RECONSIDERATION DECISION
Before: Ulana Pahuta, Adjudicator
Licence Appeal Tribunal File Number: 24-008462/AABS
Case Name: Paul Nita v. Economical Insurance Company
Written Submissions by:
For the Applicant: Jono Schneider, Counsel
For the Respondent: Nicholas Maida, Counsel
OVERVIEW
1On February 23, 2026, the applicant requested reconsideration of the Tribunal’s decision dated February 23, 2026 (“decision”).
2Stemming from an accident on November 1, 2022 and a request for benefits made pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”), the parties participated in a written hearing.
3In the resulting decision, the adjudicator found that the applicant was entitled to a treatment plan dated November 10, 2023 in the amount of $3,951.20 for physiotherapy services, but that he was not entitled to two other treatment plans for physiotherapy services dated January 12, 2024 and April 16, 2024. The adjudicator also found that the applicant was not entitled to a treatment plan dated September 30, 2024 for an orthopedic assessment, or an award.
4The grounds for a request for reconsideration are found in Rule 18.2 of the Licence Appeal Tribunal Rules, 2023 (“Rules”). To grant a request for reconsideration, the Tribunal must be satisfied that one or more of the following criteria are met:
a) The Tribunal acted outside its jurisdiction or committed a material breach of procedural fairness;
b) The Tribunal made an error of law or fact such that the Tribunal would likely have reached a different result had the error not been made; or
c) There is evidence that was not before the Tribunal when rendering its decision, could not have been obtained previously by the party now seeking to introduce it, and would likely have affected the result.
5The applicant relies on Rule 18.2(b) to support his request for reconsideration. He is seeking an order to vary the decision to find that he is entitled to the two physiotherapy services treatment plans and the treatment plan for an orthopedic assessment, together with interest and an award.
6The respondent submits that the applicant’s request for a reconsideration should be denied, and it requests an order for costs in the amount of $500.00 due to the purported frivolous nature of the reconsideration request.
RESULT
7The applicant’s request for reconsideration is granted, in part.
8Pursuant to Rule 18.4, the section of the decision addressing the treatment plan for physiotherapy services dated January 12, 2024 is cancelled.
9The applicant’s entitlement to this treatment plan has been reheard as part of this reconsideration decision. The applicant has established entitlement to this treatment plan, plus interest.
10The applicant’s request for reconsideration with respect to the other two treatment plans and an award is dismissed.
11The respondent’s costs request is denied.
ANALYSIS
12The test for reconsideration under Rule 18.2 involves a high threshold. The reconsideration process is not an opportunity for a party to re-litigate its position where it disagrees with the Tribunal’s decision, or with the weight assigned to the evidence. The requestor must show how or why the decision falls into one of the categories in Rule 18.2.
Rule 18.2(b) Error of Fact or Law
13I find that the applicant has established a ground for reconsideration under Rule 18.2(b) as it relates to the treatment plan for physiotherapy services, dated January 12, 2024.
Parties’ Positions
14The applicant highlights several alleged errors in the decision. He submits that the decision contains a material misapprehension of the evidentiary record, internal inconsistency in the reasoning, failure to engage with material evidence, and an overly narrow articulation of the legal test for assessment entitlement.
15The applicant argues that, in the decision, the adjudicator found that he had provided sufficient medical evidence to show that the November 10, 2023 treatment plan for physiotherapy services was reasonable and necessary. The applicant submits that even though similar evidence was provided for the January 12, 2024 and April 16, 2024 treatment plans, the adjudicator failed to apply the same reasoning as had been used for the November 10, 2023 treatment plan, leading to an inconsistent result. The applicant argues that the adjudicator overlooked material evidence in support of the January 12, 2024 and April 16, 2024 treatment plans, namely, clinical notes and records (“CNR”) entries from his family doctor. Given the inconsistent consideration of the various treatment plans, the applicant argues that it is impossible to reconcile the adjudicator’s finding on the November 10, 2023 treatment plan, with the finding on the January 12, 2024 and April 16, 2024 treatment plans.
16With respect to the treatment plan for an orthopedic assessment, the applicant argues that the adjudicator provided an overly narrow articulation of the test for an assessment. Further the applicant submits that in denying the treatment plan, the adjudicator relied on the fact that the applicant had previously attended an orthopedic assessment on January 11, 2024, but that the report had not been provided by the applicant. However, the applicant argues that the respondent had indirectly provided information about the report at the hearing, since the respondent’s s. 44 report by Dr. Belfon noted the specialist consultation. The applicant further argues that the fact that he had a prior orthopedic assessment does not make a further assessment unreasonable.
17The respondent submits that the applicant is attempting to re-litigate his claim. It argues that in his written hearing submissions, the applicant did not lead the adjudicator to evidence in support of the January 12, 2024 and April 16, 2024 treatment plans, nor did he make specific submissions as to why the treatment plans were reasonable and necessary. The respondent cites the Divisional Court decision in Dooman v. TD Insurance Co., 2025 ONSC 184 to argue that it is inappropriate for an adjudicator to go through the parties’ evidence to make their cases for them. The respondent argues that it is not an error of law or fact for an adjudicator to find entitlement to one treatment plan, but not to others.
18With respect to the orthopedic assessment treatment plan, the respondent submits that the adjudicator applied the correct legal test for an assessment, namely, whether it was reasonable and necessary. The respondent argues that in its submissions for the initial hearing, it had raised the issue that an orthopedic assessment would be duplicative, since the applicant had recently undergone such an assessment. The respondent argues that the applicant chose not to provide reply submissions to address this earlier assessment and why the report had not been provided as evidence. It argues that the adjudicator’s reasoning was well-supported by the evidence at the hearing, and that the applicant is attempting to re-litigate his claim.
Physiotherapy services treatment plan dated January 12, 2024
19I find that the applicant has established grounds for reconsideration pursuant to Rule 18.2(b) with respect to this treatment plan.
20At paragraphs 16 and 21 of the decision, the adjudicator found that the applicant had established entitlement to the treatment plan dated November 10, 2023, because the applicant had provided supportive, contemporaneous medical evidence that he continued to suffer from pain, but that he benefited from physiotherapy. The adjudicator referenced CNR entries from the applicant’s family physician Dr. Palcu, dated October 13, 2023 and November 10, 2023.
21I agree with the applicant that despite the fact that similar evidence had been provided for the January 12, 2024 treatment plan, the adjudicator stated that no supportive evidence had been provided by the applicant. In paragraphs 23 and 25 of the decision, the adjudicator found that the applicant had relied on the same submissions and evidence for the January 12, 2024 plan as had been submitted for the November 10, 2023 plan and that no new supportive medical evidence had been provided. However, in his hearing submissions, the applicant had referenced and provided as evidence CNR entries from his family doctor from January 10, 2024 and May 8, 2024 that similarly supported the need for ongoing physiotherapy treatment. In the decision, these CNR entries were not referenced.
22I do not agree with the respondent that the applicant did not refer to the January 10, 2024 and May 8, 2024 CNR entries in his written hearing submissions. Rather, at paragraph 15 of his hearing submissions, the applicant summarized the January 10, 2024 CNR entry, and at paragraph 19, he summarized the May 8, 2024 CNR entry. Both CNR entries were included as tabs to the submissions.
23Accordingly, I agree with the applicant that the findings at paragraphs 23 and 25 of the decision, where the adjudicator found that the applicant had relied on the same submissions and evidence in support of the January 12, 2024 treatment plan as in the November 10, 2023 treatment plan were inaccurate. I also find that the adjudicator did not engage with key evidence relied upon by the applicant in support of this treatment plan. I can then conclude that, had this error not been committed, it is likely the Tribunal would have reached a different result on this treatment plan.
Physiotherapy services treatment plan dated April 16, 2024
24I find that the applicant has not established an error of fact or law in the Tribunal’s consideration of this treatment plan.
25The applicant makes identical submissions with respect to this treatment plan, namely, that the adjudicator overlooked material evidence in support of the April 16, 2024 treatment plan, being the May 8, 2024 CNR entry from his family doctor, and applied inconsistent reasoning.
26However, from my review of the applicant’s submissions for the initial written hearing, the applicant did not provide submissions on the April 16, 2024 treatment plan. When listing the treatment plans he was disputing at the hearing, the applicant only listed the November 10, 2023 and January 12, 2024 treatment plans. The applicant did not identify the April 16, 2024 treatment plan as being in dispute, and did not provide submissions on this treatment plan. While a May 8, 2024 CNR entry was provided and summarized by the applicant, the applicant did not link this doctor’s visit to the April 16, 2024 plan. I agree with the reasoning in Dooman that it would be inappropriate for an adjudicator to go through a party’s evidence and make their case for them.
27Given the fact that the applicant did not provide submissions on this treatment plan at the hearing, I find that the applicant has not established that the Tribunal erred in its consideration of the evidence provided in support of the treatment plan.
28I find that the applicant has not established an error of fact or law in the Tribunal’s consideration of this treatment plan.
29I am not persuaded by the applicant’s argument that the Tribunal applied an overly narrow articulation of the test for an assessment. I agree with the applicant that, at paragraph 28, the adjudicator stated that the “purpose of an assessment is to determine whether a condition exists” and that the insured bears the onus to demonstrate that there are grounds on which to believe that a condition exists to warrant further investigation.
30However, the Tribunal also considered at paragraphs 30 to 32 whether another orthopedic assessment was reasonable and necessary given that the OHIP summary revealed that earlier that year, he had attended an orthopedic consultation and an anesthesiology consultation. The Tribunal noted that these reports had not been provided as evidence at the hearing, nor did the applicant provide reply submissions to explain why a further orthopedic assessment was needed. I find no error in the Tribunal’s analysis, and that the Tribunal properly considered whether another orthopedic assessment was reasonable and necessary.
31I further do not accept the applicant’s argument that the “substance” of the OHIP orthopedic consultation was before the Tribunal, because the orthopedic consultation had been noted in the IE report by Dr. Belfon. The applicant did not provide any submissions on the OHIP consultations or refer the Tribunal to CNR entries or any resulting report. Without any submissions from the applicant on this consultation, as per Dooman, I find that it would have been inappropriate for an adjudicator to have gone through the respondent’s evidence to make the case for the applicant.
32Accordingly, I find that the applicant has not established a ground for reconsideration with respect to this treatment plan.
Award
33The applicant did not provide submissions on the grounds on which he sought a reconsideration of the Tribunal’s finding on an award, nor did he provide reasons supporting such a reconsideration. Accordingly, I find that the applicant has not established any ground for reconsideration with respect to a s. 10 award.
Rule 18.4 – Varying the Decision
34Having found the applicant has established a ground for reconsideration with respect to the January 12, 2024 physiotherapy services treatment plan, I must now determine the appropriate remedy under Rule 18.4. I find it is appropriate for me to vary the part of the decision involving entitlement to the physiotherapy treatment plan, dated January 12, 2024. Specifically, based on the submissions and evidence presented at the written hearing, I find that the applicant has established entitlement to this plan.
35To receive payment for a treatment and assessment plan under s. 15 and s. 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.
36The applicant submitted that additional physiotherapy was reasonable and necessary to address his ongoing right knee, lower back, and neck pain post-accident. The treatment plan proposed 15 sessions of physical therapy, active exercises, and manual therapy. The treatment goals included pain reduction, increase in strength, increased range of motion, a return to the activities of normal living and a return to modified work activities. The applicant relied on the CNR entries of his family physician, Dr. Palcu, to establish his claim.
37The respondent relied on a s. 44 General Practitioner Report of Dr. Belfon, dated July 4, 2024, to argue that the applicant had sustained uncomplicated soft tissue injuries and that further facility-based treatment would not have any benefit beyond that of an independent exercise program.
38I find that the applicant has established that the January 12, 2024 physiotherapy services treatment plan is reasonable and necessary.
39The CNRs of Dr. Palcu reveal that throughout 2023 and 2024 the applicant continued to report ongoing right knee, right hip, lower back and neck pain. In a CNR entry dated January 10, 2024, Dr. Palcu noted that the applicant had chronic right knee pain, that he had pain when climbing downstairs and walking fast, that he was not working and that he usually goes for physical therapy, but that it had been closed for the holidays. In a May 8, 2024 CNR entry, the applicant discussed his low back pain and right knee pain and advised Dr. Palcu that the pain was better with physiotherapy. Dr. Palcu diagnosed the applicant with chronic low back pain and noted that the applicant will continue with physical therapy.
40I find that the CNRs of the applicant’s family doctor corroborate the applicant’s claim of ongoing accident-related pain, that his pain improved with physiotherapy and that at the time the OCF-18 was submitted, his family doctor recommended continuing this treatment. I find that the applicant has met his onus to prove, on a balance of probabilities, that the treatment plan for physiotherapy services is reasonable and necessary. Interest on this plan is payable in accordance with s. 51 of the Schedule.
Costs request
41As part of its reconsideration submissions, the respondent requested costs in the amount of $500.00
42I find that the respondent has not met the high threshold necessary to order costs.
43Rule 19.1 states that the Tribunal may award costs when “another party in a proceeding has acted unreasonably, frivolously, vexatiously, or in bad faith”. The party requesting costs has the onus to demonstrate such an order is merited.
44The respondent submits that the reconsideration request was frivolous, and that in his reconsideration submissions, the applicant admitted that medical documentation had not been provided to the respondent, because invoices were forwarded to the respondent and had not been paid. The respondent cites the Tribunal decision Carpizo v. Co-operators General Insurance Company, 2021 CanLII 73540 (ON LAT), where the Tribunal rejected the argument that an insurer must pay for records before a claimant produces them. The respondent submits that this failure to produce records was unreasonable, frivolous and in bad faith, in breach of the Case Conference Report and Order’s order for production of the documents, and interfered with the Tribunal’s ability to carry out a fair and efficient process.
45I find that the respondent has not established that the applicant’s behaviour merits a costs order. Firstly, the applicant was partially successful in his reconsideration request, so I do not agree that the reconsideration request was frivolous. While I agree with the respondent that the decision notes that certain medical documents had not been produced to the respondent prior to the hearing, the medical evidence appears to have been admitted as evidence at the written hearing. Accordingly, I do not agree that the Tribunal’s ability to carry out a fair and efficient process was hindered. I further do not find the decision cited by the respondent, Carpizo, to be persuasive on this point, since this decision was not dealing with costs, but rather, dealt with s. 36 and s. 33 non-compliance.
46Accordingly, the respondent has not established that it is entitled to costs in the amount of $500.00.
CONCLUSION & ORDER
47The applicant’s request for reconsideration is granted, in part.
48Pursuant to Rule 18.4, the section of the decision addressing the treatment plan for physiotherapy services, dated January 12, 2024, is cancelled.
49The applicant’s entitlement to this treatment plan has been reheard as part of this reconsideration decision. The applicant has established entitlement to this treatment plan, plus interest.
50The applicant’s request for reconsideration with respect to the other two treatment plans and an award is dismissed.
51The respondent’s costs request is denied.
Ulana Pahuta Adjudicator
Released: April 22, 2026