Licence Appeal Tribunal File Number: 24-006577/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:
Ahmed Kakar
Applicant
and
Chubb Insurance Company of Canada
Respondent
DECISION
ADJUDICATOR:
Sarah Guergis
APPEARANCES:
For the Applicant:
Katayoun Noohi, Counsel
For the Respondent:
Colin MacDonald, Counsel
HEARD: In Writing
OVERVIEW
1Ahmed Kakar, the Applicant, was involved in an automobile accident on October 4, 2019, 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, Chubb Insurance Company of Canada, 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 $299.22 ($2,767.79 less $2,468.57 approved) for a psychological re-assessment and progress evaluation, proposed by Ideal Counselling and Psychotherapy Services in a treatment plan/OCF-18 (“plan”) submitted on May 15, 2022?
ii. Is the Applicant entitled to $299.22 ($2,543.37 less $2,244.15 approved) for psychological services, proposed by Ideal Counselling and Psychotherapy Services in a plan submitted on September 4, 2022?
iii. Is the Applicant entitled to $5,286.59 for psychological services, proposed by Allmed Assessments Centre in a plan submitted on September 30, 2024?
iv. Is the Applicant entitled to $2,460.00 for the cost of a chronic pain assessment, proposed by Allmed Assessments Centre in a plan submitted on August 14, 2024?
v. Is the Respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the Applicant?
vi. Is the Applicant entitled to interest on any overdue payment of benefits?
RESULT
3I find that no plans are payable.
4As no plans are payable, no interest or award are owing.
PROCEDURAL ISSUES
5The Respondent requests an order dismissing the LAT Application.
6It submits that the issues in dispute involve improperly duplicated claims for medical and rehabilitation benefits or claims improperly made just prior to the expiry of the 5-year period, in non-compliance with s. 20 of the Schedule. It submits in further detail:
i. The treatment plans listed as issues 1-2 were partially approved, and the remaining amounts are duplicative and unreasonable;
ii. The treatment plan listed as issue 3 was submitted 4 days prior to the expiry of the 5-year mark and was denied pursuant to s. 20 of the Schedule;
iii. The treatment plan listed as issue 4, it is a duplicate of an OCF-18 from 2021 that was approved and paid in full; and
iv. The Applicant has clearly abandoned his claim for a s. 10 award, as no submissions on the subject have been made and no particulars have been produced, in breach of the Case Conference Report and Order.
7The Applicant did not provide reply submissions to address these claims from the Respondent.
8I find that the preliminary issue under s. 20 of the Schedule was not properly raised by the Respondent, either in the case conference, or by way of motion. Therefore, I will not consider these claims as preliminary issues.
9I will address the Respondent’s submissions in my analysis below, as required.
ANALYSIS
Is the Applicant entitled to $299.22 ($2,767.79 less $2,468.57 approved) for a psychological re-assessment and progress evaluation, proposed by Ideal Counselling and Psychotherapy Services in a plan submitted on May 15, 2022? &
Is the Applicant entitled to $299.22 ($2,543.37 less $2,244.15 approved) for psychological services, proposed by Ideal Counselling and Psychotherapy Services in a plan submitted on September 4, 2022?
10I find that the Applicant is not entitled to the balance of these plans.
11To 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.
12The Applicant submits that she is entitled to the medical benefits outlined in the LAT Application as they were, and this treatment continues to be reasonable and necessary as a direct result of her ongoing accident-related impairments.
13The Applicant does not point me to evidence which would establish the reasonableness and necessity of the balance of these specific plans in their written submissions. Nor did they provide reply submissions.
14The Applicant relies, generally, on Dr. Kaji’s psychological assessment reports from October 3, 2021, and May 7, 2022. The Applicant submits that she was diagnosed with:
i. Adjustment Disorder with Severe Depression and Anxiety
ii. Post-Traumatic Stress Disorder (PTSD);
iii. Severe Specific Phobia (Vehicular);
iv. Persistent Somatoform Pain Disorder; and
v. Nonorganic Disorder of the Sleep-Wake Schedule.
15The Respondent submits that “in both cases, the only line item remaining on the respective treatment plans was $299.22 for re-assessment and progress evaluation.”
16The Respondent further submits that the inclusion of both “re-assessment and progress evaluation” and “documentation review and progress report writing” as separate line items on the treatment plan is duplicative and unreasonable. Further, that no evidence or submissions have been provided as to why these duplicative line items are both reasonable and necessary in the circumstances.
17As it is the Applicant’s onus to demonstrate the reasonableness and necessity of the specific outstanding amounts of these plans. I find that they have not met their onus. The Applicant did not provide a breakdown of the balance of these plans, nor did they explain in their submissions why the remaining amounts are reasonable and necessary.
18Therefore, on a balance of probabilities, I find that the balance of these plans are not payable.
Is the Applicant entitled to $5,286.59 for psychological services, proposed by Allmed Assessments Centre in a plan submitted on September 30, 2024?
19I find that this plan is not payable.
20The Applicant does not point me to evidence to establish the reasonableness and necessity of this specific plan in their written submissions, nor did they provide reply submissions.
21The Respondent submits that this plan is not reasonable or necessary because the Applicant did not submit any plans to the insurer between September 2022 and September 2024. Therefore, it submits that no further treatment was required by the Applicant.
22I find that, as the Applicant did not make submissions specific to this plan, the Applicant has not met their onus to establish why this specific plan is reasonable and necessary.
23Therefore, on a balance of probabilities, I find that this plan is not payable.
Is the Applicant entitled to $2,460.00 for the cost of a chronic pain assessment, proposed by Allmed Assessments Centre in a plan submitted on August 14, 2024?
24I find that this plan is not payable.
25Again, the Applicant did not point me to evidence to establish the reasonableness and necessity of this plan in their written submissions, nor did they provide reply submissions.
26The Respondent submits that this issue is duplicative and reflects a treatment plan that was submitted on August 14, 2024, for a chronic pain assessment in the amount of $2,460.009, and it is identical to an OCF-18 submitted on August 29, 2021.
27I find the Applicant did not meet their onus to establish why this specific plan is reasonable or necessary because they did not provide submissions in support of this plan.
28Therefore, on a balance of probabilities, I find that this plan is not payable.
Interest
29As no plans are payable, no interest is owing.
Award
30The Applicant made no submissions regarding an award under s. 10 of Reg. 664.
31Therefore, they did not meet their onus to establish that the Respondent unreasonably withheld benefits.
32Therefore, no award is owing.
ORDER
33I find that no plans are payable.
34The Applicant is not entitled to interest or an award.
Released: April 9, 2026
Sarah Guergis
Adjudicator