Licence Appeal Tribunal File Number: 25-010769/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:
Rosa Campos
Applicant
and
Aviva Insurance Company of Canada
Respondent
DECISION
VICE-CHAIR:
Henry Harris
APPEARANCES:
For the Applicant:
Kristoffer Diocampo, Counsel
For the Respondent:
Geoffrey Keating, Counsel
Court Reporter:
Beverly Kowbel
HEARD by Videoconference:
March 24, 2026
OVERVIEW
1Rosa Campos (the “applicant”) was involved in an automobile accident on January 14, 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 Aviva Insurance Company of Canada (the “respondent”) and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
2The applicant advised at the start of the hearing that she would not be calling any witnesses. Further, the respondent was not scheduled to call any witnesses. As such, following an opportunity for the parties to enter documentary evidence, the hearing proceeded directly to closing submissions.
ISSUES
3The issues in dispute are:
i. Is the applicant entitled to $3,181.80 for physiotherapy services, proposed by York Medical in a treatment plan/OCF-18 (“plan”) dated October 4, 2023?
ii. Is the applicant entitled to $4,359.10 for physiotherapy services, proposed by York Medical in a plan dated November 29, 2023?
iii. Is the applicant entitled to $1,630.00 ($3,030.00 less $1,400.00 approved) for social work counselling, proposed by York Medical in a plan dated October 16, 2023?
iv. Is the applicant entitled to $1,950.00 ($4,150.00 less $2,200.00 approved) for social work counselling, proposed by York Medical in a plan dated January 31, 2024?
v. Is the applicant entitled to $2,200.00 for a chronic pain assessment, proposed by York Medical in a plan dated October 17, 2023?
vi. Is the applicant entitled to interest on any overdue payment of benefits?
4At the start of the hearing, the applicant withdrew issues 1, 2, 3 and 4 as listed in the case conference report and order dated December 4, 2025 (the “CCRO”), consisting of catastrophic impairment, income replacement benefits (“IRB”) for two different time periods and a treatment plan for chiropractic services. As a result, the respondent withdrew the preliminary issue raised in relation to IRB.
5For issue (i) above, the CCRO refers to the plan as dated May 10, 2023. However, I have updated to include the correct date of the plan as set out above.
6For issues (iii) and (iv) above, I have updated to reflect that these plans for social work counselling have been partially approved as set out above.
RESULT
7The applicant is not entitled to the outstanding balances or plans in dispute, or interest.
8The application is dismissed.
PROCEDURAL ISSUE
9The respondent raised at the end of its closing submissions that none of the OCF-18s in dispute were made part of the evidentiary record and therefore the Tribunal has no basis to say that any of the plans are reasonable and necessary. The applicant was provided an opportunity to make a reply, however, she did not address the issue of OCF-18s not being entered as part of the record.
10At that stage in the hearing, I noted that the respondent’s explanation of benefits (“EOB”) letters on record did not include the corresponding OCF-18s that form the issues in dispute. Accordingly, I requested that the applicant immediately file the five OCF-18s with the Tribunal.
11The respondent objected to the Tribunal’s request for the filing of the OCF-18s. The respondent argued that the Tribunal established that the evidentiary portion of the hearing ended prior to the start of the closing submissions, and that the respondent would be highly prejudiced if new evidence was admitted after it made its closing submissions. In reply, the applicant noted that she did not have the OCF-18s as they get electronically submitted directly from the service provider to the respondent through HCAI, but that she would obtain copies and provide to the Tribunal.
12I agree with the respondent that the OCF-18s in dispute had not been entered into evidence by the applicant. Indeed, the applicant advised at the start of the hearing that she was not filing a document brief nor calling any witnesses, but rather would be relying on the respondent’s document brief.
13While I note the respondent’s objection, and am alive to the fact that the applicant is obligated to make their own case, I find the missing OCF-18s are evidence necessary for my full and satisfactory understanding of the issues in dispute, as they are the very documents giving rise to the issues between the parties. In this regard, I agree with Executive Chair Lamoureux’s statement in J.R. v. Certas Home Insurance Company, 2018 CanLII 13161 (ON LAT) at para. 21 (Tribunal reconsideration decision), as follows:
Just as an insurer reviews a complete OCF-18 in order to properly decide whether to fund the insured’s request, the Tribunal generally requires the same document in order to properly understand both the insured’s request and the insurer’s response. Put simply, the Tribunal cannot fairly adjudicate an application in most cases without a complete copy of the very document giving rise to the parties’ dispute.
14Further, I do not agree that the respondent is prejudiced by requesting the missing OCF-18s because there is no dispute that these documents exist and that the respondent was in receipt of them. The respondent denied the OCF-18s which form the basis of this dispute. As such, it is aware of the case against it and is in no way prejudiced by my review of the information contained therein. In fact, the respondent made submissions as to the reasonableness and necessity of the treatment plans. In the end, the admission of the missing documents that form the basis of the dispute into evidence allows me to adjudicate this matter with all of the relevant documentation before me.
15Finally, under Rule 9.1 of the Licence Appeal Tribunal Rules, 2023 (the “Rules”), the Tribunal may request further particulars or documentation from a party “at any stage in a proceeding” as it consider “necessary for a full and satisfactory understanding of the issues”. I find that the missing OCF-18s are necessary for my full and satisfactory understanding of the issues in dispute in this matter.
16For these reasons, I am allowing the five OCF-18s into evidence in this hearing.
ANALYSIS
17To receive payment for a plan under sections 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.
The applicant is not entitled to the plans for physiotherapy services proposed by York Medical
18I find the applicant has not proven on a balance of probabilities that the plans for physiotherapy services are reasonable and necessary.
19The plan dated October 4, 2023 prepared by Ms. Sheila Iaboni, physiotherapist, sought funding of $3,181.80 for 20 sessions of physiotherapy and 20 sessions of active rehabilitation.
20The plan dated November 29, 2023 prepared by Ms. Iaboni, sought funding of $4,359.10 for 20 sessions of physiotherapy, 20 sessions of active rehabilitation, and 10 sessions of chiropractic treatment.
21The applicant submits that the plans for physiotherapy are reasonable and necessary because past treatment helped provide temporary pain relief for 3 to 4 hours at a time before the pain returned.
22I acknowledge that the Tribunal has found that medical treatment is reasonable and necessary if it results in the temporary relief from pain if it leads to improvement in function. However, the applicant did not provide any submissions directing me to any evidence to support entitlement to the plans. As already noted above, the applicant did not submit a document brief or call any witnesses. She did not provide me with information as to what specific goods and services were recommended, the goals of the plans, how the applicant would benefit from any of the treatment, the cost and why the plans are reasonable and necessary as a result of the applicant’s accident-related impairments.
23Although I allowed the OCF-18s into evidence at the conclusion of the hearing, this does not negate the absence of submissions by the applicant on the specifics of the plans. It is well-settled that OCF-18s alone are not sufficient evidence of the reasonableness and necessity of a plan. Rather, additional medical evidence is required.
24Further, the applicant’s submissions focussed on critiquing the insurer’s examination (“IE”) reports, arguing the assessments did not engage with her full clinical picture. However, she did not direct me to any contemporaneous medical evidence, such as clinical notes and records (“CNRs”) of a family doctor or rehabilitation clinic, addressing her clinical picture, how it relates to the plans for physiotherapy or other treatment, and the impact of past treatment on her course of recovery. It is not the Tribunal’s role to go through a party’s evidence to make their case for them: see Dooman v. TD Insurance Company, 2025 ONSC 184 at para. 50 (Div. Ct.).
25Accordingly, I find on a balance of probabilities that the applicant has not met her onus of demonstrating that the plans for physiotherapy are reasonable and necessary.
The applicant is not entitled to the unapproved balances for the plans for social work counselling proposed by York Medical
26I find the applicant has not proven on a balance of probabilities that the unapproved balances of the plans for social work counselling are reasonable and necessary.
27The plan dated October 16, 2023 prepared by Dr. San Bui, chiropractor, and Mr. Sebastian Tharimackal Joseph, social worker, sought funding of $1,630.00 ($3,030.00 less $1,400.00 approved) for 12 sessions of social work counselling ($1,680.00 at $140/hour), 4 hours for reassessment/discharge report ($560.00 at $140/hour), and the balance for document review, completion of OCF-18, training and education, and provision of relaxation resources.
28The plan dated January 31, 2024 prepared by Mr. Joseph and Ms. Sheila Iaboni, physiotherapist, sought funding of $1,950.00 ($4,150.00 less $2,200.00 approved) for 20 sessions of social work counselling ($2,800.00 at $140/hour), 4 hours for reassessment/discharge report ($560.00 at $140/hour), and the balance for document review, completion of OCF-18, training and education, and provision of relaxation resources.
29The applicant did not provide any submissions directing me to any evidence to support entitlement to the plans. The applicant did not address what specific goods and services were recommended, the goals of the plans, how the applicant would benefit from any of the treatment, the cost and why the plans are reasonable and necessary as a result of the applicant’s accident-related impairments.
30The respondent explained in its submissions that these plans for social work counselling were partially approved. Specifically, that the total number of sessions in the plans were approved, but at an hourly rate of $100.00, rather than the $140.00 as proposed in the plans. Completion of the OCF-18 in the amount of $200 was also approved, with other ancillary services denied. The respondent submitted that it is well-established that the applicable hourly rate for social workers is not more than $100.00, although no authority was referenced by the respondent.
31The applicant did not indicate that the plans were partially approved, and did not make any submissions on the unapproved balance or other hourly rate for a social worker.
32Although the Professional Services Guideline, Superintendent’s Guideline No. 03/14 (“PSG”) does not provide an hourly rate for social workers, it provides that the maximum hourly rate for unregulated providers is $58.19 per hour. Given that the PSG is silent on the maximum hourly rate for a social worker, it is left to the parties to determine what the acceptable hourly rate would be, and if they are unable to do so, the Tribunal must decide.
33I find that the applicant has not met her burden of proving that an hourly rate greater than $100.00 per hour is reasonable and necessary in the circumstances. The applicant has not directed me to evidence to support an hourly rate greater than $100.00 per hour for social worker services. As a result, I accept that $100.00 per hour is a reasonable hourly rate for social worker services.
34Accordingly, I find on a balance of probabilities that the applicant has not met her onus of demonstrating that the unapproved balances of the plans for social work counselling are reasonable and necessary.
The applicant is not entitled to the plans for a chronic pain assessment proposed by York Medical
35I find the applicant has not proven on a balance of probabilities that the plan for a chronic pain assessment is reasonable and necessary.
36The plan dated October 17, 2023 prepared by Dr. Bui and Dr. Sherman Ho Yin Li, physician, sought funding of $2,200.00 for a chronic pain assessment.
37The applicant did not provide any submissions directing me to any evidence to support entitlement to the plan. The applicant did not address what specific goods and services were recommended, the goals of the plan, how the applicant would benefit from the plan, the cost and why the plan is reasonable and necessary as a result of the applicant’s accident-related impairments.
38Further, I give weight to the IE paper review report of Dr. Ramunas Saplys, orthopaedic surgeon, dated October 26, 2023, which the respondent relied upon in denying the plan. Dr. Saplys opined that the applicant would have achieved maximum medical recovery nine months post-accident and would not have sustained chronic pain as a result of accident-related injuries. As such, Dr. Saplys was of the opinion that a chronic pain assessment was not reasonable or necessary. As already noted above, while the applicant was critical of Dr. Saplys’ reports, she did not direct me to any contemporaneous medical evidence to support this plan. In the absence of any persuasive evidence to the contrary, I accept Dr. Saplys’ opinion.
39Accordingly, I find on a balance of probabilities that the applicant has not met her onus of demonstrating that a chronic pain assessment is reasonable and necessary.
Interest
40Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since no benefits are owing, interest does not apply.
ORDER
41For the reasons outlined above, I find that:
i. The applicant is not entitled to the outstanding balances or plans in dispute, or interest; and
ii. The application is dismissed.
Released: April 30, 2026
Henry Harris
Vice-Chair