Licence Appeal Tribunal File Number: 24-008248/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:
Ryan J. Major
Applicant
And
Nordic Insurance Company of Canada
Respondent
DECISION
ADJUDICATOR:
Rebecca Hines
APPEARANCES:
For the Applicant:
Ryan Major, Applicant
For the Respondent:
Jonathan B. White, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Ryan J. Major, the applicant, was involved in an automobile accident on March 13, 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, Nordic Insurance Company of Canada, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issue in dispute is:
- Is the applicant entitled to $1,402.23 for chiropractic services, proposed by CBI Health in a treatment plan (“OCF-18”) dated February 1, 2024?
RESULT
3The applicant is not entitled to the OCF-18 dated February 1, 2024, for chiropractic treatment in the amount $1,402.23 proposed by CBI Health.
ANALYSIS
The applicant is not entitled to the OCF-18 for chiropractic treatment in the amount of $1,402.23 proposed by CBI Health
4To receive payment for a medical benefit 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. 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 same are reasonable.
5The OCF-18 dated February 1, 2024, was authored by Dr. Sood, chiropractor and recommended 10 sessions of chiropractic treatment along with fees for planning, documentation and form completion for a total cost of $1,422.31. The goal of the OCF-18 was to reduce pain and increase strength and range of motion.
6On May 3, 2024, the respondent sent the applicant an Explanation of Benefits (“EOB”) denying the OCF-18. It relied on the insurer examination (“IE”) report of Dr. Bansal who determined that the applicant sustained soft tissue injuries of the neck and right shoulder as a result of the accident. The doctor also opined that the applicant’s diagnosis of right shoulder instability which required surgery on January 10, 2023, was not accident related. The doctor concluded that the OCF-18 was not reasonable and necessary in relation to the accident.
7The applicant submits that he sustained a significant injury to his right shoulder as a result of the accident which resulted in debilitating pain and various functional limitations. His submissions referred to the clinical notes and records (“CNRs”) of Dr. Matthew, orthopaedic surgeon who performed surgery in January 2023 and nerve tests of a pain clinic. However, he did not file this evidence with the Tribunal in support of this written hearing. He also makes various allegations that the respondent unreasonably withheld benefits which has resulted in his condition worsening and his development of a psychological impairment. The applicant’s submissions did not address why the OCF-18 for chiropractic treatment in dispute is reasonable and necessary. Instead, he argues that he is entitled to a lump sum payout of $20,000 for future medical treatment.
8The respondent submits that the applicant has not met his onus in proving entitlement to the OCF-18 in dispute because his submissions did not make any arguments to support that it is reasonable and necessary. Further, he did not submit any medical evidence in support of his position for this written hearing, including the OCF-18 in dispute. The respondent relies on the IE report of Dr. Bansal dated April 23, 2024, who determined that the OCF-18 is not reasonable and necessary as a result of the accident. It also relies on the CNRs of the applicant’s treating practitioners: Dr. Smith and Dr. Matthew which support that the applicant’s right shoulder instability and need for surgery is unrelated to the accident. Finally, the respondent argues that the Tribunal does not have jurisdiction to grant the applicant a $20,000 lump sum payout for future medical treatment.
9I find that the applicant has not met his onus in proving that the OCF-18 for chiropractic treatment is reasonable and necessary for the following reasons.
10First, I find the Tribunal does not have jurisdiction to order the respondent to pay a lump sum of $20,000 for future medical benefits on his claim. The applicant has cited no authority or jurisprudence in support of the relief sought. I find that s. 280 of the Insurance Act, R.S.O. 1990, c. I.8 provides this Tribunal with jurisdiction to resolve disputes involving an insured person’s entitlement to statutory accident benefits. The Tribunal’s jurisdiction to decide a dispute flows from an insurer’s denial of a benefit, which in this case is the OCF-18 in dispute. I conclude that there is nothing in the Schedule that provides me with the authority to order the respondent to pay for medical benefits which have never been applied for or denied.
11Second, I find that the applicant did not provide any arguments or submit any evidence which establishes that the OCF-18 for chiropractic treatment is reasonable and necessary. For example, he did not identify the goals of treatment, how the goals would be met to a reasonable degree or make submissions that the overall costs of achieving same are reasonable. In addition, it is well established law that submissions are not evidence, and in this case the applicant did not submit any evidence to support that the OCF-18 is reasonable and necessary.
12Third, the applicant filed improper reply submissions where he submitted a report of Dr. Van Ameringen, his treating psychiatrist dated July 17, 2025. The report notes that following the accident the applicant has been suffering from ongoing chronic pain and functional limitations which has led to a deterioration of his mental health. Of significance, the date of this report pre-dates the deadline of the applicant’s reply submissions by one-day. I note that the respondent was not properly served with this evidence as per the deadline in the Tribunal’s case conference report and order. However, I find it unnecessary to exclude this evidence because it had no bearing on the ultimate result of this decision because the doctor does not discuss the applicant’s need for chiropractic treatment. For these reasons, I give this report no weight.
13Finally, in contrast the respondent relies on the various CNRs of the applicant’s treating practitioners which support that the dislocation of the applicant’s right shoulder is not accident related. I find the CNRs of Dr. Smith demonstrate that the applicant attended his family doctor regularly and he does not report any accident-related complaints. Moreover, he does not report any issues with his right shoulder until December 2020 which is nine months post-accident. I find the applicant has not linked the right shoulder instability to the accident. Finally, it relies on the IE report of Dr. Bansal who determined that the disputed OCF-18 for chiropractic treatment is not reasonable and necessary and that the right shoulder instability is not accident related. Based on the evidence before me I accept Dr. Bansal’s opinion.
14For the above-noted reasons, the applicant has not met his onus in proving on a balance of probabilities that the OCF-18 for chiropractic treatment is reasonable and necessary.
ORDER
15For the reasons noted above, I make the following order:
The applicant is not entitled to the OCF-18 dated February 1, 2024, for chiropractic treatment in the amount $1,402.23 proposed by CBI Health.
The application is dismissed.
Released: January 8, 2026
__________________________
Rebecca Hines
Adjudicator