Licence Appeal Tribunal File Number: 24-013475/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:
Yvita Baldoz
Applicant
and
Aviva General Insurance Company
Respondent
DECISION
VICE-CHAIR: Henry Harris
APPEARANCES:
For the Applicant: Mobina Khan, Counsel
For the Respondent: Mark Vella, Counsel
HEARD: By way of written submissions
OVERVIEW
1Yvita Baldoz (the “applicant”) was involved in an automobile accident on November 28, 2021, 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 Aviva General Insurance Company (the “respondent”) 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 $7,738.72 for a chiropractic services, proposed by Aqua Wellness Centre Ltd. in a treatment plan/OCF-18 (“plan”) dated January 10, 2025?
ii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
iii. Is the applicant entitled to interest on any overdue payment of benefits?
3For issue (i) above, the case conference report and order dated February 20, 2025 (the “CCRO”) refers to the plan as dated January 22, 2025 for a chiropractic assessment. However, based on my review of the plan, I have updated the issue to include the correct date of the plan as set out above, as well as to indicate that the plan is for chiropractic services rather than an assessment.
4The respondent submits that issues 1, 2, 3 and 4 as listed in the CCRO are no longer in dispute, as each of those plans listed as being at issue have been approved by letter from the respondent to the applicant dated July 21, 2025. The letter indicates that the respondent is prepared to approve the four plans, and will provide payment upon receipt of invoices from the treatment provider and evidence of what has been submitted and paid by Manulife, the applicant’s extended health coverage provider.
5I find that the respondent has provided evidence of its approval of the four plans, by way of a copy of its letter dated July 21, 2025. The applicant did not file reply submissions. As such, I find that these issues have been resolved and are no longer in dispute.
RESULT
6The applicant is not entitled to the plan for chiropractic services, interest or an award.
7The plan is not payable pursuant to s. 38(11) of the Schedule.
8The application is dismissed.
ANALYSIS
The applicant is not entitled to the plan for chiropractic services
9I find that the applicant has not proven on a balance of probabilities that the plan for chiropractic services is reasonable and necessary.
10To receive payment for a 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.
11The plan dated January 10, 2025 prepared by Dr. Roy Priesnitz, chiropractor, sought funding of $7,738.72 for sessions of massage therapy (24), acupuncture (24), physiotherapy (12) and chiropractic treatment (12).
12The applicant submits that the recommended treatment is reasonable and necessary. The applicant argues that her ongoing pain and functional limitations justify the continued need for care. The applicant further submits that the respondent’s denial of the plan on January 24, 2025, relies on semantics, outdated assessment and procedural complaints, rather than substantive medical evidence.
13The respondent counters that the applicant has not discharged her onus to prove that the plan is reasonable and necessary. It submits that the applicant has not provided any evidence as to the goals of the proposed treatment, how the plan will achieve those goals and how the cost is reasonable.
14The respondent further submits that the plan in dispute was denied on January 24, 2025, because there was no objective medical evidence received to support the treatment being sought. While the denial refers to the insurer’s examination (“IE”) report of Dr. Michael Hanna, general practitioner, dated July 5, 2022, the respondent also arranged and relied upon the March 18, 2025 IE report of Dr. Shafik Dharamshi, general practitioner, in denying the plan.
15I find that the applicant has not proven on a balance of probabilities that the plan in dispute is reasonable and necessary for the following reasons.
16Firstly, although the applicant submits that the plan is reasonable and necessary, she has not directed the Tribunal to any specific medical evidence in support of her submission. At the end of her submissions, the applicant referred to two clinical notes and records (“CNRs”), one dated July 12, 2022 from Dox Medical and the other dated April 14, 2023 from Aqua Wellness, the treating clinic that prepared the plan in dispute. I do not find these specific CNRs to be contemporaneous medical evidence which supports the plan in dispute. The Dox Medical entry was nearly 2 1/2 years prior to the plan, and recommended a 4-8 week trial of physiotherapy and massage therapy. Further, it noted no functional deficits and normal range of motion. Similarly, I do not find the treatment record entry identified by the applicant from Aqua Wellness to be sufficient evidence establishing the need for ongoing treatment. The entry is not contemporaneous to the plan that was submitted nearly two years later.
17Secondly, I find that the applicant has not addressed the goals of the plan or how the goals of the treatment would be met if she received the treatment, which is essential to meeting the test that the treatment is reasonable and necessary. Further, she did not address whether and how the overall cost of the plan is reasonable.
18Thirdly, the IE report of Dr. Dharamshi found that the applicant did not demonstrate any accident-related impairment from a musculoskeletal perspective. I give weight to the IE report because Dr. Dharamshi conducted an in-person physical examination of the applicant as well as a document review of the applicant’s medical history. He opined that the applicant had attained maximum medical improvement and maximum medical recovery, and that no further improvement is anticipated for soft tissue injuries sustained 3 1/2 years earlier. Based on the evidence submitted, I find that Dr. Dharamshi’s opinion is not rebutted by any other medical evidence.
19Accordingly, I find that the applicant has not met her onus of demonstrating on a balance of probabilities that the plan is reasonable and necessary.
The applicant has not established that the denial of the plan was non-compliant
20I find that the applicant has not proven on a balance of probabilities that the respondent’s denial letter dated January 24, 2025 did not comply with the requirements in s. 38(8) of the Schedule.
21Section 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 an impairment to which the MIG applies.
22Although the applicant criticized the respondent’s denial, her submissions did not identify whether she was making an argument under s. 38(8) or address the test for non-compliance. Despite this, I find that the January 24, 2025 denial identifies the plan in dispute, outlines the medical and other reasons for the denial, including referencing and extracting portions of the IE report of Dr. Hanna. While the January 24, 2025 denial is compliant, I note that the respondent also scheduled a further IE with Dr. Dharamshi and provided such IE report and its findings to the applicant in its subsequent denial letter dated March 24, 2025.
23Accordingly, I find that the denial is compliant with s. 38(8) of the Schedule and thus the plan is not payable under s. 38(11).
Interest
24Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since no benefits are owing, interest does not apply.
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.
26As the respondent did not unreasonably withhold or delay payment of benefits, no award is payable.
ORDER
27For the reasons outlined above, I find that:
a. The applicant is not entitled to the plan in dispute, interest or an award;
b. The plan is not payable pursuant to s. 38(11) of the Schedule; and
c. The application is dismissed.
Released: April 23, 2026
Henry Harris
Vice-Chair