Citation: Missra v. TD General Insurance Company, 2026 ONLAT 24-014165/AABS

Licence Appeal Tribunal File Number: 24-014165/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:

Amit Missra

Applicant

and

TD General Insurance Company

Respondent

DECISION

ADJUDICATOR: Jeff Chatterton

APPEARANCES:

For the Applicant: Ian Drong, Counsel

For the Respondent: Priyanka Monpara, Counsel

HEARD: In Writing

OVERVIEW

1Amit Missra, the applicant, was involved in an automobile accident on February 3, 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, TD General 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:

1. Is the applicant entitled to $5,814.98 for medical cannabis, proposed by Dr. Bhatti in a treatment plan/OCF-18 ("treatment plan") submitted October 31, 2022?
2. Is the applicant entitled to $462.64 for medical cannabis, submitted on a claim form (OCF-6) dated November 17, 2022?
3. Is the applicant entitled to $2,200.00 for a social work assessment, proposed by Helen Leimonis in a treatment plan submitted November 17, 2022?
4. Is the applicant entitled to $5,001.38 for medical cannabis, proposed by Eric Grief in a treatment plan submitted dated November 4, 2024?
5. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
6. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

3The applicant is not entitled to medical cannabis, in the treatment plan in issue 1, the claim form in issue 2 and treatment plan in issue 4.

4The social work assessment, identified in issue number 3, is payable pursuant to s. 38 of the Schedule.

5Interest is payable as per the Schedule for the treatment plan in issue number 3.

6An award is not payable.

ANALYSIS

Is the applicant entitled to medical cannabis

7The applicant is not entitled to treatment plans/claim form in issue numbers 1, 2 and 4.

8To 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.

9In dispute are two treatment plans and an OCF-6. The treatment plans call for medical cannabis pharmaceuticals, prescribed by pain specialist Dr. Mansimram Bhatti and Dr. Eric Grief in order to reduce pain and assist with depression in order to return to the activities of normal living.

10The applicant argues the cannabis is reasonable and necessary, and that Dr. Bhatti has made clear that cannabis is an important factor in not only treating the applicant's chronic pain, but also assists him with depression and a sleep disorder. The applicant further argues that the insurer's expert, Dr. Chris Aldridge, is a general practitioner and not an expert in chronic pain or psychological issues, and therefore the respondent's evidence should be given less weight.

11The respondent argues that medical cannabis is not reasonable or necessary, and relies on a s. 44 Insurer's Examination (IE) report conducted by Dr. Aldridge, dated December 8 2022, with a follow up report dated January 7, 2025.

12While I am alive to the argument that Dr. Aldridge is not an expert in chronic pain or psychological issues, I find his report to be of significance in relation to the applicant's reporting about his experience of medical cannabis. During the IE, on November 25, 2022, the applicant reported having used cannabis for four weeks, but was unable to describe any clear benefit. Conversely, the applicant reported that Cymbalta or Wellbutrin provided some benefit to his mood.

13The applicant was re-assessed four years post-accident, on December 19, 2024, by Dr. Aldridge. In this session, the applicant reported that cannabis produced only mild benefits (approximately 10%) versus Tylenol, which created 20 to 30% reduction in symptoms.

14The respondent cites a Tribunal case law, referring to Capone v. Wawanesa Mutual Insurance Company, 2024 CanLII 94143 (ON LAT), where the Tribunal determined:

i. The applicant reports minimal improvement with medical cannabis and she advised Dr. Singh she is not satisfied with the treatment that was approved. Since the applicant admits she derives no benefit from medical cannabis, she has not met her burden of proof that the plan for medical cannabis is reasonable and necessary as result of the accident because the treatment has not been beneficial.

15Although not binding on me, I find Capone is relevant to the case at hand and agree with the reasoning. Here the applicant has reported he is receiving little benefit from the use of medical cannabis, and that other pharmaceuticals are delivering greater benefit.

16As the applicant has reported he is receiving little net benefit from the use of medical cannabis, I find the applicant has not, on the balance of probabilities, met his onus to establish that the treatment plans or OCF-6 for medical cannabis are reasonable and necessary.

Is the Social Work Assessment payable due to a violation of s.38(8) of the Schedule?

17The Social Work Assessment is payable pursuant to section 38 of the Schedule.

18Section 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 its obligations under section 38(8), 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) and it is prohibited from taking the position that the insured person has a impairment to which the MIG applies.

19The applicant argues that the denial letter, dated November 9, 2022, is difficult to understand, since the respondent has failed to provide sufficient reasoning for the denial. He argues the respondent has provided only a 'boilerplate' reasoning for denying the benefit, when it wrote in the denial letter that: "[b]ased on all of the medical documentation we have on file, it does not support the requested treatment plan."

20In its submissions, the respondent focused on listing the reasons why the assessment was not reasonable or necessary, arguing that it was a duplication of previously approved services. The respondent did not provide a response regarding the Explanation of Benefits letter, or the suggestion that it violated s. 38(8).

21I agree with the applicant that the November 9, 2022 letter is not compliant with s. 38 as the respondent has not provided a sufficient medical reason for the denial. The phrase "[b]ased on the medical documentation we have on file, it does not support the requested treatment plan" is boilerplate language which does not speak to the respondent's rationale for denying the specific treatment plan in dispute or the applicant's specific condition. While I am alive to the arguments put forward by the respondent in its written submissions, the fact remains there was no reference to these reasons, such as a duplication of services, in the November 2022 Explanation of Benefits such that the requirements of s. 38(8) would be met.

22For this reason, I agree that the respondent's November 9, 2022 denial of the treatment plan for a Social Work Assesmsent does not comply with s.38(8) of the Schedule. It is therefore payable pursuant to s. 38(11).

23The treatment plan in dispute is payable pursuant to section 38(11) of the Schedule.

Interest

24Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Interest applies on the Social Work Assessment treatment plan identified as issue number 3, as per the Schedule.

Award

25The applicant sought an award under s. 10 of Reg. 664. Under s. 10, the Tribunal may grant an award of up to 50 per cent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits.

26The applicant has not provided any submissions on an award.

27While I agree that the respondent has erred in the way it issued the Explanation of Benefits letter, I do not find that such conduct rises to the level of an award. As such, and because the applicant has not provided me with submissions, I do not find an award to be payable.

ORDER

28The application is granted in part.

i. The applicant is not entitled to medical cannabis, identified in issues 1, 2 and 4.

ii. The treatment plan for a Social Work Assessment, identified as issue 3, is payable under s. 38 of the Schedule.

iii. Interest is payable as per s. 51 of the Schedule.

iv. An award is not payable.