OVERVIEW

1Jumana Azar, the applicant, was involved in an automobile accident on November 11, 2019, and sought benefits from Certas Home and Auto Insurance Company, (the respondent) pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 2010 (including amendments effective June 1, 2016) (the "Schedule").

2The applicant was denied benefits by the respondent, based predominantly on the results of various section 44 insurer's examinations ("IEs"). Other benefits were denied on the basis they were previously approved, or that 260 weeks had elapsed since the date of the accident pursuant to the Schedule. The applicant applied to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the "Tribunal") for resolution of the dispute.

Pre-hearing procedural issues

3A case conference was convened on September 26, 2025. The applicant attended self-represented, having lost her legal representative on August 22, 2025. She left the case conference early, and the case conference proceeded in her absence.

4The hearing commenced on February 23, 2026. The applicant advised that she had not received the respondent's document brief, which consisted of over 4,000 pages. The respondent re-served the applicant with its document brief, and the Tribunal granted the applicant the remainder of the day to review the material. The applicant indicated that she would seek the assistance of a support person to review the document brief and determine whether she wanted to file any additional documents that are not contained within the respondent's materials.

5The parties agreed to allow the respondent to present its witnesses first since it had arranged a pre-set schedule with its expert witnesses before commencement of the hearing.

The Videoconference Hearing

6At the commencement of the hearing, the applicant affirmed her intention to represent herself, and she wanted to move forward with her claim. The applicant did not request an adjournment and as such we proceeded with the hearing. We allowed for numerous breaks and assisted the applicant by giving her detailed instructions on how we would proceed through the hearing, which she was able to follow.

7The applicant did not file a document brief with the Tribunal and relied solely on her oral testimony, except for the late filed documents during closing submissions. The parties agreed to forego opening statements and proceed directly to witnesses' testimony and the evidence.

8This matter was scheduled for a five-day videoconference hearing, however on consent of the parties the hearing was completed in four days.

ISSUES IN DISPUTE

9Preliminary issue: The preliminary issue to be decided is:

1. Is the applicant barred from proceeding to a hearing for the following benefits: Issues 2-4 listed below, because the applicant failed to attend an IE under s. 44 of the Schedule?

10Substantive issues: The issues in dispute at the hearing are:

1. Has the applicant sustained a catastrophic impairment as defined by s. 3.1(1) 7 and 8 of the Schedule?
2. Is the applicant entitled to an income replacement benefit ("IRB") in the amount of $185.00 per week for the period from June 30, 2025 to date and ongoing?
3. Is the applicant entitled to attendant care benefits ("ACBs") in the amount of $12,275.41 per month for the period from November 8, 2023 to date and ongoing?
4. Is the applicant entitled to $7,781.00 for occupational therapy services, proposed by Innovative Occupational Therapy in a treatment plan/OCF-18 ("plan") dated October 17, 2023?
5. Is the applicant entitled to the plans for physiotherapy services, proposed by PhysioPlus Health Group, as follows: i. $998.00 in a plan dated December 17, 2024; and, ii. $831.76 for a plan dated December 17, 2024?
6. Is the applicant entitled to $4,288.85 for medical marijuana, proposed by Medical Marijuana Group Consulting Ltd. In a plan dated March 11, 2025?
7. Is the applicant entitled to $3,500.00 ($17,265.00 less $13,765.00 approved) for catastrophic ("CAT") assessments, proposed by Okell Rehabilitation Services Inc. in a plan dated November 22, 2023?
8. Is the applicant entitled to $2,000.00 for an occupational therapy ("OT") assessment, proposed by Innovative Occupational Therapy in a plan dated November 29, 2023?
9. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
10. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

11The panel finds:

1. The applicant is not statute-barred from proceeding with the issues of IRBs, ACBs, or the treatment plan for occupational therapy services.
2. The applicant did not sustain a catastrophic impairment pursuant to Criterion 7 or 8.
3. The applicant is not entitled to an IRB.
4. The applicant is not entitled to an ACB.
5. The applicant is not entitled to the treatment plans in dispute.
6. No interest or award is payable.

PROCEDURAL ISSUES

The late submission of the applicant's documents was allowed

12The respondent opposed the applicant's submission of supplementary documents which were served during the hearing. It submitted that it would be procedurally unfair to allow the applicant to rely on these records because some of the records were served on it for the first time. The applicant argues that the records are relevant to address the issues in dispute. In its written hearing submissions, the respondent requests that the CNRs of ProLife Wellness Centre dated November 14, 2024, not be considered as it was provided to the respondent after the final production deadline of February 16, 2025.

13The Case Conference Report and Order ("CCRO") dated November 21, 2024 ordered that, by no later than 90 calendar days after the case conference (i.e., February 16, 2025), the parties needed to disclose any additional items responsive to items that have already been produced which they intend to present as evidence at the hearing.

14The CNRs of ProLife Wellness Centre are dated November 14, 2024, and the respondent indicates the records were produced with the applicant's written submissions on June 25, 2025.

15In reply, the applicant submits that the CNRs of ProLife Wellness Centre were served by email to the respondent on November 14, 2024, and the respondent paid for the cost of the records. The applicant produced copies of the email correspondence dated November 14, 2024, and a copy of the receipt of payment dated November 19, 2024, from the respondent for the CNRs of ProLife Wellness Centre.

16We are allowing the document to be admitted because the applicant has produced evidence that the records were served on the respondent on November 14, 2024. Therefore, the respondent has not been prejudiced since it had ample opportunity to obtain further s. 44 assessments or addendum reports after receiving the records.

ANALYSIS

The applicant is not statute-barred from proceeding with her claim disputing her entitlement to post-104 IRBs

17We find that the applicant is not barred from disputing the above-noted benefits for failing to attend s. 44 IEs.

18The respondent submits the applicant has not attended the functional abilities evaluation ("FAE"), and that the IE was properly scheduled and compliant with the requirements of notice pursuant to section 44 of the Schedule. It submits that it would be unfair to proceed with these issues without affording it the opportunity to complete post-104 IRB assessments, including the FAE, despite having paid post-104 IRBs during the period from November 12, 2021 to June 29, 2025.

19The applicant submits that she made every effort to attend the IE. She also asked to attend the FAE virtually because she had a medical appointment with her doctor, but her requests were ignored by the respondent.

20Section 44(1) of the Schedule permits an insurer to examine an insured person by one or more regulated health professionals (or a vocational rehabilitation expert) to determine whether the insured person is, or continues to be, entitled to a benefit. Section 44 provides certain requirements for an insurer to comply with in order to invoke its rights to an IE. This section stipulates that this must not be done more often than is "reasonably necessary."

21Section 44(5) of the Schedule supports that if an insurer requires an examination under this section, they shall give the insured person a notice setting out a) the medical and any other reasons for the examination; b) whether the attendance of the insured person is required at the examination; c) the name of the person or persons who will conduct the examination along with their titles and specialization; and d) if the attendance of the insured person is required at the examination, the day, time and location of the examination and, if the examination will require more than one day, the same information for the subsequent days.

22Section 44(9)(2)(iii) of the Schedule requires an insured person to cooperate with the examination and to submit to all reasonable examinations requested by the examiner.

23Section 55(1)2 of the Schedule provides that an insured person shall not apply to the Tribunal if the insurer has provided the insured person with notice that it requires an examination under section 44, but the insured person has not complied.

24The respondent must prove that a notice of examination is compliant with section 44(5) of the Schedule in order to rely on it as a basis to seek a statutory bar under section 55. In seeking such a remedy, the respondent must ensure that it provides specific details of the applicant's conditions, the benefit being denied, and any section it relies upon. (See Hedley v. Aviva Insurance Company of Canada, 2019 ONSC 5318; B.H. v. Aviva Insurance Company, 2018 CanLII 84051 (ON LAT); and 16-003316/AABS v. Peel Mutual Insurance Company, 2018 CanLII 39373 (ON LAT)). The reasons must be clear enough so that an unsophisticated person can make a well-informed decision on whether to attend the examination.

The notices of examination did not comply with s. 44(5)

25We find that the notices did not comply with section 44(5) of the Schedule.

26The notice of examination ("NOE") dated May 9, 2025 does not indicate the type of examination, the medical and any other reasons for the examination, whether the examination is in person, the date or the time of the examination, or the name of the person conducting the examination. The NOE dated May 29, 2025 was for a re-scheduled IE, which indicates the IE is to determine the applicant's ongoing entitlement to income benefits. However, the NOE dated May 29, 2025 does not indicate the type of examination, whether the examination is in person, the date or the time of the examination, or the name of the person conducting the examination. Since the NOE dated May 29, 2025 in evidence is incomplete, and the above noted information is missing, we are unable to determine whether the NOE is compliant. Therefore, the notice is not in compliance with s. 44(5) of the Schedule.

27The respondent relies on an explanation of benefits ("EOB") dated June 24, 2025, which refers to a notice of examination ("NOE") dated May 29, 2025, for an FAE scheduled for June 24, 2025 which the applicant did not attend. The EOB dated June 24, 2025, indicates that the NOE dated May 29, 2025 included reasons for an IE to determine the applicant's entitlement to post-104 IRBs beyond June 29, 2025. The respondent submits that it paid an IRB for over 5 years and 7 months before it stopped the benefit due to non-compliance. The respondent makes no submissions nor does it point to any evidence to explain the reason it required an IE to determine the applicant's continued entitlement to an IRB.

28The respondent's subsequent notices dated June 27, 2025 and August 1, 2025 are also non-compliant for the same reasons because although the NOEs indicate the reason is the applicant's ongoing entitlement for income benefits, the type of examination, whether the examination is in person, the date or the time of the examination, or the name of the person conducting the examination is not in evidence. Therefore, it is not possible to determine whether this information was provided to the applicant. In subsequent EOBs dated July 25, 2025 and September 3, 2025, the respondent indicated that the applicant did not attend the re-scheduled FAEs on July 22, 2025, and September 2, 2025 with Dr. Paul Cha.

29However, even if the respondent's NOEs were complaint with s. 44(5) of the Schedule, we find that the applicant had a reasonable explanation for not attending the re-scheduled September 2, 2025 IE. It is the applicant's onus to prove that she had a reasonable explanation for not attending the s. 44 IEs.

30The interpretation of a "reasonable explanation" is guided by Horvath and Allstate Insurance Company of Canada, 2003 ONFSCDRS 92 and was more recently reiterated in K.H. v. Northbridge, 2019 CanLII 101613 (ON LAT). The guiding principles are summarized as follows:

a. An explanation must be determined to be credible or worthy of belief before its reasonableness can be assessed; b. The onus is on the insured person to establish a "reasonable explanation"; c. Ignorance of the law is not a "reasonable explanation"; d. The test for "reasonable explanation" is both a subjective and objective test that should take into account both personal characteristics and a "reasonable person" standard; e. The lack of prejudice to the insurer does not make an explanation automatically reasonable; and, f. An assessment of reasonable includes a balancing of prejudice to the insurer, hardship to the claimant and whether it is equitable to relieve against the consequences of the failure to comply with the time limit.

30The respondent agrees that it completed IE paper review reports by Dr. Eisen dated November 3, 2025, and by Dr. Moddel dated November 13, 2025, after the assessors completed their IE CAT assessments regarding the applicant's entitlement to post-104 IRBs. However, it submits that it required an in-person FAE regarding the applicant's eligibility for continued payment of post-104 IRBs.

31It is noted that the applicant also attended a transferable skills analysis/vocational assessment on August 5, 2025, and a labour market survey, completed by Denys Remedios, vocational assessor. However, she refused to participate in vocational testing or transferable skills analysis procedures, and she discontinued the interview portion of the assessment after one hour with complaints of severe physical and headache pain. The applicant provided reasons for her non-participation at the assessment, indicating she has already participated in multiple assessments.

32The applicant submits that she sent an email to the respondent's adjuster, Paul Gardner, on September 2, 2025, to advise that she is not feeling well and she is unable to go anywhere for the assessment, and she prefers they call her for the assessment, as she is going to her doctor. The applicant produced a copy of the email dated September 2, 2025, which was admitted as evidence at the hearing as late filed evidence. The applicant submits that she was willing to undergo a virtual assessment, as scheduled, and she did not request that the IE be re-scheduled.

33The respondent submits that an in-person FAE was required, but it made no submissions as to whether it responded to the applicant's email dated September 2, 2025 requesting that the FAE be changed to a virtual assessment.

34We find that the NOEs dated May 9, 2025, May 29, 2025, June 27, 20-25 and August 1, 2025 did not comply with section 44(5) of the Schedule. We further find that the applicant provided a reasonable explanation for not attending the re-scheduled FAE on September 2, 2025, but the respondent did not reply, or accommodate her request to reschedule the IE. As a result, we find that the applicant may proceed with her claim for post-104-week IRBs.

The applicant is not statute-barred from proceeding with her claim for ACBs or the OCF-18 for occupational therapy services dated October 17, 2023

34The respondent made no submissions nor did it direct the panel to evidence in support of the preliminary issue regarding whether the applicant may proceed with her claims for ACBs and the plan dated October 17, 2023 for occupational therapy services. It is noted that the applicant attended a s.44 IE OT assessment on September 19, 2024 with Kitty Shum, occupational therapist, to address her entitlement to an ACB and the plan dated October 17, 2023 for occupational therapy services.

35Given the lack of submissions and evidence on this point, we find that the applicant may proceed with her application to dispute entitlement to ACBs and the plan dated October 17, 2023 for occupational therapy services.

The applicant has not sustained a CAT impairment as defined by the Schedule

36We find that the applicant has not demonstrated on a balance of probabilities that she sustained a catastrophic impairment as a result of the accident.

37On June 14, 2024, the applicant applied for a catastrophic impairment determination under paragraphs 7 and 8 of s. 3.1(1) of the Schedule, referred to as Criterion 7 and 8, respectively.

38This matter is complicated by the fact that the applicant had a significant pre-accident medical history. She was involved in a prior accident in 2011 in another country in which she reported to treatment providers that she sustained a spinal fracture, and the medical records have not been produced to describe the extent of her injuries.

39There were also various pre- and post-accident events in the applicant's life that may have an impact on her pre- and post-accident physical and psychological condition. For example, she experienced trauma in Palestine with her family and as a refugee. She also experienced a subsequent incident involving a laceration of her finger, which lead to complications and several surgeries and permanent deformity of her finger.

The applicant is not CAT impaired under Criterion 7

40In order to qualify under Criterion 7, the applicant must prove that she has a combination of physical and psychological impairment ratings from medical professionals that meet the 55% WPI threshold. The psychological impairment rating is determined in accordance with the methodology set out in Chapter 14, Section 14.6 of the American Medical Association's Guides to the Evaluation of Permanent Impairment, 6th edition, 2008, and is combined with the physical WPI rating from the 4th edition of the Guides using the Combined Values Table.

41To obtain the WPI% rating under Chapter 14, three scales are administered by assessors to determine a person's score which include 1) the Brief Psychiatric Rating Scale ("PRS"), 2) the Global Assessment of Function ("GAF"), and 3) the Psychiatric Impairment Rating Scale ("PIRS"). The median score is then taken from the three scales and represents a person's total WPI% from a psychological perspective.

42The applicant did not rely on any CAT reports in support of her position. She relies on the CNRs of Dr. D'Souza and her doctors at Four Corners Medical Centre. The applicant testified that she developed neuropathy in her back and extremities after the accident, accompanied by shaking in her hands. The applicant testified that she has back pain radiating to her extremities, with shaking and numbness in her hands which caused her finger laceration incident, as a result of the accident.

43The applicant testified that she had a pre-existing condition of chronic pain from an earlier accident in 2011, but her condition had improved at the time of the subject accident. In addition, she testified that she has a pre-existing psychological condition of depression, which was exacerbated by the accident.

44The applicant's testimony contradicts her reports to her doctors regarding her medical history and her post-accident condition. The applicant testified that she disagrees that she had prior spinal surgeries, which contradicts her reports to Dr. Mariam Abdurrahman, psychiatrist, during a consultation at St. Joseph's Health Centre on April 28, 2018.

45The respondent relies on the CAT IE assessment reports dated January 31, 2025, by Dr. Zeeshan Waseem, physiatrist, and Dr. Garry Moddel, neurologist. Dr. Waseem determined that the applicant's WPI ratings for physical impairments are cervicothoracic spine 5%; thoracolumbar spine 5%; lumbosacral spine 5 %; right wrist 4%; headaches (greater occipital neuralgia) 5%; left hip trochanteric bursitis 3%; and possibly right digit deformity 1% (if determined to be accident-related). Dr. Moddel assigned a rating of 3% WPI regarding the applicant's headaches, which he attributes to overuse of medication.

46The respondent also relies on the assessment of Dr. Joel Eisen, psychiatrist. Dr. Eisen provided a rating of 15% WPI, based on a possible exacerbation of the applicant's pre-existing psychological impairments. However, he cautioned that the psychological test results are unreliable.

47We find that the reports in evidence by Dr. Waseem and Dr. Eisen do not support that the applicant satisfies the criteria of 55% or more WPI and therefore, she has not met her burden of establishing that she is catastrophically impaired under Criterion 7.

48We find the applicant's physical WPI% rating is 27%, (which includes a rating for headaches) and her psychological WPI% rating is 15%. As a result, she does not meet the CAT threshold under Criterion 7. We will now address Criterion 8.

The applicant did not sustain a CAT impairment under Criterion 8

49In order to meet the threshold for a catastrophic impairment under Criterion 8, the applicant must demonstrate that she sustained three marked (class 4) impairments out of the four spheres of functioning or one extreme (class 5) impairment as a result of the accident due to a mental and behavioural disorder. These impairments are assessed under Chapter 14 of the American Medical Association's Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, (the "Guides"). Mental and behavioural impairments are rated according to how seriously they affect a person's useful daily functioning. The Guides sets out the four spheres of functioning and the levels of impairment including activities of daily living; social functioning; concentration, persistence and pace; and adaptation (deterioration in a work-like setting).

50The applicant testified that her mental health condition deteriorated after the accident. She testified that the deterioration in her mental health has caused disagreements with everyone, including health care providers, friends and family. The applicant testified that she is isolated and alone, however, she does have two to three friends that will assist her in emergencies, and other tasks. The applicant testified that she has completed anger management programs on November 1, 2023 and May 10, 2024. The applicant agrees that she did have pre-existing depression, however, she was able to work, maintain a relationship, and participate in other activities including volleyball and soccer.

51The respondent relies on the IE CAT report dated January 31, 2025, by Dr. Joel Eisen, psychiatrist. During the assessment with Dr. Eisen on January 9, 2025, the applicant attributed her anger issues, depression and crying episodes to the accident, and she denied any pre-existing emotional problems. Dr. Eisen comments that the applicant reports that her difficulties with anger, memory and concentration, weight loss, poor sleep, depression and suicide attempts only occurred after the accident, which contradicts the medical evidence. Dr. Eisen opines that these inconsistencies raise concerns about causation and apportionment in his evaluation of her impairments that are related to the accident.

52Dr. Eisen concluded that it was unclear if the applicant sustained any mental health impairment directly related to the subject accident. He explained that the applicant has pre-existing posttraumatic stress disorder, adjustment disorder, depression, anxiety, somatic symptom disorder, and borderline personality disorder. Given the applicant's unreliable reporting of her medical history, Dr. Eisen found that the applicant may have sustained a class 2 impairment in the 4 spheres of functioning under Criterion 8 as a result of the accident because there were discrepancies between the medical evidence and the applicant's reported level of functioning before the accident. Thus, the applicant cannot meet her onus to establish three marked impairments out of the four spheres of functioning, if the panel finds that she sustained less than a marked impairment in less than three spheres of activities of daily living; social functioning; concentration, persistence and pace; and adaptation.

53The panel finds that the applicant has not demonstrated that she meets the catastrophic impairment threshold under Criterion 8 as we find she has not sustained a marked impairment in three of the four spheres of functioning. Since we have found that the applicant does not have a class 4 impairment in the domains of activities of daily living, and social functioning, and the CAT IE assessors have found she does not have a class 4 impairment in any spheres of functioning as a result of the accident, it is not necessary to determine whether she has a class 4 impairment in the spheres of concentration, persistence and pace, or adaptation.

54We find that the applicant has failed to meet her burden with regard to causation. In Sabadash v. State Farm et al., 2019 ONSC 1121, the Divisional Court clarified the "but for" test is the appropriate causation test to be used in accident benefits matters. We are unpersuaded by the applicant's submissions regarding her post-accident psychological impairments and chronic pain/headaches. She has failed to demonstrate that these impairments or their exacerbation would not have occurred but for the accident.

Activities of daily living ("ADL")

55We find the applicant has not sustained a marked impairment in her ADLs that is owing to a mental or behavioural disorder as a result of the accident.

56The Guides describe ADL as self-care, personal hygiene, communication, ambulation, travel, sexual function, sleep, and social and recreational activities. Any limitations in these activities should be related to the mental disorder rather than to such factors as lack of money or lack of transportation. In the context of the individual's overall situation, the quality of these activities is judged by their independence, appropriateness, effectiveness, and sustainability. It is necessary to assess the overall degree of restriction or combination of restrictions, not just the number of restricted activities.

57While we agree the applicant's ADL are impaired to some degree overall, we are not convinced this is owing to a mental or behavioural disorder as required by the Guides.

58We find the applicant's testimony largely credited her impairments in this area of functioning to physical pain and not psychological symptoms. She testified that after the accident, the shaking in her hands prevented her from returning to driving long distances, handling dishes and electronic devices, food preparation, laundry, and organizing. She also mentioned that she has not returned to recreational activities such as volleyball and soccer.

59The applicant further testified that she relies on pain medication and CPD oil every day to reduce her symptoms of chronic pain, shaking, and cold intolerance, and her physical pain symptoms have increased without physical therapy, massage therapy, and acupuncture. We find this evidence further underscores physical pain as the primary contributor to the applicant's ADL impairments.

60Dr. Eisen's testimony and his report attributes the applicant's impairments in ADLs of self-care, personal hygiene, communication, ambulation, travel, sexual function, sleep and social and recreational activities to a pre-accident condition rather than the subject accident. Dr. Eisen's opinion is supported by psychiatrist Dr. Michael Tseng, and his assessment of the applicant on November 8, 2019, just three days before the accident, in which the applicant reported the same physical symptoms of chronic pain, tremors and cold intolerance. The applicant reported to Dr. Tseng that she used cannabis every day to control her pain, anxiety, mood and sleep.

61We find that, on a balance of probabilities, the applicant has not established that her ADL are markedly impaired because of a mental or behavioural disorder. Rather, we find this evidence is more consistent with Dr. Eisen's rating of a mild impairment owing to a mental and behavioural disorder, with pain and a pre-accident condition being a contributor to overall impairment.

Social Functioning

62According to the Guides, this area of functioning refers to an individual's capacity to interact appropriately and communicate effectively with other individuals. Social functioning includes the ability to get along with others, such as family members, friends, neighbours, grocery clerks, landlords or bus drivers. Impaired social functioning may be demonstrated by a history of altercations, evictions, fear of strangers, avoidance of interpersonal relationships, social isolation, or similar events or characteristics. It is not only the number of aspects in which social functioning is impaired that is significant, but also the overall degree of interference with a particular aspect or combination of aspects.

63The applicant's testimony regarding her level of function in her relationships with family and friends does not support that her mental impairments significantly impede useful function. The applicant testified that she is alone, and nobody talks to her and her family has blocked her calls. The applicant testified that she had a romantic relationship after the accident which lasted for over three years and ended because of sexual issues. She continues to depend on her friends to do her nails and eyebrows, and she can count on them in an emergency. She further testified that she relies on others to walk her dog.

64The applicant demonstrates a level of function in the community that does not significantly impede useful function. The applicant testified that she does light shopping alone, and she can ride her motorcycle and drive a car independently.

65The panel finds that the applicant attributes all of her mental and behavioural impairments to the accident, despite other evidence of pre-existing mental health problems. The applicant has reported to several assessors that she fled Palestine because of traumatic events such as an assault in jail, and her family threatening her life at gunpoint. In a consultation report dated April 28, 2018, Dr. Mariam Abdurrahman, psychiatrist, describes a triggering event between the applicant and her sister, which exacerbated the applicant's symptoms of posttraumatic stress disorder. Dr. Abdurrahman mentions the applicant's daily use of cannabis to calm her down and reduce her traumatic nightmares. In his report dated November 11, 2019, Dr. Tseng mentions the applicant's daily nightmares, and traumatic events in Palestine including an abusive marriage, death threat from her brother, and involvement with police. Dr. Tseng further describes the applicant's difficulties in Canada including poverty, unemployment, lack of social and family contact, including the previous altercation with her sister in the spring of 2018.

66Dr. Eisen concluded that the applicant has a mild impairment in social functioning as a result of the accident. In his testimony and his report, Dr. Eisen refers to the applicant's ability to maintain relationships with a boyfriend and other friends since the accident. He notes in his report that she maintains a close relationship with her mother. The applicant testified that she goes out to get groceries or other items. The applicant recently moved to another apartment following her breakup with her boyfriend, and she has friends she can rely on in an emergency, and for helping her with her personal grooming and cleaning.

67We find the applicant has at most, a mild impairment in social functioning because her impairment levels are compatible with some, but not all useful functioning. The surveillance evidence is consistent with the applicant's testimony that she continues to be active in the community by going shopping and maintaining her motorcycle. Although, the applicant testified that she is easily agitated at times, there is no evidence that she is confined to her home or that she has had any altercations with any members of the public. None of the assessors had any issues with the applicant's ability to communicate effectively. The panel finds this to be consistent with her presentation during her testimony.

68For the above-noted reasons, we find that the applicant has not met her onus to demonstrate on a balance of probabilities that she sustained a marked impairment in social functioning as a result of the accident.

69Having found that the applicant did not sustain a marked impairment in the spheres of ADL or social functioning, it follows that the applicant has not demonstrated that she suffers from a marked impairment in three of the four spheres of functioning. Accordingly, we find that the applicant has not sustained a catastrophic impairment under Criterion 8, as a result of the accident.

Issue ii: The applicant is not entitled to an IRB

70The panel finds that the applicant has not demonstrated entitlement to an IRB under s. 6 of the Schedule for the reasons set out below.

71To receive payment for a post-104-week IRB under s. 6(2) of the Schedule, the applicant must demonstrate on a balance of probabilities that she suffers from a complete inability to engage in any employment or self-employment for which she is reasonably suited by education, training or experience.

72The applicant testified that her functional abilities are adversely affected by a brain injury, chronic back pain, neuropathy, nerve damage and shaking in her hands, which interferes with her ability to engage in any occupation. She further testified that she is unable to work as a dental hygienist because she injured her hand, and she is unable to hold a dental instrument properly due to her small right finger deformity. The applicant testified that she cries all day because she is alone.

73The applicant has provided conflicting information in her testimony and to assessors regarding her ability to work before the accident. The applicant testified that she worked at Jack Astors before the accident and she attempted to return to work as an Uber driver for approximately two weeks after the accident. However, the applicant admitted on cross-examination that she was working at 4 am on January 11, 2021, as an Uber driver, which was over a year after the accident. The T4 slips and paystubs for Jack Astors are found in the respondent's document brief and indicate the applicant worked at Jack Astors for approximately one month from mid-August to September 27, 2019. Yet, three days before the accident, the applicant reported to Dr. Tseng that she has no motivation to work, and she cries continuously at home. The applicant's testimony regarding her pre-accident ability to work conflicts with her reports to various assessors that she was working on a full-time basis before the accident which is contrary to her reports to Dr. Tseng. In addition, on November 26, 2019, the applicant reported to Dr. Harpreet Thind, family physician, that her work permit was not approved, which increased her stress and anxiety levels.

74The respondent submits that the applicant has not produced any evidence in support of her entitlement to a post-104 IRB. The respondent relies on the IE paper review report dated November 3, 2025, by Dr. Garry Moddel, neurologist. Dr. Moddel testified that the applicant has mild degenerative changes in her spine but there is no nerve damage. At the hearing, Dr. Moddel reviewed the MRI of the cervical spine report dated October 9, 2023, which depicts impingement on the left C6 nerve root, however, he testified that the applicant's clinical presentation does not corroborate the presence of nerve damage. Dr. Moddel does not provide evidence either in his report or his testimony whether the applicant has a complete inability to engage in any employment or self-employment for which she is suited by education, training or experience.

75The respondent also relies on the IE paper review report dated November 3, 2025, by Dr. Eisen. During the original assessment on January 9, 2025, the applicant reported to Dr. Eisen that she was working 40-60 hours per week at the time of the accident as a bartender in a wedding hall, in addition to two other jobs, and her pain from a previous accident had resolved. Dr. Eisen concluded in his report dated November 3, 2025 that the applicant does not suffer from a complete inability to work in any occupation due to a psychiatric impairment as a result of the accident.

76We give less weight to the testimony of Dr. Moddel because he bases his opinion on the reports of Dr. Zabieliauskas and Dr. Kassardjian, which are not in evidence. Dr. Moddel testified that Dr. Kassardjian bases his opinion on the premise that the applicant has a possible traumatic brain injury with post traumatic migraine type headaches, and he disagrees. Dr. Moddel attributes the applicant's headaches to overuse of medication.

77The panel finds that the applicant has not met her burden of proving on a balance of probabilities that as a result of the accident, she suffers a complete inability to engage in any employment for which she is suited by reason of education, training or experience. The applicant did not direct us to any evidence in support of the complete inability test under s. 6 of the Schedule. As a result, the applicant has not established on a balance of probabilities that she is entitled to an IRB under the post-104-week test from June 30, 2025 to date and ongoing. We find that since the applicant has not met her burden to establish entitlement to a post-104-week IRB, it is not necessary to determine the quantum of IRB payable.

Issue iii: The applicant is not entitled to an attendant care benefit

78The panel finds that the applicant is not entitled to an attendant care benefit in the amount of $12,275.41 per month for any period claimed.

79Section 19 of the Schedule states that an insurer shall pay for all reasonable and necessary expenses incurred by or on behalf of an insured person as a result of an accident for attendant care services ("ACBs") provided by an aide or attendant. Section 42(1) of the Schedule provides that an application for ACBs must be in the form of, and contain the information required to be provided in, the version of the document entitled Assessment of Attendant Care Needs ("Form 1"). The maximum payable under the Schedule is $3,000.00 per month for non-CAT insureds.

80To establish entitlement to an ACB, the applicant bears the burden to prove that the ACB expenses are reasonable and necessary and are incurred pursuant to section 19(1) of the Schedule. Under section 3(7)(e)(iii), an expense is not considered incurred unless the person who provides a service did so in the course of his or her employment, occupation or employment in which he or she would ordinarily have been engaged but for the accident or sustained an economic loss as a result of providing the goods or services to the insured person.

ACB in the amount of $12,275.41 per month from November 8, 2023 to November 11, 2024

81Neither party spent any time addressing the amount of attendant care the applicant is claiming of $12,275.41 per month. The parties did not make submissions or direct the panel to a Form 1, which is required under s.19 of the Schedule for making a claim for ACBs. In addition, since the applicant has not demonstrated that she sustained a catastrophic impairment as a result of the accident, her claim for an ACB would be limited to $3,000.00 per month.

82The applicant testified that she does not brush her teeth as frequently as she did before the accident, and she relied on her boyfriend to complete housekeeping tasks after the accident until their relationship ended in 2025. The applicant testified that she fractured three fingers on her left hand and lacerated her small finger on her right hand after the accident, leading to several surgeries and a permanent deformity of the small finger. However, the applicant has not established that the injuries to her fingers are causally connected to the accident.

83The respondent submits that the applicant has not provided any evidence that the ACB amounts have been incurred, and she is not entitled to an ACB beyond 260 weeks after the accident pursuant to section 20.

84Since no Form 1s were made exhibits during the hearing, we do not have specific details about the applicant's claims for each level of attendant care, and we are unable to determine whether her claim for attendant care is reasonable and necessary. Although we find that the evidence supports that the applicant has some functional limitations, we are not persuaded that her limitations are related to the accident.

85We find that the applicant has not established on a balance of probabilities that she is entitled to an ACB for the period from November 8, 2023 to November 11, 2024. Therefore, it is not necessary to determine whether an ACB was incurred.

ACB at a rate of $12,275.41 per month from November 12, 2024 to date and ongoing

86Section 20 of the Schedule provides that no medical, rehabilitation and attendant care benefit is payable for expenses incurred more that 260 weeks (5 years) after the accident, for insured persons who were at least 18 years of age at the time of the accident, except if the insured person sustains a catastrophic impairment as a result of the accident.

87Since we have found that the applicant has not demonstrated that she sustained a catastrophic impairment as a result of the accident, we find that she would not be entitled to an ACB beyond 260 weeks after the accident pursuant to section 20.

88To receive payment for a treatment plan (OCF-18) 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. The applicant bears the onus of proving on a balance of probabilities that each item in an OCF-18 is reasonable and necessary.

89There are six treatment plans in dispute: a fully denied plan for occupational therapy in the amount of $7,781.00; two fully denied plans for physiotherapy services in the amount for $998.00 and $831.76; a fully denied plan for medical marijuana in the amount of $4,288.85; a partially approved plan for catastrophic assessments in the amount of $3,500.00 ($17,265.00 less $13,765.00 approved); and a plan for an occupational therapy assessment in the amount of $2,000.00.

90The applicant submits that she needs continued treatment, however, she does not direct us to any evidence in support of the disputed treatment plans. Without this information, we cannot perform the analysis needed to determine whether the applicant has established her onus under ss. 15 and 16.

91However, even if we base our analysis on the descriptions provided at the case conference, we find the applicant has not met her onus to demonstrate the reasonable and necessary nature of these benefits.

92The respondent submits that the applicant is not entitled to medical benefits beyond 260 weeks after the accident unless she has demonstrated that she has sustained a catastrophic impairment pursuant to section 20 of the Schedule.

93We conclude that considering the applicant has not established that she has sustained a catastrophic impairment as a result of the accident, she is not entitled to medical benefits beyond 260 weeks after the accident. As a result, the treatment plans for physiotherapy services dated December 17, 2024, and the plan dated March 11, 2025 for medical marijuana exceed the 260 week maximum under section 20, and the applicant is not eligible for these benefits.

94We find that the applicant has not met her onus to establish whether the plans for an occupational therapy assessment, occupational therapy services, and the unapproved amount for the catastrophic assessments are reasonable and necessary as a result of the accident. The applicant did not identify the OCF-18s, provide submissions on them, or direct us to copies of the OCF-18s. She did not address the stated goals of the plans or address why they were reasonable and necessary. Nor did she direct us to specific medical evidence in support of their reasonableness and necessity. Therefore, she is not entitled to these benefits.

The applicant is not entitled to interest or an award

95Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since no benefits are overdue, there is no interest payable.

96Under s.10 of Reg.664, 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.

97Since the respondent did not unreasonably withhold or deny benefits, there is no basis for an award.

ORDER

98For the reasons set out above, we find that:

i. The applicant is not statute-barred from proceeding with the issues of IRBs, ACBs, or the treatment plan for occupational therapy services. ii. The applicant has not demonstrated that she has sustained a catastrophic injury pursuant to Criterion 7 or 8. iii. The applicant is not entitled to an IRB. iv. The applicant is not entitled to an ACB. v. The applicant is not entitled to the treatment plans in dispute. vi. The applicant is not entitled to interest, or an award. vii. The application is dismissed.