ss. 38(11)2 and 38(15) of the Schedule.

ANALYSIS

8The test for reconsideration under Rule 18.2 involves a high threshold, and the requesting party must show how or why the decision falls into one of the categories in Rule 18.2. 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.

Rule 18.2(b) – Errors of Fact or Law

9The respondent raises two alleged errors with the decision, namely, the Tribunal misinterpreted its submissions, and it “appears to have ignored critical evidence”. Though I have found the respondent has established only the second of these two grounds, I will address both in turn.

Interpretation of the Respondent’s Submissions

10First, I do not find the respondent has shown how the alleged misinterpretation of its submissions would likely have impacted the outcome. Specifically, the respondent claims the Tribunal erred when it summarized its position on s. 38 as follows at paragraph 13 of the decision:

The respondent argues that the shall pay provision of s. 38(11)2 only applies between the period starting on the 11th business day after the day the insurer received the application and ending on May 4, 2023, when it provided a compliant notice. In that case, since we are dealing with a period outside of the shall pay period, the respondent argues that I must consider whether the proposed plan is reasonable and necessary.

11According to the respondent, its actual position was that “although a deficiency under Section 38(8) existed and [it] was unable to rely on the MIG as per Section 38(11), the treatment plan must still be reasonable and necessary to be found payable.”

12Even if I accepted the respondent’s allegation that the Tribunal incorrectly summarized its position, I do not see how correcting this error would have any impact on the outcome of the analysis. The wording in s. 38 is clear—if there is a breach of s. 38(8), the remedy under s. 38(11) is triggered. There is no obligation to prove that the expenses proposed in a treatment plan are reasonable and necessary. Rather, the applicant only has to show that the plan was incurred in accordance with the timeline under s. 38(11)2. Therefore, even if the Tribunal stated that the respondent argued for a reasonable and necessary analysis of the treatment plan, the outcome of its s. 38 analysis would have remained the same.

Second Denial Letter

13Next, the respondent claims the Tribunal ignored a second denial letter for this plan, and, in doing so, it erred in finding there was no end to the shall pay period under s. 38(11)2. I find the respondent has made out this ground for reconsideration under Rule 18.2(b).

14At the end of paragraph 20 of the decision, the Tribunal wrote: “I note that I was not offered any subsequent notice to the May 4, 2023 notice relating to this proposed plan and the shall pay period is there not capped in advance of this hearing.”

15At paragraph 25 of its written submissions (under the header detailing its arguments about the chiropractic services treatment plan), the respondent stated (emphasis added):

[The respondent] denied this OCF-18 by way of Explanation of Benefit dated May 4, 2023 pursuant to the MIG, and maintained this denial by way of Explanation of Benefit dated October 11, 2024 pursuant to Dr. Kassam’s opinion.

16In light of the incongruence between these two statements, I find the respondent has shown an error in the decision. I also find that, if the Tribunal had reviewed a subsequent denial of the treatment plan in dispute, the outcome of its s. 38 analysis would likely have been different.

17The applicant challenges this ground by claiming that the respondent is attempting to re-argue its position from the hearing. She also claims there is no obligation on the part of the Tribunal to list every piece of evidence referenced by the parties. Finally, the applicant argues that the respondent had “the opportunity to make submissions on whether the October 11, 2024 notice complies with the Schedule”, but it chose not to make this argument.

18It is well-established that adjudicators are not expected to address every document and submission presented during the hearing, as they are only obligated to show they turned their minds to the key aspects of the parties’ cases. I also accept that the reconsideration process is not a venue to ask the Tribunal to re-litigate positions considered at first instance.

19However, in the present case, this is not what the respondent is asking the Tribunal to do. Rather, it is asking the Tribunal to explicitly address its second denial letter—a piece of evidence that is a key aspect of the respondent’s case.

20I also do not accept the applicant’s position that the respondent did not make s. 38(8) submissions about this letter. This second denial was clearly connected to the first denial letter in its submissions, i.e., “[The respondent] denied this OCF-18 by way of Explanation of Benefit dated May 4, 2023… and maintained this denial by way of Explanation of Benefit dated October 11, 2024”. The May 4, 2023 and October 11, 2024 letters were also both included under the same tab, further proof that the respondent intended these two letters to be read in tandem.

21Taken together, I find the respondent has established an error that meets the standard under Rule 18.2(b).

Rule 18.4 – Varying the Decision

22Considering the availability of the parties’ written hearing submissions, I find I can adequately re-hear this part of the dispute within the confines of my reconsideration decision. I see no prejudice facing the parties from this arrangement, especially as it will foster a timelier resolution of the dispute. Therefore, pursuant to Rule 18.4, I am re-hearing this part of the decision to determine what impact, if any, the October 11, 2024 denial letter has on the Tribunal’s s. 38 analysis.

23Section 38(8) requires an insurer to inform an insured person, within 10 business days after it receives the treatment plan, of the medical and other reasons why it considered the goods and services not to be reasonable and necessary if it denies a plan. Pursuant to s. 38(11), if an insurer fails to comply with these obligations, it must pay for the goods and services that relate to the period starting on the 11th business day after the insurer received the application and ending on the day the insurer gives a notice described in s. 38(8). It is also prohibited from taking the position that the insured person has an impairment to which the Minor Injury Guideline applies.

24In the oft-quoted decision of 16-003316/AABS v. Peel Mutual Insurance Company, 2018 CanLII 39373 (ON LAT) (“Peel Mutual”), the Tribunal provides helpful guidance for how to apply s. 38(8) of the Schedule (at paragraph 21):

The ultimate purpose underlying s. 38(8) is to require an insurer to respond to a treatment plan not only quickly but also reasonably, in a manner that respects an insured’s ability, when entitled, to access timely treatment. To that end, an insurer’s “medical reasons” for denying a plan should engage the specific details about the insured’s condition forming the basis for the insurer’s decision. They should also be adequate enough to allow an unsophisticated person to understand them and make an informed decision in response. Those entitled to accident benefits should not have to wonder why they are denied treatment. Nor should they have to incur the temporal, emotional, and financial costs associated with engaging the Tribunal in order to obtain the treatment they should have received long before. If s. 38(8) is to achieve its purpose, it must require insurers to accompany any denial of benefits with meaningful and accurate reasons based on an insured’s medical condition as described in the file at hand.

25With this guidance in mind, I find the October 11, 2024 letter is a compliant denial of the chiropractic services treatment plan (submitted April 13, 2023).

26In its written submissions, the respondent argued that the October 11, 2024 letter “maintained” the earlier denial of this treatment plan set out in the first denial letter. The respondent also noted that this second denial is based on the opinion it obtained from Dr. Adam Kassam, physiatrist (dated October 9, 2024).

27The applicant did not address this letter in her initial written submissions, nor did she provide a reply to the respondent’s submissions.

28After identifying the specific treatment plan in dispute, the October 11, 2024 letter provides the following reasons for why the respondent decided not to approve these proposed chiropractic services:

We are maintaining our denial of the Treatment and Assessment Plan submitted by Dr. Tavares proposing additional physical treatment. Based upon a thorough review of the documentation, the in-persona [sic] examination and their expertise, Dr. Kassam opined that you sustained uncomplicated soft tissue injuries of the mid and lower back. These injuries have resolved and the assessor reports they found no ongoing accident-related impairments from a musculoskeletal perspective. The injuries you suffered in the accident December 18, 2022 are predominantly minor injury… Dr. Kassam is of the opinion that additional physical treatment is not expected to provide any additional benefits and are therefore not reasonable and necessary.

29At the end of the letter, the respondent notes that it has “included information outlining your right to dispute our decision”, and it indicates that a copy of Dr. Kassam’s report is appended.

30Following on the reasoning from Peel Mutual, I find this letter complies with s. 38(8) of the Schedule. It provides “medical and other reasons” that a layperson can understand. Specifically, the respondent points to the report from Dr. Kassam to indicate that it believes the applicant’s injuries are “uncomplicated soft tissue injuries” that have resolved. Therefore, there was no need for “additional physical treatment”, which was the subject of the treatment plan in dispute.

31I also note that there are suggestions of what the applicant can do to try and remedy the respondent’s concerns, namely, she can work with her treatment providers to submit further medical documents to demonstrate that there are ongoing injuries that require physical treatment. Taken together, I find the level of detail in this letter meets the standard under s. 38(8).

32Due to this finding, I can then conclude that the s. 38(8) breach found in the decision was remedied through this second, subsequent letter. By extension, the shall pay period under s. 38(11)2 ends on this date. Pursuant to Rule 18.4, I am varying the decision to comply with these findings.

33The respondent also asked me to find that no services have been incurred between May 4, 2023 and October 11, 2024. I do not find it is necessary to reach this conclusion. Rather, if the applicant has incurred any part of the treatment plan during this period, payment is owed. If not, no payment is owed.

CONCLUSION & ORDER

25The respondent’s request for reconsideration is granted, in part.

26Pursuant to Rule 18.4, paragraph 28(ii) of the decision is varied to read:

The treatment plan for $4,217.20 for chiropractic services is payable, if incurred between May 4, 2023 and October 11, 2024, under ss. 38(11)2 and 38(15) of the Schedule.

Craig Mazerolle Vice-Chair