Rezgui v. Traders General Insurance Company
Licence Appeal Tribunal File Number: 24-011184/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:
Samira Rezgui
Applicant
and
Traders General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Sofia Ahmad
APPEARANCES:
For the Applicant:
Yanira E Monterroza, Paralegal
For the Respondent:
Natalie Spinelli, Paralegal
HEARD: In Writing
OVERVIEW
1Samira Rezgui, the applicant, was involved in an automobile accident on September 19, 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 the respondent, Traders General Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
2The applicant was driving a 2013 Honda Civic which was followed by another vehicle, which in turn, was followed by a third vehicle. The third vehicle struck the rear of the second vehicle causing it to collide with the rear of the applicant’s vehicle. Considerable physical force was transferred to the applicant’s vehicle during the collision.
ISSUES
3The issues in dispute are:
i. Is the applicant entitled to $3,631.87 for physiotherapy services, proposed by Airport Rehab Centre in a treatment plan/OCF-18 (“plan”) dated August 20, 2022; and
ii. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
4Based on the evidence before me, I find that the applicant has demonstrated that she is entitled to $3,631.87 for physiotherapy services, as well as interest in accordance with s. 51 of the Schedule on the overdue payment of benefits.
ANALYSIS
Is the treatment plan for the applicant’s physiotherapy services reasonable and necessary?
5The applicant’s treatment plan for physiotherapy services is reasonable and necessary.
6To 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.
7This treatment plan is composed of 12 sessions of chiropractic treatment, 15 sessions of physiotherapy and 12 sessions of massage therapy.
8The applicant further submits the OCF-18 goals are pain reduction, improved range of motion and strength and return to daily and pre-accident work activities. The applicant argues that her recovery is hindered by the mechanism of the accident with multiple injury sites, ongoing pain and sleep disturbance. The diagnosed injuries include sprains/strains of the cervical, thoracic, and lumbar spine, right shoulder sprain, left limb pain, headache, sleep disorders and WAD2 with neck pain and musculoskeletal signs.
9The respondent submits that the applicant was on short term disability at the time of the motor vehicle accident due to a left ankle strain. I find this ankle strain to be unrelated to the injuries sustained in the motor vehicle accident because this injury is a different part of her body. The applicant seemed to have recovered from this ankle strain. There is no mention of ankle strain as an injury as a result of the motor vehicle accident.
10The applicant reports to her family physician, Dr. David Palmer, pain in the neck, upper and lower back, and left leg with prolonged sitting, standing and walking, and she has difficulty bending, lumbar loading and stooping with disturbed sleep and challenges in household chores and self-care.
11The applicant submits that she saw her family physician, Dr. Palmer, on September 27, 2021. He notes that the applicant has pain in the right shoulder, chest, and whole back right leg. He recommends physiotherapy and massage therapy. He further notes that she is unable to work from September 19, 2021, until further notice, due to injuries from her motor vehicle accident.
12The applicant further submits that Dr. Palmer has provided ongoing clinical documentation confirming persistent shoulder, lumbar and knee impairments. The records document functional limitations, reduced range of motion, and the need for continued physiotherapy.
13The applicant submits the clinical notes and records of her physician, We Care Rehab, which document ongoing musculoskeletal pain, including severe lower back and gluteal pain radiating to both legs and shoulder and upper back discomfort. The clinical notes and records reflect small improvements and that the applicant has not yet achieved full functional recovery.
14The respondent submits that the treatment plan is neither reasonable, nor necessary mainly based on the opinion of its s. 44 assessor, Dr. Ijaz Chaudhry
15The respondent submits the Insurer’s Examination report of Dr. Chaudhry dated October 27, 2022, more than a year after the motor vehicle accident. Dr. Chaudhry diagnosed the applicant with cervical spine sprain (WAD2), lumbar spine sprain/strain, right shoulder sprain/strain, soft tissue and non-specific soft tissue injury to the right knee. He reports that the applicant has some residual pain. He opines that the applicant has reached maximum medical improvement (MMI).
16The respondent further submits Dr. Chaudhry’s plan for the applicant to continue with her home exercise, stretching and strengthening, yoga and daily walking as a form of general conditioning; swimming is also recommended. Dr. Chaudhry opines that the treatment plan proposed is unlikely to aid in recovery as the applicant’s condition has plateaued. He opines that the treatment plans are not reasonable nor necessary.
17I put little weight on Dr. Chaudhry’s opinion that the applicant’s injuries are only soft tissue in nature and have been resolved. Several assessments document persistent pain, functional limitations and the need for ongoing treatment. This is because Dr. Chaudhry minimizes the applicant’s injuries in his notes. I do not find his findings to be accurate of persuasive. These ongoing impairments demonstrate that the applicant has more than just soft tissue injuries. Dr. Chaudhry’s opinion contrasts with the medical evidence submitted by the applicant. I agree with the applicant that the injuries are more than soft tissue in nature.
18The applicant submits that an ongoing benefit was documented in prior physiotherapy, including improvement in range of motion, decreased pain and increased functional capacity. The clinical notes and records of the applicant’s family physician and We Care support these findings. I find them to be persuasive since they document the progress of the applicant’s recovery from her injuries which were sustained in the motor vehicle accident. I agree with the applicant, and accordingly find that these objective improvements support the continuation of treatment as reasonable and necessary to maintain progress and prevent regression.
19I find on a balance of probabilities that the treatment plan for physiotherapy is both reasonable and necessary.
Interest
20Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Interest applies in this case.
ORDER
21I order as follows:
i. The applicant is entitled to $3,631.87 for physiotherapy services, proposed by Airport Rehab Centre dated August 22, 2022; and
ii. Interest is payable.
Released: April 24, 2026
Sofia Ahmad
Adjudicator