Licence Appeal Tribunal File Number: 24-015021/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:
William Jones
Applicant
and
Definity Insurance Company
Respondent
DECISION
ADJUDICATOR:
Bernard Trottier
APPEARANCES:
For the Applicant:
Dino Ranchan Pius, Counsel
For the Respondent:
Domenic Nicassio, Counsel
HEARD:
By way of written submissions
OVERVIEW
1William Jones, the applicant, was involved in an automobile accident on November 8, 2022, 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 Definity 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:
- Is the applicant entitled to assessments, proposed by All Health Medical Centre (“All Health”) as follows:
i. $2,200.00 for a psychological assessment, in a treatment plan/OCF-18 (“treatment plan”) dated September 28, 2024?
ii. $2,580.00 for an orthopaedic assessment, in a treatment plan dated September 23, 2024?
iii. $2,320.00 for a chronic pain assessment, in a treatment plan dated September 23, 2024?
iv. $2,580 for a physiatry assessment, in a treatment plan dated September 23, 2024?
Is the applicant entitled to interest on any overdue payment of income replacement benefits (“IRBs”)?
Is the applicant entitled to interest on any overdue payment of the proposed medical and rehabilitation benefits above?
Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
RESULT
3The applicant is entitled to the disputed psychological and chronic pain assessments, plus interest.
4The applicant is not entitled to the disputed orthopaedic and physiatry assessments.
5The applicant is not entitled to interest on overdue payment of IRBs.
6The applicant is not entitled to an award.
PROCEDURAL ISSUE
7In his reply submissions, the applicant submits that the respondent cited the Schedule of Benefits: Physician Services Under the Health Insurance Act (February 14, 2025 (effective March 3, 2025)) (the “Schedule of Benefits”) in its hearing submissions without having previously disclosed this document as evidence. The applicant claims that the respondent failed to produce this document in accordance with the production exchange timelines ordered in the Case Conference Report and Order of March 17, 2025 (the “CCRO”). The applicant argues that it would be procedurally unfair and prejudicial to allow the respondent to rely on a document not previously disclosed to the applicant, according to the CCRO-ordered timelines. For this reason, the applicant argues that the Schedule of Benefits should be excluded from the evidence for this hearing.
8In the CCRO, the respondent was not granted a sur-reply to respond to the procedural issue raised by the applicant in his reply and, therefore, it did not argue this procedural issue.
9The Schedule of Benefits is a schedule under Regulation 552 of the Health Insurance Act, R.S.O. 1990, c. H.6. As such, it is part of Ontario law, readily available to the applicant. Accordingly, I consider it as a legal authority, not as evidence subject to the evidence disclosure orders of the CCRO. For these reasons, I allow the respondent to cite the Schedule of Benefits.
ANALYSIS
Background
10At the time of the accident, the applicant was 61 years old and employed full-time as a bus driver with the St. Catharine’s Transit Commission. On November 8, 2022, the applicant was involved in an accident in his private vehicle. Diagnostic imaging, dated November 9, 2022 and December 21, 2022, revealed that the applicant suffered fractures to his C7 and T1 vertebrae in the accident.
IRBs no longer in dispute, but interest on IRBs remains in dispute
11The CCRO of March 17, 2025 identified the issues in dispute, including IRBs and interest on overdue payment of benefits. On June 25, 2025, the parties resolved the dispute over IRBs, and the applicant subsequently withdrew this issue from the proceeding. In their submissions, the parties dispute the issue of interest on IRBs separately from the issue of interest on the disputed medical and rehabilitation benefits.
The disputed psychological assessment is payable
12To receive payment for all of the disputed treatment and assessment plans 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.
13On September 28, 2024, about 23 months post-accident, the applicant underwent a pre-screen evaluation with Ms. Shankari Sivararjasingam, occupational therapist with All Health, to identify the presence of psychological symptoms that would warrant an assessment by a psychologist. On November 1, 2024, Ms. Sivararjasingam submitted the treatment plan for a psychological assessment, in which she noted symptoms of depression, anxiety, flashbacks and social withdrawal. The stated goals of the assessment were to evaluate the applicant’s psychological symptoms, identify or rule out a diagnosis, and formulate a plan for recovery.
14On November 4, 2024, the respondent denied the treatment plan and requested that the applicant attend a psychological insurer’s examination (“IE”). On June 17, 2025, the applicant attended an in-person IE with Dr. Christopher Friesen, psychologist, to determine whether the proposed treatment plan was reasonable and necessary. In his report dated June 30, 2025, Dr. Friesen opined that the applicant was, at most, experiencing a mild adjustment disorder with depressed mood, secondary to pain and associated functional impairment, and that the treatment plan was not necessary at that time.
15The applicant argues that the psychological assessment is reasonable and necessary, and therefore payable, for the following reasons:
The OCF-18 is for a psychological assessment, not ongoing treatment;
Dr. Friesen confirmed a diagnosis of depressive symptoms, low mood and feelings of uselessness, indicating that the goals of the proposed assessment would be accomplished;
The respondent’s request for an IE demonstrates that the proposed psychological assessment is reasonable and necessary.
16The applicant argues, citing Z. E. A. R. v. Gore Mutual Insurance Company, 2020 CanLII 42667 (ON LAT) (“Z. E. A. R.”), that it would be unfair to permit the respondent to examine an injured person by an examiner of its choosing, but deny the applicant the same opportunity.
17The respondent submits that, in the nearly two years from the date of the accident to the submission of the treatment plan, the applicant reported no corroborating psychological complaints to physicians. The respondent submits, further, that the applicant did not report any psychological complaints in his Disability Certificate/OCF-3, dated December 18, 2024, where the applicant referenced physical pain and made no reference to psychological impairments. The respondent relies on the IE of Dr. Friesen, where he reports that the applicant told him that he did not feel that he would benefit from psychological treatment at that time.
18In his reply submissions, the applicant argues that his psychological complaints are corroborated in the clinical notes and records (“CNRs”) of Linda Johnson, nurse practitioner with iScope Concussion and Pain Clinics, who diagnosed the applicant, on April 29, 2025, with fatigue and mood disturbance affecting his function. The applicant argues, further, that the applicant reported to Dr. Freisen that he did not feel that he would benefit from psychological treatment, but that he wanted “to leave the option open for the future if things change.”
19I find that the evidence before me indicates that the applicant suffered psychological sequelae because of the accident. The pre-screening observations of Ms. Sivararjasingam are corroborated by the CNRs of Ms. Johnson and, to an extent, by the report of Dr. Friesen. I find that Dr. Friesen diagnosed the applicant with a mild adjustment disorder and depressed mood, even though his low mood was secondary to pain and associated functional impairment, and that further investigation into the condition is warranted. I find that it would be unfair to permit the respondent to have the applicant examined by its IE assessor, but to deny the applicant the opportunity to be examined by an assessor of his choosing, as cited in Z. E. A. R.
20I find that the observations of Ms. Sivararjasingam, Ms. Johnson and Dr. Freisen outweigh the applicant’s omission of psychological complaints in his OCF-3 dated December 18, 2024.
21I find that the applicant is entitled to an opinion of a psychological assessor, apart from that of Dr. Freisen, to determine a course of treatment for his psychological issues due to the accident. For the reasons above, I find that the proposed treatment plan for a psychological assessment is reasonable and necessary, and therefore payable.
The disputed orthopaedic assessment is not payable
22The applicant directed me to the OCF-18, submitted by Dr. Michael West, orthopaedic surgeon, dated September 23, 2024, where the stated goals of the treatment plan were to reduce pain, increase strength and range of motion, identify impairments, help achieve maximum recovery, and formulate a plan for a return to activities of daily living.
23In its Explanation of Benefits (”EOB”) dated November 4, 2024, the respondent indicated that it did not dispute whether the proposed assessment was medically reasonable and necessary. However, it indicated that, before it could fund the cost of the assessment, it required documentation that the proposed assessment was not available under Ontario Health Insurance Plan (“OHIP”) funding with a referral from his treating physicians. It indicated further, that in the event that the proposed non-OHIP-funded assessment was required due to extensive wait times, it required documentation on the duration of the wait time and indication that the wait time would be detrimental to the applicant’s recovery.
24The applicant argues, citing G.T. v. Unifund Assurance Company, 2017 CanLII 81567 (ON LAT) (“G.T.”), that the respondent has the legal burden to advance evidence or submissions that, on balance, the assessments were reasonably available, whether in whole or in part, from OHIP. The applicant submits that an orthopaedic assessment is not available under OHIP, and because the respondent has already conceded that they are medically reasonable and necessary, the applicant is entitled to have it funded by the respondent.
25The respondent argues that, under s. 47(2) of the Schedule, it is not liable to pay for medical and rehabilitation benefits that are reasonably available to the insured person under “any insurance plan or law or under any other plan or law.” The respondent argues that, because the applicant had access to an orthopaedic assessment under OHIP, it was not required to pay for the proposed non-OHIP-funded assessment.
26The respondent argues, further, that the proposed orthopaedic assessment could be arranged through the applicant’s physicians with PromptDoc Urgent Care Clinic (“PromptDoc”), where he had more than 10 visits over 2023 and 2024. The respondent adds that the applicant saw an orthopaedic spine surgeon at the Hamilton General Fracture Clinic on December 21, 2022, where he was assessed by Dr. Colby Oitment, orthopaedic surgeon, under the OHIP Schedule of Benefits code A065A. The respondent submits, further, that the applicant was referred by Dr. Fotina Raptis, general practitioner (“GP”) with PromptDoc, to an orthopaedic spine specialist at the Hamilton General Fracture Clinic on May 3, 2024, for a follow-up assessment.
27The respondent argues that, under the OHIP Schedule of Benefits, a patient is entitled to repeat orthopaedic assessments, specific orthopaedic assessments and follow-up visits, with services that include evaluation of injuries, review of imaging and physical complaints, and follow-up planning.
28While I am not bound by the decision in G.T., I find it instructive regarding the onus of determining whether services can be obtained through OHIP in lieu of a private clinic. In G.T., the Tribunal found that:
an insurer must advance some evidence or submission that, on balance, establishes that the benefit at issue, whether in whole or in part, was reasonably available to the insured from a collateral provider [OHIP]. If an insurer has satisfied that onus, the burden then shifts to the insured to prove that the benefit at issue was not in fact reasonably available.
29In the present matter, I find that the respondent has advanced evidence that an orthopaedic assessment is available through OHIP, because the applicant obtained such an assessment previously and was referred to an OHIP-funded orthopaedic assessor by his treating GP several months before the OCF-18 was submitted. I find that the applicant has not demonstrated that the orthopaedic assessment proposed by All Health is not reasonably available to the applicant through OHIP.
30For the reasons above, I find that the applicant has not demonstrated that the proposed non-OHIP-funded orthopaedic assessment is reasonable and necessary, and therefore I find that it is not payable.
The disputed chronic pain assessment is payable, while the disputed physiatry assessment is not
31The applicant directed me to the OCF-18 for a chronic pain assessment, submitted by Dr. Igor Wilderman, chronic pain consultant, and Dr. Mikhail Shteynberg, chiropractor, dated September 23, 2024, where the stated goals of the treatment plan were to reduce pain, increase strength and range of motion, establish any further diagnoses, and formulate a plan for a return to activities of daily living. The applicant directed me further to the OCF-18 for a physiatry assessment, submitted by Dr. Ali Grouse, physiatrist, also dated September 23, 2024, where the stated goals of the treatment plan were to reduce pain, increase strength and range of motion, evaluate chronic pain features, and formulate a plan for a return to activities of daily living
32As with the EOB for the orthopaedic assessment, the EOBs for the chronic pain and physiatry assessments, dated November 4 and 11, 2024, respectively, indicated that the respondent did not dispute whether the proposed assessments were medically reasonable and necessary. The EOBs indicated that the respondent required documentation that the proposed assessments were not available under OHIP, and that if the non-OHIP-funded assessments were required due to excessive wait times, it required documentation on the duration of the wait times and indication that the wait times would be detrimental to the applicant’s recovery.
33The applicant relies again on G.T. to argue that, because the respondent admitted the assessments were reasonable and necessary, the respondent has the onus to demonstrate that the proposed chronic pain and physiatry assessments are reasonably available through OHIP. The applicant argues that the respondent’s submissions regarding codes in the OHIP Schedule of Benefits are insufficient evidence that the proposed chronic pain and physiatry assessments would be covered by OHIP.
34The respondent argues that, under s. 47(2) of the Schedule, the applicant should seek the proposed chronic pain and physiatry assessments through OHIP first. The respondent argues that both a chronic pain assessment and a physiatry assessment could be obtained from a general practitioner under code A425 (comprehensive physical medicine and rehabilitation consultation) or under code A313 (medical specific assessment) within the OHIP Schedule of Benefits. The respondent argues that the applicant has not provided evidence that he approached his physicians at PromptDoc to ask them to refer him for chronic pain and physiatry assessments through OHIP, or that PromptDoc physicians believed that such assessments could not be accessed through OHIP.
35Although the adjuster initially agreed that the proposed chronic pain and physiatry assessments were reasonable and necessary, the respondent now argues, in its submissions, that the physiatry assessment is not. The respondent submits that the goals of the proposed physiatry assessment are identical to those of the chronic pain assessment. The respondent directed me to part 9(b) of the physiatry OCF-18, where it states that the assessment will evaluate persistent soft tissue pain, which continues to interfere with essential daily activities, and it will evaluate chronic pain features. The respondent directed me to part 9(d) of the both OCF-18s, where neither Dr. Wilderman nor Dr. Ghouse indicated that they were aware of any concurrent treatment that would be provided by any other provider, even though the goals were essentially the same and both assessments were proposed by All Health.
36I find that, on balance, the respondent has not established that the chronic pain and physiatry assessments are reasonably available through OHIP. The evidence before me indicates that both a chronic pain assessment and a physiatry assessment are normally performed by specialists in those areas. While the respondent asserts that they can be performed by GPs, the OHIP Schedule of Benefits codes it provided do not lead me to conclude that they would be performed by a GP without further specialization.
37The applicant has the onus to demonstrate that the proposed assessments are reasonable and necessary, which includes identifying how they are not duplicative. I find that, on balance, the applicant has not demonstrated that the proposed physiatry assessment, whose stated goal is to evaluate chronic pain features, is materially different from the chronic pain assessment. For this reason, I find that the proposed physiatry assessment is not payable.
38Because I find that the proposed chronic pain assessment is not reasonably available through OHIP, I conclude that it is reasonable and necessary, and therefore payable. Because I find that the physiatry assessment is duplicative of the chronic pain assessment, I find that it is not reasonable and necessary, and therefore not payable.
Interest on overdue payment of IRBs is not payable
39The Tribunal may award interest to which an insured person is entitled pursuant to s. 51 of the Schedule. If payment of a benefit then owing to the insured is overdue, the insurer shall pay interest on the overdue amount at the rate of 1 per cent per month, compounded monthly, from the time the benefits first became payable under the Schedule. Under s. 36 of the Schedule, specified benefits such as IRBs are overdue if they are not paid within 10 business days of the insurer receiving the required information.
40The dispute over interest on IRBs arises because, although the respondent eventually paid the claimed IRBs, and continues to pay them, the applicant claims that they were “overdue” as set out in s. 51(1).
41The parties agree that the applicant received short-term/long-term disability (“STD/LTD”) benefits from his employer’s collateral benefits in the months following the accident, and that he attempted a return to work from March 4 to April 16, 2024, about 17 months post-accident.
42On March 19, 2024, the applicant submitted an Election of Income Replacement, Non-Earner or Caregiver Benefit/OCF-10 and a Disability Certificate/OCF-3 to the respondent.
43On March 27, 2024, the respondent advised the applicant that the OCF-3 completed by Dr. Thomas Mazzone, GP with PromptDoc, indicated that the applicant did not suffer a substantial inability to perform the essential tasks of his employment, and therefore the applicant was not entitled to IRBs.
44On May 21, 2024, the applicant sent a revised OCF-3 from Dr. Mazzone. On May 27, 2024, the respondent advised the applicant that the OCF-3 was incomplete because parts 1 to 4 had not been completed by the applicant. In this correspondence, the respondent advised the applicant that, to be entitled to IRBs, he was required to provide, under s. 33 of the Schedule, a complete OCF-3, STD/LTD files, an Employer Confirmation Form/OCF-2, details of post-accident income and Notices of Assessment (“NOAs”) for 2022 and 2023.
45The applicant submits that, on June 7, 2024, the respondent’s handling adjuster requested, via email, an OCF-2, or a Record of Employment, or an STD/LTD file to calculate IRBs. The applicant emphasizes that the adjuster indicated “or” in her request, not “and”. The applicant submits that he provided the STD/LTD file that same day, and that the adjuster confirmed receipt. The applicant submits, further, that he received no further correspondence from the respondent regarding other IRB documentation until December 11, 2024. The applicant argues that the 6-month period of no requests for further IRB-related information was because the respondent disregarded the applicant’s IRB claim. For this reason, the applicant argues that he is entitled to interest on overdue IRBs, pursuant to s. 51 of the Schedule, from June 21, 2024 (10 business days after June 7, 2024) to June 30, 2025, plus interest from June 30, 2025, to the date a decision is rendered by the Tribunal.
46On March 19, 2025, the respondent paid the applicant an initial lump sum of $12,614.52 for IRBs owed from November 15, 2022 to March 3, 2024.
47On June 6, 2025, the applicant served a forensic accounting report, authored by J.S. Held ULC (“J.S. Held”), indicating that the respondent owed a further lump sum of $23,658.66 for IRBs owed to June 30, 2025, based on a total of $33,500.80 payable, less $12,615.53 already paid, plus $2,772.38 in interest. The J.S. Held report indicated that, in accordance with s. 51 of the Schedule, interest on overdue payment of IRBs was due from June 21, 2024 (10 business days after receipt of the STD/LTD file on June 7, 2024) to June 30, 2025.
48On June 25, 2025, the respondent paid the applicant $20,886.26 for the period ending June 30, 2025, which excluded the $2,772.38 in interest calculated by J.S. Held. The respondent’s correspondence on that date indicated that the J.S Held calculations were confirmed by the report of Davis Martindale LLP, dated June 18, 2025. The correspondence was silent regarding the interest calculated by J.S. Held.
49The respondent argues that IRBs were not “overdue” before June 30, 2025, for the following reasons:
The applicant did not submit a complete Disability Certificate/OCF-3 until January 8, 2025, after requests from the respondent (on March 27, 2024, on April 16, 2024 and on May 27, 2024) to provide a complete OCF-3. The respondent argues that no IRBs are owed before a complete OCF-3 is submitted, under s. 36(3) and s. 67(1) of the Schedule, citing Ram v. Unifund Assurance Company, 2024 CanLII 126304 (ON LAT) (“Ram”). The respondent argues that, because fields in the OCF-3 remained blank until January 8, 2025, no benefit was payable before then, and therefore IRBs were not overdue before that date.
The applicant did not provide an Employer’s Confirmation Form/OCF-2 until February 26, 2025. The respondent argues that no IRBs are owed until the OCF-2 is submitted, because the Tribunal has found that provision of an OCF-2 is a reasonable request under s. 33(1) of the Schedule for calculating IRBs, and that under s. 33(6), no specified benefit is payable where an applicant is non-compliant with a s. 33(1) request. The respondent cites 17-005692 v. Aviva Insurance Company of Canada, 2018 CanLII 83499 (ON LAT) (“17-005692”) and Rejin v. Pembridge Insurance Company, 2022 CanLII 136076 (ON LAT) (“Rejin”) to argue that IRBs were not payable before the OCF-2 was submitted on February 26, 2025, and therefore IRBs were not overdue before that date.
The applicant returned to work from March 4 to April 16, 2024. The respondent argues that the CNRs of the applicant’s physicians at PromptDoc, from April 10, 2023 to May 27, 2023, were unclear on the duration of his return to work, and whether his condition was accident-related or the result of degenerative changes. The respondent argues that it still required the information requested under s. 33, in its May 27, 2024 correspondence with the applicant, to calculate IRBs.
The applicant provided the respondent with Canada Revenue Agency (“CRA”) Information Return for Electronic Filing of an Individual’s Income Tax and Benefit Return (T183) forms for 2020 to 2023 on February 28, 2025. The respondent argues that the T183 forms were self-reported, and that it was reasonably required, citing Rejin, to wait for CRA-issued NOAs, for the purpose of verifying the applicant’s pre- and post-accident income. The applicant did not provide NOAs for 2021 to 2023 until June 12, 2025. The respondent argues that, under s. 33, again citing Rejin, no IRBs were payable before the 2022 and 2023 NOAs were provided on June 12, 2025, and therefore IRBs were not overdue before that date.
50The respondent argues that it exceeded its obligations under the Schedule when it paid the initial lump sum on March 19, 2025 (covering the IRB period from November 15, 2022 to March 3, 2024), despite not having received the requested 2022 and 2023 NOAs. It argues that the IRBs were not overdue, because the applicant had still not satisfied the previous s. 33 requests.
51The respondent argues that it again exceeded its obligations under the Schedule when it paid the second lump sum on June 25, 2025, because it had not received the requested 2024 NOA, which would assist it in calculating the applicant’s income during and after the 2024 return-to-work period.
52The respondent argues that, because IRBs were not overdue before June 30, 2025, the applicant is not entitled to interest before that date, and because IRBs continue being paid, there is no entitlement to interest on IRBs after that date.
53In weighing the arguments, I recognize that the parties need to balance precision and reasonability in calculating IRBs. The consumer protection purpose of the Schedule means that an applicant cannot be denied benefits because, for example, he cannot provide a tax document that will only be available in the future.
54I am not persuaded by the applicant’s argument that the adjuster’s use of the word “or”, in its email of June 7, 2024, removed the applicant’s responsibility, under s. 33(1), to provide the documents requested by the respondent in its formal correspondence of May 27, 2024. I find that the requirements for an OCF-3 and an OCF-2 are reasonable under s. 33(1) of the Schedule, as the respondent requested in its correspondence of May 27, 2024, and supported by Ram, 17-005692 and Rejin. Therefore, I find that the initial IRB payment was not payable before February 26, 2025, because the applicant had not provided his OCF-2 until then.
55I find that the respondent’s request for documents, on May 27, 2024, was reasonable in light of the applicant’s receipt of STD/LTD benefits, and his return to work in 2024. While I am not bound by it, the decision in Rejin is instructive in that an IRB is not payable in a period when an injured person has not provided requested information, under s. 33 of the Schedule, without a reasonable explanation. I find that the applicant has not provided a reasonable explanation as to why he did not fulfill the reasonable request for documents other than the STD/LTD file. For that reason, I find that the respondent was reasonable when it made the second lump-sum IRB payment on June 25, 2025, after receipt of the J.S. Held report that indicated the applicant claimed no IRBs during the return-to-work period. I find that the respondent met the requirements of the Schedule in paying IRBs, and that the IRBs were not overdue as set out in s. 51.
56For the reasons above, I find that the applicant has not demonstrated that IRBs were overdue as set out in the Schedule, and therefore interest on IRBs is not payable.
Interest on overdue payment for assessments is payable
57I find that the payment for the psychological assessment should have been made when the OCF-18 was submitted to the respondent on September 28, 2024. I find that the applicant is entitled to interest at a rate of 1% per month, compounded monthly, on amounts then owing.
58I find that the payment for the chronic pain assessment should have been made when the OCF-18 was submitted to the respondent on September 23, 2024. I find that the applicant is entitled to interest at a rate of 1% per month, compounded monthly, on amounts then owing.
Award
59The 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.
60In general, the threshold for the Tribunal to grant an award under s. 10 is whether there was unreasonable behaviour in withholding or delaying benefits, which amounts to the insurer being excessive, imprudent, stubborn, inflexible, unyielding and immoderate. See, for example, the Tribunal’s decision in S.M. v. Unica Insurance Inc., 2020 CanLII 61460 (ON LAT).
61The applicant submits that the respondent failed to calculate and pay IRBs in a timely manner. He argues that the respondent had all the documents it needed to calculate the quantum of IRBs by June 7, 2024, yet failed to calculate them until June 25, 2025. He argues that the respondent adjusted his claim in bad faith, and willfully and wrongfully withheld IRBs from the applicant.
62The respondent submits that the late-filed OCF-3, OCF-2, back-to-work information and NOAs were reasonably required under the Schedule, and their absence prevented it from completing its IRB calculations and approving payment. It argues, also, that it exceeded its obligations under the Schedule to pay IRBs to the applicant, despite never receiving the applicant’s 2024 NOA. For these reasons, the respondent argues there is no basis for an award under s. 10 of the Regulation.
63I do not find that the respondent was unreasonable in reaching its conclusions on the payment of IRBs, and therefore I deny the applicant’s claim for an award under s. 10 of the Regulation regarding IRBs.
64I do not find that the respondent was unreasonable in reaching its conclusions on the proposed treatment plans, and I deny the applicant’s claim for an award under s. 10 of the Regulation regarding these benefits.
ORDER
65The applicant is entitled to the disputed psychological and chronic pain assessments, with interest.
66The applicant is not entitled to the disputed orthopaedic and physiatry assessments.
67The applicant is not entitled to interest on overdue payment of IRBs.
68Because no benefits were unreasonably withheld or delayed, the applicant is not entitled to an award under s. 10 of Reg. 664.
Released: April 23, 2026
__________________________
Bernard Trottier
Adjudicator