Citation: Sharifa v. Coachman Insurance Company, 2026 ONLAT 24-009272/AABS

Licence Appeal Tribunal File Number: 24-009272/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:

Rasha Sharifa

Applicant

and

Coachman Insurance Company

Respondent

DECISION

ADJUDICATOR: Matthew Frontini

APPEARANCES:

For the Applicant: Kelisa Reyes, Paralegal

For the Respondent: Jason H Goodman, Counsel

HEARD: By way of written submissions

OVERVIEW

1Rasha Sharifa, the applicant, was involved in an automobile accident on March 18, 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, Coachmen Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the "Tribunal") for resolution of the dispute.

ISSUES

2The following are the issues in dispute:

i. Is the applicant entitled to $6,143.01 for psychological services, proposed by Center for Psychological and Counseling Services Inc. in an OCF-18/treatment plan ("treatment plan") dated February 15, 2024?

ii. Is the applicant entitled to $2,686.00 for a Neurological Assessment, proposed by HAL Disability in a treatment plan dated November 30, 2023?

iii. Is the applicant entitled to $2,173.88 for physiotherapy services, proposed by Dun-Dix Healthcare Clinic Inc. in a treatment plan dated December 19, 2023?

iv. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?

v. Is the applicant entitled to interest on any overdue payment of benefits?

PRELIMINARY PROCEDURAL Issue

3The case conference report and order dated December 9, 2024 ("CCRO") lists four treatment plans in dispute in this application. The CCRO indicates that the OCF-18 for a Driving Assessment, proposed by the Centre for Psychological Counseling Services Inc. in a treatment plan dated September 13, 2021, was added as an issue in dispute at the case conference with the respondent's consent.

4While applicant provided arguments regarding her entitlement to this treatment plan, the respondent's submissions indicate that this treatment plan was approved on November 10, 2023. The correspondence containing this approval was sent to the applicant, her counsel and the service provider.

5In her Reply submissions, the applicant did not contest that this treatment plan is not in dispute and was not in dispute when the applicant commenced this proceeding on July 25, 2024. Instead, she submitted that the Tribunal should when considering whether an award should be ordered, take into consideration the respondent's conduct in failing to indicate that this issue was not in dispute when it was added at the case conference. I will address this submission, together with the applicant's other submissions regarding an award below.

6Based on the evidence and submissions before me, I find that the Driving Assessment treatment plan is not in dispute between the parties.

RESULT

7I find that:

i. the applicant is partially entitled to the treatment plan for psychological services, proposed by the Center for Psychological and Counseling Services Inc. in a treatment plan dated February 15, 2024, in the amount of $3,898.89;

ii. the applicant is not entitled to $2,686.00 for a Neurological Assessment, proposed by HAL Disability in a treatment plan dated November 30, 2023;

iii. the applicant is not entitled to $2,173.88 for physiotherapy services, proposed by Dun-Dix Healthcare Clinic Inc. in a treatment plan dated December 19, 2023;

iv. the respondent is not liable to pay an award under s. 10 of Reg. 664; and

v. the applicant is entitled to interest pursuant to s. 51 of the Schedule in respect of her partial entitlement to the treatment plan for psychological counsel proposed by the Center for Psychological and Counseling Services Inc.

ANALYSIS

The applicant is partially entitled to the treatment plan for psychological services, proposed by the Center for Psychological and Counseling Services

8I find that the applicant has established on a balance of probabilities that she is partially entitled to the treatment plan proposed by the Center for Psychological and Counseling Services. This treatment plan recommends twelve 1.5-hour psychological counseling sessions, to which the applicant is entitled, and twelve 1.5-hour in-car driving reintegration therapy sessions, to which the applicant is not entitled.

9To receive payment for a treatment and assessment plan under ss. 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.

10The applicant submits that the medical evidence establishes that this treatment plan is reasonable and necessary. In support of her position, she references her reporting of her driving anxiety to medical professionals at Mississauga Health Centre between April and November 2021. She also relies on a s. 25 psychological assessment report, two psychotherapy progress reports, and a s. 25 driver anxiety assessment report.

11The psychological assessment report, dated January 19, 2023, was prepared by Dr. El Saidi, psychiatrist, following a clinical interview and administration of seven psychometric tests. Dr. El Saidi diagnosed the applicant with (1) Major Depressive Disorder; (2) Post-Traumatic Stress Disorder; and (3) Somatic Symptom Disorder. Dr. El Saidi's report provided further opinions on the applicant's removal from the Minor Injury Guideline and entitlement to specified benefits. Finally, Dr. El Saidi's report recommended an initial sixteen sessions of psychological counselling and assessments for chronic pain, driver anxiety and nutrition. The respondent approved the initial sixteen sessions for psychological counseling and the driver anxiety assessment.

12Dr. El Saidi and Gilan Abdelaal, psychotherapist, authored two psychotherapy progress reports, dated June 8, 2023, and October 21, 2023. Based on the applicant's progress, Dr. El Saidi and Gilan Abdelaal recommended additional counseling sessions and a driving anxiety / reintegration assessment.

13Dr. Svetlana Gabidulina and Mr. Oleg Kaganovich authored a driver anxiety assessment report, dated January 9, 2024, relating to the applicant's ability to safely and confidently drive a motor vehicle. The assessment comprised a clinical interview, administration of five psychometric tests, and an in-vehicle assessment. The assessors reported observing anxious behaviours while driving and the evaluation of the applicant and the assessment resulted in a diagnosis DSM-5 diagnosis of Situational (isolated) Phobias, severe (automobile anxiety – driver/passenger). The assessors recommended the applicant participate in a minimum of 12-in-vehicle reintegration therapy sessions.

14The respondent relies on the s. 44 reports of Dr. Goodfield, psychologist, dated February 29, 2024, April 12, 2024, and June 18, 2024, which comprised both a paper review and a final in-person assessment. Following these assessments, Dr. Goodfield opined that this treatment plan is not reasonable and necessary. This finding was based on his psychological assessment, including clinical interview, of the applicant during an earlier s.44 assessment. Dr. Goodfield's findings were as documented in a psychological assessment report dated February 16, 2023. During that assessment interview, the applicant reported that she had stopped driving for three months following the accident but had since resumed most of her normal driving activity. Dr. Goodfield's February 2023 assessment opined that the applicant met the DSM-5 criteria for an Adjustment Disorder with Mixed Anxiety.

15Dr. Goodfield's opinion in the June 2024 assessment report was also based on a clinical interview and administration of psychological testing. Dr. Goodfield's opinion specifically acknowledged the applicant's mental impairments and injuries, while opining that they do not meet the criteria for a driving phobia that would require in-car reintegration therapy:

Based on the current assessment, Ms. Sharifa currently meets the DSM-5 criteria for an Adjustment Disorder with Mixed Anxiety and Depressed Mood, mild. She does not meet full criteria for Specific Phobia, noting only some mild lingering anxiety when there are lots of cars on the road. She does not avoid driving though restricts herself to short distances (under 15 minutes) due to her pain.

16I note that in considering the reasonableness and necessity of the psychological services treatment plan, Dr. Goodfield's assessment reports focus on the driving reintegration sessions services. Dr. Goodfield does not comment on the reasonableness and necessity of the twelve 1.5-hour sessions of psychological counselling also recommended in the treatment plan. Rather, Dr. Goodfield's assessment report recommended an additional eight 1-hour psychological counseling sessions, ideally conducted in person.

17I find that the applicant has not established on a balance of probabilities that the driving reintegration therapy sessions in the treatment plan are reasonable and necessary. Dr. El Saidi's assessment report recommends psychological counseling and a driving anxiety assessment, which the respondent approved. The report does not opine on the applicant's need for driving reintegration treatment. Similarly, the June and December 2023 psychotherapy progress reports recommend further counselling and a driving anxiety assessment but do not opine on driving reintegration sessions.

18Finally, I place more weight on the Dr. Goodfield's opinion regarding the applicant's psychological diagnosis and this treatment plan compared to Dr. Gabidulina's opinion. Dr. Goodfield's diagnosis of the applicant with adjustment disorder has remained consistent over the course of the applicant's recovery from the accident. Dr. Goodfield specifically opined that the applicant did not meet the criteria for a diagnosis of a phobia related to driving. A key factor in the Dr. Goodfield's reasoning was that the applicant's driving habits in her daily life, as reported to him during her February 2023 s. 44 assessment, was inconsistent with described severity of her anxiety in 2024, three years after the accident. I find that the applicant has not established that the denied in-car reintegration therapy sessions are reasonable and necessary as a result of the accident.

19I also find that the applicant has established that the psychological counselling sessions in the treatment plan are reasonable and necessary. Based on the evidence before me, there is a general consensus among the healthcare practitioners that have assessed the applicant that some additional psychological counselling is reasonable and necessary. The respondent's evidence, through Dr. Goodfield, does not address why eight 1-hour sessions of counselling is reasonable and necessary while twelve 1.5-hour sessions would not be.

20I find that that the applicant has established on balance of probabilities that she is partially entitled to the treatment plan for psychological services in the amount of $3,898.89. Specifically, she entitled to the goods and services other than the twelve 1.5-hour car reintegration sessions totalling, which comprise $2,2244.12 of the treatment plan's total of $6,143.01.

The applicant is not entitled to the neurological assessment proposed by HAL Disability

21I find that the applicant has not established on a balance of probabilities that she is entitled to this treatment plan for a neurological assessment.

22In considering the reasonableness and necessity of an assessment, the applicant bears the onus to demonstrate on a balance of probabilities that there are grounds on which to believe that a condition exists that would warrant further investigation by way of an assessment.

23The applicant's submissions reference reports to various health care providers and assessors that she suffers headaches, mood disturbances, nausea and dizziness. The applicant further submits that this reported symptomology is indicative of a neurological injury and therefore an investigation into whether there is a neurological injury is reasonable and warranted.

24The respondent submits that the applicant has not met her burden in establishing on a balance of probabilities that an investigation is warranted. The respondent notes that the applicant's family doctor indicated "no neurological deficits" on several occasions and there is no medical evidence in support of such an assessment.

25I find that the applicant has not established that an investigation into whether she has suffered a neurological injury as result of the accident is warranted. The applicant has not identified compelling medical evidence that she suffers from neurological condition as a result of the accident. Specifically, the applicant has not identified any evidence of a medical professional suggesting there are neurological deficits or that an assessment is warranted. Although the applicant references her reporting of various complaints to medical professionals, none of these records indicate that the complaints are neurological in nature or that an assessment is warranted. There are only the applicant's submissions in support of the proposition that her symptomology is because of a neurological injury caused by the accident. Submissions are not evidence, and the applicant's submissions alone do not establish that an investigation is warranted.

26I find that the applicant has not established on a balance of probabilities that she is entitled to this treatment plan for a neurological assessment.

The applicant is not entitled to the treatment plan for physiotherapy services proposed by Dun-Dix Healthcare Clinic Inc.

27I find that the applicant has not established on a balance of probabilities that she is entitled to this treatment plan for physiotherapy services.

28The treatment plan indicates that the applicant suffers functional impairments in her activities of daily living as a stay-at-home mother caused by the exacerbation of pain. The treatment plan's goals include pain reduction and a return to activities of normal living. To accomplish these goals, 12 half-hour sessions of each of massage, physiotherapy and chiropractic adjustments are proposed.

29The applicant's submissions focus on the reasonableness of the goals of the treatment plan and further argue that the respondent's denial, allegedly based on the passage of the time since the accident alone, is insufficient. Regardless, the applicant has not identified contemporaneous supporting medical evidence that indicates that her activities of daily living have been impaired because of the accident and therefore the services in the treatment are necessary.

30The applicant's submissions and evidence do not meet her burden to establish on balance of probabilities that this treatment plan is reasonable and necessary. Specifically, the applicant has not identified sufficient supporting medical evidence to establish that the services in the treatment plan are necessary as a result of the accident.

Interest

31Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. I find that the applicant is entitled to interest pursuant to s. 51 of the Schedule in respect of her partial entitlement to the treatment plan for psychological counselling proposed by the Center for Psychological and Counseling Services Inc. in accordance with s. 51.

Award

32The 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.

33The only benefits that the respondent was found to have delayed were in connection to the applicant's partial entitlement to the treatment plan for psychological services. The applicant has not made specific submissions as to how this benefit was unreasonably delayed.

34I also reject the applicant's submissions that an award is payable with respect to the inclusion of the approved driving assessment as an issue in dispute in this application. There was no unreasonable delay or withholding of these benefits, which were approved in November 2023, prior to the filing of this application on July 25, 2024. It should be recalled that the applicant requested an indulgence at the case conference, held on December 3, 2024, to add this treatment plan as an issue in dispute in this application. The applicant did not include the OFC-18 or denial in her case conference summary but did reference a denial dated April 12, 2024. Despite failing to include the relevant documents with her request, the respondent consented to the inclusion of this treatment plan as an issue in dispute. However, review of that April 2024 denial, filed with the applicant's hearing submissions, indicates that it denied the February 15, 2024 treatment plan, not the 2023 driving anxiety assessment treatment plan. Rather, that denial notes that the s. 44 assessor did not have a copy of the 2023 driving anxiety assessment report for his review in connection with the February 2024 treatment plan. It should also be noted that section 24 of the CCRO specifies that the applicant shall immediately advise the Tribunal of any issues in dispute that have been resolved. The inclusion of this treatment plan as an issue in dispute was due to the applicant's error, not the respondent's conduct in relation to the payment of these benefits.

35I find that the respondent is not liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant

ORDER

36I find that:

i. the applicant is partially entitled to the treatment plan for psychological services, proposed by the Center for Psychological and Counseling Services Inc. in a treatment plan dated February 15, 2024, in the amount of $3,898.89.

ii. the applicant is not entitled to $2,686.00 for a Neurological Assessment, proposed by HAL Disability in a treatment plan dated November 30, 2023.

iii. the applicant is not entitled to $2,173.88 for physiotherapy services, proposed by Dun-Dix Healthcare Clinic Inc. in a treatment plan dated December 19, 2023.

iv. the respondent is not liable to pay an award under s. 10 of Reg. 664; and

v. the applicant is entitled to interest pursuant to s. 51 of the Schedule in respect of her partial entitlement to the treatment plan for psychological counsel proposed by the Center for Psychological and Counseling Services Inc.