Citation: Cardoso v. Definity Insurance Company, 2026 ONLAT 25-002608/AABS

Licence Appeal Tribunal File Number: 25-002608/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:

Elsie Cardoso

Applicant

And

Definity Insurance Company

Respondent

DECISION

VICE-CHAIR:

Henry Harris

APPEARANCES:

For the Applicant:

Bassan Hagos, Counsel

For the Respondent:

Martin Forget, Counsel

Ainsley Shannon, Counsel

Court Reporter:

Siriana Taylor

HEARD by Videoconference:

November 3, 4, 5, 6 and 7, 2025

OVERVIEW

1Elsie Cardoso (the “applicant”) was involved in an automobile accident on November 27, 2019 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:

i. Has the applicant sustained a catastrophic impairment as defined by the Schedule?

ii. Is the applicant entitled to attendant care benefits (“ACB”) in the amount of $1,950.82 per month from May 15, 2023 to July 19, 2023?

iii. Is the applicant entitled to ACB in the amount of $1,836.62 ($2,688.36 less $851.74 approved) per month from July 20, 2023 to ongoing?

iv. Is the applicant entitled to housekeeping benefits in the amount of $100.00 per week from November 27, 2019 to date?

v. Is the applicant entitled to $4,823.00 for ophthalmology services, proposed by Dr. Rick Thompson in a treatment plan/OCF-18 (“plan”) dated October 28, 2024?

vi. Is the applicant entitled to $2,486.00 for a neurological assessment, proposed by Downsview Healthcare Inc. in a plan dated January 19, 2023?

vii. Is the applicant entitled to $1,435.00 for a neuro-optical assessment, proposed by Thompson Optometry in a plan dated May 3, 2023?

viii. Is the applicant entitled to $4,823.00 for an oculo-visual assessment, proposed by Thompson Optometry in a plan dated October 28, 2024?

ix. Is the applicant entitled to $2,200.00 for a physiatry assessment, proposed by Milan Unarket Medicine in a plan dated May 5, 2023?

x. Is the applicant entitled to $2,200.00 for a speech and language therapy assessment, proposed by Speech Therapy Centers of Canada in a plan dated May 18, 2023?

xi. Is the applicant entitled to $2,486.00 for a driving assessment, proposed by Drivelab Inc. in a plan dated June 8, 2023?

xii. Is the applicant entitled to the medical services proposed by Therapy Connections, as follows:

i. $3,415.19 for occupational therapy services, in a plan dated May 28, 2024;

ii. $2,200.00 for an assessment of attendant care needs, in a plan dated May 12, 2023;

iii. $1,200.00 for an occupational therapy assessment, in a plan dated May 12, 2024;

iv. $3,716.80 for occupational therapy services, in a plan dated September 4, 2024;

v. $2,200.00 for a social worker assessment, in a plan dated September 4, 2024;

vi. $5,907.98 ($7,583.69 less $1,675.71 approved) for other assistive devices, in a plan dated August 8, 2024;

vii. $6,820.67 ($7,102.67 less $282.00 approved) for other assistive devices, in a plan dated August 12, 2024;

viii. $240.00 ($3,631.98 less $3,391.98 approved) for occupational therapy services, in a plan dated November 13, 2024;

ix. $3,513.80 for case management services, in a plan dated November 18, 2024;

x. $5,239.71 for other assistive devices, in a plan dated January 17, 2025;

xi. $2,658.99 for occupational therapy services, in a plan dated April 27, 2023;

xii. $2,200.00 for a social work assessment, in a plan dated May 3, 2023; and

xiii. $3,716.80 for rehabilitation support services, in a plan dated June 29, 2023?

xiii. Is the applicant entitled to the medical services proposed by Crystin Franic Occupational Therapy Professional Corporation, as follows:

i. $2,200.00 for an occupational therapy assessment, in a plan dated 9, 2024 (month missing);

ii. $1,200.00 for an occupational therapy assessment, in a plan dated May 9, 2023; and

iii. $4,361.31 ($5,329.71 less $968.40 approved) for home modifications, in a plan dated November 12, 2024?

xiv. Is the applicant entitled to $497.20 for medical services, submitted on a claim form (“OCF-6”) dated August 9, 2024?

xv. Is the applicant entitled to $372.90 ($625.38 less $252.48 approved) for medical massage services, submitted on an OCF-6 dated October 23, 2024?

xvi. Is the applicant entitled to $1,226.90 for medical services, submitted on an OCF-6 dated December 16, 2024?

xvii. Is the applicant entitled to $3,051.55 for other assistive devices, submitted on an OCF-6 dated November 6, 2024?

xviii. Is the applicant entitled to $124.30 ($515.28 less $390.98 approved) for medical services, submitted on an OCF-6 dated January 17, 2025?

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

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

3On the final day of the hearing, the applicant withdrew issue 4(12)(xiii) as listed in the case conference report and order dated July 7, 2025 (the “CCRO”). The issues in dispute have been adjusted accordingly.

4For issue xi above, the CCRO refers to a plan dated June 6, 2023. However, in reviewing the plan it is dated June 8, 2023, which I have reflected above.

5For issue xii(ii) above, the CCRO refers to a plan for occupational therapy services. However, in reviewing the plan, I find it is for an assessment of attendant care needs, which I have reflected above.

6For issue xii(v) above, the CCRO refers to a plan for occupational therapy services. However, in reviewing the plan, I find it is for a social worker assessment, which I have reflected above.

7For issue xii(x) above, the CCRO refers to a plan in the amount of $5,239.71 for other assistive devices dated January 17, 2025. I find there is no plan in that amount before me and that this is duplicative of issue xiii (iii) above ($5,329.71 less $968.40 approved), which I will address in my analysis below.

8For issue xiii(i) above, the CCRO refers to a plan dated “9, 2024”, with the month missing. I have addressed this in my analysis below.

9For issue xiii(ii) above, the CCRO refers to a plan dated May 9, 2023. However, in reviewing the plan it is signed by the applicant on May 12, 2023, which I have reflected above.

10For issue xviii above, the CCRO refers to an amount claimed of $1,214.30 ($515.28 less $390.98 approved). However, in reviewing the plan and the application I find the remaining amount claimed is $124.30, which I have reflected above.

RESULT

11The applicant has not established that she sustained a catastrophic impairment as defined by the Schedule under Criterion 8.

12The applicant has not established entitlement to ACB in any of the disputed amounts claimed for any of the periods in dispute.

13The applicant has not established entitlement to housekeeping benefits.

14The applicant has not established entitlement to the plans in dispute, the expenses claimed on OCF-6s or interest.

15The application is dismissed.

PROCEDURAL ISSUES

Respondent’s motion to strike award claim granted

16At the start of the hearing, the respondent brought a motion to strike the applicant’s special award claim under s. 10 of Reg 664 (the “award claim”) due to not providing particulars of the award claim.

17The respondent submitted that the applicant failed to provide particulars of the award claim within 30 days after receipt of the log notes. The CCRO required the adjusters’ log notes to be provided to the applicant no later the 45 days after the case conference, which would have been August 21, 2025, and for the applicant to provide the respondent with particulars of the award claim not later than 30 days after receipt of the log notes. The respondent produced the log notes for the applicant on August 8, 2025 in compliance with the CCRO. The respondent argued that the purpose of providing particulars is make the respondent aware of the case it has to meet and that be a denial of procedural fairness if the applicant was permitted to proceed with her award claim without providing particulars.

18The applicant argued that this is the fourth Tribunal application relating to this accident, and that particulars of the award claim were provided during the third application. I asked the applicant when such particulars were provided and gave her time to review her file on such details. She was unable to provide a date or details on such prior particulars.

19I granted the respondent’s motion to strike the award claim. I find that particulars of the award claim were not provided to the respondent and that the applicant did not provide a persuasive explanation for her failure to provide such particulars. The applicant’s argument that some particulars were provided in a previous Tribunal applicant was not substantiated by the applicant nor would that be sufficient to comply with the CCRO. Without proper notice of the details of the claim, the respondent is prejudiced as it does not know the claim it must meet and have an opportunity to prepare its response to the particulars of the award claim. It is well established that a party has the right to know the case. The onus is on the applicant to put forward their case, in accordance with the Rules and in compliance with the CCRO. I find it would be a breach of procedural fairness to the respondent to allow the applicant to proceed with the award claim without the particulars being produced in advance of the hearing in accordance with the order made at the case conference. Therefore, the award claim is struck as an issue in dispute at this hearing.

Applicant’s request for adjusters to testify granted

20The applicant requested to have Marriam Maqsood and Angela Cowen, adjusters with the respondent, testify. The applicant argued that summons had been issued for these adjusters, and that their testimony was relevant to an OCF-10 election for benefits and the issue of entitlement to interest for any overdue payment of benefits.

21The respondent objected to allowing the adjusters to testify on the basis that the CCRO has not been complied with in that they were not listed as witnesses in the CCRO, nor in the list of witnesses exchanged by the parties. Further, the respondent argues that the applicant has not provided a summary of the evidence these witnesses will give at the hearing, nor how their evidence would be relevant to the issues in dispute, particularly given that the award claim had been struck as an issue at this hearing.

22I granted the applicant’s request to allow the two adjusters to testify, with limitations. As they would be called as the applicant’s witness, she would be required to proceed by way of direct examination and be limited to 15 minutes for each witness. I note that the applicant remains within her limit of 7 witnesses as set out in the CCRO, including calling the two adjusters as witnesses, and that no issue was raised as to the validity of service of the summonses.

Respondent’s motion to exclude reassessment of attendant care needs report granted

23On the third day of the hearing, during the applicant’s direct examination of Ms. Cristyn Franic, occupational therapist (“OT”), the respondent objected to admitting Ms. Franic’s July 24, 2025 reassessment of attendant care needs report, arguing that it does not relate to an issue currently before the Tribunal. Specifically, that the report relates to a new Assessment of Attendant Care Needs (“Form 1”) dated July 23, 2025, and that this Form 1 is not at issue in this hearing. As such, the respondent has not had opportunity to prepare a response report. The applicant argued that the report relevant as it has Ms. Franic’s most recent observations of the applicant.

24I granted the respondent’s motion to exclude Ms. Franic’s July 24, 2025 report. I find that the applicant had already led evidence of Ms. Franic’s June 27, 2023 assessment of attendant care needs report and the corresponding June 15, 2023 Form 1 which forms the basis of issue of ACB currently in dispute at this hearing. In addition, a letter from Ms. Franic dated October 7, 2024 and Ms. Franic’s clinical notes and records (“CNRs”) were entered into evidence, and Ms. Franic testified at the hearing. I find this would allow the applicant to present Ms. Franic’s observations of the applicant, without prejudicing the respondent by introducing a report that it has not had an opportunity to respond to. I find that this prejudice cannot be mitigated if the report was admitted into evidence.

Neurological report of Dr. Farhadi admitted without cross-examination at consent of the parties

25The parties did not come to the hearing with an agreed timetable for the witnesses to testify. I directed the parties on morning of the first day of the hearing to meet privately to work out the timetable, and took an adjournment to try to accommodate this. There continued to be some uncertainty in the following days of the hearing as to when the section 25 neurosurgeon, Dr. Francis Farhadi, would be available. Ultimately, the respondent accommodated to allow the applicant to call Dr. Farhadi at the only time he was being presented as being available, being the afternoon of the fourth day of the hearing, during the time that the respondent would otherwise be leading its evidence.

26On the afternoon of the fourth day, Dr. Farhadi had to cancel testifying due to a led was unable to testify due to a medical emergency. He was then rescheduled to testify on the final day of the hearing. However, on the morning of the final day of the hearing, the parties advised that Dr. Farhadi would not be attending the hearing and that they had agreed that Dr. Farhadi’s May 24, 2024 neurological assessment report would be entered into evidence, without the respondent having an opportunity for cross-examination. I admitted this report on consent of the parties.

ANALYSIS

Background

27On November 27, 2019, the applicant was the driver of a vehicle involved in accident around 3 pm when she was driving her son home from school. She made a right turn at a stop sign and was hit on the driver’s side by another driver who failed to stop. Airbags did not deploy, she did not lose consciousness and did not hit her head. She exchanged information with the other driver and they called police. As the vehicle was drivable, she was advised to take the vehicle to the nearest collision centre to file a report. She drove home and had her neighbour take her to the collision centre, where she filed a report. The next day she dropped her vehicle off for repair, and left with a rental car.

28The applicant did not seek medical attention at the time of the accident. Two weeks after the accident, on December 11, 2019, she saw her family doctor, Dr. Grant Shechtman, reporting lower left side pain radiating to arch of foot with numbness. She was prescribed pain medication and referred to physiotherapy. Past medical history consists of a previous motor vehicle accident in 2008, where she experienced back pain and was found to have a left side L4-5 herniated disc, and was diagnosed in 2009 with psychological impairments of Major Depressive Disorder (severe), Pain Disorder and Post-traumatic Stress Disorder. The applicant has not been employed since the 2008 accident and continues to receive Canada Pension Plan disability benefits.

The applicant has not sustained a catastrophic impairment under Criterion 8

29I find the applicant has not established that she has sustained a catastrophic impairment as a result of the accident for the reasons that follow.

30The applicant seeks a catastrophic (“CAT”) impairment determination under s. 3.1(1)8 of the Schedule, referred to as Criterion 8. The applicant bears the burden of proof on a balance of probabilities standard.

31In order to meet the threshold for CAT status under Criterion 8, an individual must have sustained at least three marked (class 4) impairments or one extreme (class 5) impairment out of the four spheres of functioning as a result of the accident due to a mental and behavioural disorder. These impairments are assessed under Chapter 14 of the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th Edition, 1993 (the “Guides”).

32Mental and behavioural impairments are rated according to how seriously they affect a person’s useful daily functioning. The Guides sets out the four areas or “spheres” of functioning and the relative levels of impairment. The test to determine whether the applicant has sustained a catastrophic impairment is a legal one and not a medical one: Liu v. 1226071 Ontario Inc. (Canadian Zhorong Trading Ltd.), 2009 ONCA 571 at paras 29-30.

33The four spheres of functioning, five classes of impairment and rating criteria set out in the Guides are outlined in the chart below.

Area or Aspect of Functioning

Class 1: NO Impairment

Class 2: MILD Impairment

Class 3: MODERATE Impairment

Class 4: MARKED Impairment

Class 5: EXTREME Impairment

Activities of Daily Living

No impairment is noted

Impairment levels are compatible with most useful functioning

Impairment levels are compatible with some, but not all useful functioning

Impairment levels significantly impede useful functioning

Impairment levels preclude useful functioning

Social Functioning

Concentration, Persistence and Pace

Adaption (in a work-like setting)

34The parties’ catastrophic assessors gave the following ratings:

Sphere

Applicant

Respondent

Activities of Daily Living

Class 4

Class 2

Social Functioning

Class 4

Class 2

Concentration, Persistence, and Pace

Class 4

Class 2

Adaptation

Class 4

Class 2

35To be satisfied that the applicant meets the definition of CAT impairment, she must demonstrate that: (1) she has a mental/behavioural disorder; (2) that this mental/behavioural disorder is a result of the subject motor vehicle accident; and (3) that the impairments resulting from this mental/behavioural disorder rise to the level of one extreme impairment or marked impairments in three out of four of the domains of functioning.

36The applicant submits that she sustained a CAT impairment under Criterion 8. The applicant relies on the CAT s. 25 assessment report dated January 9, 2024 of Dr. Shrenik Parekh, psychiatrist. In his report, Dr. Parekh refers to the CAT s. 25 assessment report dated November 27, 2023 of Mr. Varun Madan, OT. Dr. Parekh found the applicant to have accident-related diagnoses of Somatic Symptom Disorder with Predominant Pain; Major Depressive Disorder; and Post-Traumatic Stress Disorder. Dr. Parekh rated the applicant with a marked impairment under all four spheres of functioning.

37The respondent submits that the applicant has not proven that she suffers a CAT impairment under Criterion 8 and relies on the CAT insurer’s examination (“IE”) assessment reports dated September 26, 2024, completed by Dr. Nabil Phillips, psychiatrist, and Ms. Jessica Oh, OT, who prepared both an in-home assessment and a situational assessment of the applicant. Dr. Phillips diagnosed the applicant with Adjustment Disorder with Mixed Emotional Features (pre-existing); and Generalized Anxiety Disorder (pre-existing). Dr. Phillips was of the opinion that the accident may have contributed in part to the exacerbation of the underlying symptoms of these disorders. Dr. Phillips found the applicant to have a mild impairment under all four spheres of functioning.

38Given the mental or behavioural disorder diagnoses of the applicant and respondent’s assessors, there is no dispute that the applicant suffers from a mental or behavioural disorder as a result of the accident. Therefore, the only issue in dispute is whether her accident-related mental/behavioral impairments constitute marked impairments in three out of four of the domains of functioning or one extreme impairment under the Guides.

39The applicant has not satisfied me that she meets the CAT threshold under Criterion 8 as I do not find she has a marked impairment in three out of the four areas of function, which I will address now.

Activities of Daily Living (“ADL”)

40I find the applicant has not met her onus to establish that she sustained a marked impairment under the domain of ADL.

41The Guides specify that activities of daily living include such activities as self-care, personal hygiene, communication, ambulation, travel, sexual function, sleep, and social and recreational activities. Any limitation in these activities should be related to the person’s mental disorder. The quality of these activities is judged by their independence, appropriateness, effectiveness, and sustainability given the context of the individual’s overall situation. It is necessary to define the extent to which the individual is capable or initiating and participating in these activities independent of supervision or direction.

42The applicant testified that prior to the accident, as a single mother, she was the primary caregiver to three of her children living at home with her at her home in Etobicoke. At the time of the accident, she cared for her son who was 10 years old and has a learning disability, her daughter who was 13 years old, and a disabled adult daughter in her 20s with fragile X syndrome, a condition that requires constant supervision due to developmental delay. Another daughter in her 30s lives in Toronto. She also cared for her elderly parents, including her father who had been sick for many years and had a stroke as well as being diagnosed with dementia. He would bring them food, take them to appointments and manage their finances including paying bills.

43The applicant was not employed at the time of the accident. She reported to Dr. Phillips that she had not worked since having a previous motor vehicle accident on April 4, 2008. Since that time, she has had herniated disc problems, and that the pain and discomfort, as well as depression and anxiety, were the reasons she has been on long-term disability following the 2008 accident.

44The applicant testified that post-accident she cannot drive, cannot go on the subway, cannot go up and down the stairs, cannot sit for long and cannot enjoy anything. At other times during her testimony, the applicant stated she cannot drive too far or for too long. She said that when she tries to do things she gets overwhelmed. Around the house, she acknowledges that she can fold laundry, wipe the counter, tidy the couch and pillows, and is able to use a stick vacuum for cleaning floors.

45I find the evidence shows the applicant has useful function and is capable of initiating without supervision or direction in important areas of ADL, such as self-care, personal hygiene, communication and ambulation. Both the s. 25 and IE assessments took place more than four years post-accident. During this time, the applicant managed her personal care with little or no assistance. She reported to some assessors that a personal support worker (“PSW”) comes once a week to assist with food preparation (cutting vegetables), hair washing and linen changes. However, both of the applicant’s ACB assessor OTs testified that the applicant was not receiving any attendant care or PSW services at any time prior to their assessments in 2023, and the applicant testified that she does not recall.

46Dr. Parekh, who conducted his assessment virtually, reported that the applicant was offered breaks during the 90 minute assessment but declined. He indicated that the applicant reported that she independently feeds and toilets, but gets assistance from her daughter and PSW with grooming and bathing. He notes she is able to drive locally, and use the phone and computer independently. She can independently make simple meals, as well as manage her money and medications, sometimes requiring reminders. She reported to Mr. Madan that in the morning she gets up slowly due to aggravated pain and stiffness, performs her stretching exercises and grooms herself.

47Dr. Phillips noted that while her activity level is somewhat compromised by neck and back pain and reduced stamina, she has been trying to pace herself by taking longer rests. She is self-sufficient in her daily activities, able to prepare meals for herself and does some light housework. Dr. Phillips opined that, from a psychiatric perspective, the applicant is capable of living independently and performing almost all of the activities of daily living.

48Much of her testimony was focussed on demands being placed on her to care for other people, such as her parents. The ability to care for others, while not a direct consideration for ADLs, may show that if a person has the capacity to care for others, they are able to care for themselves. Dr. Phillips testified that the applicant has been carrying out the role of caregiving in the home environment. There was no evidence presented of neglect of her children in the nearly six years since the accident, with her son who is now a 16 year old high school student, a daughter 19 years old in university, and a disabled adult daughter in her late 20s. Overall, the evidence shows that her impairment levels are compatible with most useful functioning.

49Accordingly, I find the applicant has not met her onus to establish that she sustained a marked impairment under the domain of ADL.

Social Functioning

50I find the applicant has not sustained a marked impairment under the domain of social functioning.

51The Guides specify that the factors to consider under the social functioning domain are an individual’s capacity to interact appropriately and communicate effectively with other individuals. It includes the ability to get along with others, such as family members, friends, neighbours, grocery clerks, landlords or bus drivers. Impaired social functioning may be demonstrated by a history of altercations, evictions, fear of strangers, avoidance of interpersonal relationships, social isolation, or similar events or characteristics. An individual’s ability to initiate social contact with others, communicate clearly with others, and interact and actively participate in group activities are seen as strengths in social functioning.

52The applicant testified that prior to the accident she enjoyed watching her kids play sports, going to parks and museums, and taking the train for different day trips. She would go to the community centre and swim, and would sometimes go out for lunch or dinner. She would help her son with homework, and sometimes watch the hockey game on TV. Post-accident, the applicant says that she cannot do any of these activities anymore. She has trouble focussing when trying to have a conversation and it makes her head hurt and she becomes tired. She gets overwhelmed when there are too many people around or too many things going on. She testified that she does not have any friends and does not really talk to people.

53Dr. Parekh cites the applicant’s reporting to Mr. Madan that she has very little motivation to socialize post-accident. She does not like to meet people, declines invitations, does not like to entertain at home and feels embarrassed due to her injuries.

54I find this to be inconsistent with various records that show the applicant demonstrating the capacity to interact appropriately and communicate effectively with others. The CNRs of Mr. Andrew Peterkin, psychotherapist, who the applicant saw on a weekly basis during the period of September 2021 to February 2022, document that during this time she was taking care of her kids, helping her parents, helping neighbours and visiting a friend. The applicant complained that she did not have time for herself, as a result of these responsibilities and interactions with family and friends. On Mr. Peterkin’s advice, the applicant implemented strategies such as working on a schedule for tasks including setting times for rest and coping strategies for stress, such as journaling, going for walks, writing, watching TV and playing video games (such as Zelda) with her son.

55Mr. Peterkin also documents that they worked on strategies to set boundaries with the demands of her mother and her children. The applicant reported that she felt proud of herself for implementing these strategies. The CNRs of Mr. Peterkin indicate that she reported she was doing better with relationships and seeing changes as a result of communicating and having family members respect her boundaries. She also wants to start building healthy relationships with others again and “mentioned a guy she knows that she may ask to get coffee with”. When various questions regarding these strategies were put to the applicant on cross-examination including her seeing Mr. Peterkin for therapy, her responses were all that she “does not recall”. Both Dr. Parekh and Dr. Phillips reviewed Mr. Peterkin’s CNRs as part of their assessments.

56Further, Ms. Oh, testified in connection with her in-home and situational assessment of the applicant in July 2024, that the applicant described that she remains very close with her children and that they talk and interact regularly. She also indicated that she maintains a close relationship with her mother, although she has less patience for her. She maintains amicable contact with her neighbours, but that she has not seen or gone out with her friends “in years”, although they text once in a while. She reported that she is able to maintain polite exchanges with service staff, service providers, and members of the public to complete errands.

57During a community outing task that involved a visit to a bakery chosen by the applicant, Ms. Oh observed her allowing a construction worker to go ahead of her in line while she decided what she wanted to order. She also quietly told the bakery clerk that the items she ordered were overcooked. Ms. Oh testified that these acts demonstrated emotional regulation and an awareness that she did not want to be loud or cause a scene in the bakery.

58Such capacity to interact appropriately and communicate effectively with other individuals are seen as strengths in social functioning in the Guides.

59Accordingly, I find the applicant has not met her onus to establish that she sustained a marked impairment under the domain of social functioning.

60As a result, since the applicant cannot meet the minimum required three marked impairments and has not been assessed to have an extreme impairment, I do not need to assess the applicant’s impairment level in concentration, persistence, and pace, or adaptation. However, for completeness I note that the applicant’s impairments do not rise to the level of marked in those domains for the reasons that follow.

Concentration, Persistence and Pace (“CPP”)

61I find the applicant has not sustained a marked impairment under the domain of CPP.

62The Guides specify that CPP refers to the ability to sustain focused attention long enough for the timely completion of tasks commonly found in work settings. In activities of daily living, concentration may be reflected in the ability to complete everyday household tasks. Deficiencies in CPP are best noted from previous work attempts or from observations in work-like settings. The Guides specify that psychological tests are useful in assessing intelligence, memory and concentration. Strengths and weaknesses in mental concentration may be described in terms of frequency of errors, the time it takes to complete the task and the extent to which assistance is required to complete the task.

63The applicant testified she has trouble focussing and gets overwhelmed when there are too many people around or too many things going on, and as a result feels she is unable to get things done.

64Dr. Parekh opined that the applicant’s preoccupation with pain symptoms, distractibility and fatigue will affect her ability to perform detailed step by step instructions. He further found that poor motivation and psychoemotional issues as a result of her injuries further impact her ability.

65Dr. Phillips noted that the applicant is able to initiate tasks and that her focus and attention is preserved when she is busy doing her own tasks. He found that she was able to present her thoughts and feels in an organized manner, and that her subjective complaints of forgetfulness have not reached a level to provide an objective, measurable concern.

66I find the evidence, including as discussed in the domains above, demonstrates the applicant’s ability to sustain her focused attention to complete tasks in work-like settings. As a further example, she reported to Mr. Peterkin in 2022 that her daughter was tricked out of getting a refund from a store for shoes that she bought for her boyfriend. The applicant took her daughter back to the store and was able to get the refund for her daughter. She reported that she was proud of herself, and felt stronger and capable of doing more for herself and was building confidence, stating “I can now stand my ground”. Dr. Phillips testified that this demonstrates an ability to complete a complex cognitive and social task. That she is able to be analytical in considering what is right vs. wrong, assertive enough to go to the person who did the wrong, and to give feedback that she is proud of her actions. He indicated this goes against major depression.

67Another example in the area of CPP is the July 2024 situational assessment. Prior to Ms. Oh arriving for the community outing, the applicant reported that she woke up at 5am, washed up and got dressed, had coffee and went to McDonalds for pick up. Ms. Oh testified that this demonstrates her motivation and taking care of herself. For the situational assessment, she gathered the money for the budget, took her cane and informed her daughter she was stepping out. In walking to the bakery, she engaged in light conversation with Ms. Oh while maintaining focus as she walked through a construction area and traffic. Ms. Oh testified that her ability to persist in the task when faced with all this outside stimuli demonstrates functional cognition and emotional regulation. In contrast, I note that the applicant declined completing a community outing in October 2023 with the applicant’s assessor, Mr. Madan, citing feeling tired and in pain. As such, Dr. Parekh did not have the benefit of observations of the applicant’s interactions in the community as part of their respective assessments. I find the July 2024 community outing to provide valuable insight into the applicant’s abilities to focus in completing tasks and appropriate social engagement in daily tasks.

68In addition, surveillance evidence relied on by the respondent shows the applicant engaging independently in various activities. On February 1, 2024, the applicant is seen attending to multiple errands. She is observed leaving her house unaccompanied at 10am, driving to a bakery and walking in and making purchases, attending RBC Bank, Sobeys grocery store to shop, driving to Royal York TTC station to make a purchase, going through Tim Hortons drive-thru and returning home around 11:30 am. In the afternoon she drove to her parents at 2 pm, picked them up and drove them to St. Joseph’s hospital. Other surveillance conducted that week showed days of multiple errands that the applicant undertook by car, driving throughout the day. While I appreciate that surveillance is a snapshot in time, the surveillance taken over a number of days shows a level of functioning in activities, including accessing the community through driving, shopping walking and interacting with people in stores and elsewhere. She is able to navigate to her intended destinations without getting lost, find her car where she parked it on the street or parking lot, and pay for her purchases, including pumping gas and paying with her credit card.

69I find these examples considered together, show a pattern that demonstrates an ability to sustain a level of focused attention necessary to complete such tasks.

70Accordingly, I find the applicant has not met her onus to establish that she sustained a marked impairment under the domain of CPP.

Adaptation

71I find the applicant has not met her onus to establish that she sustained a marked impairment under the domain of adaptation.

72The Guides specify that adaptation is the functional ability to adapt to stressful circumstances in work or work-like settings. Deterioration or decompensation in work or work-like settings refers to the repeated failure to adapt to such stressful circumstances, in which an individual may withdraw from the situation or experience an exacerbation of signs and symptoms of a mental disorder. The person may decompensate or have difficulty maintaining activities of daily living, continuing social relationships, and completing tasks. Stressors common to the environment include attendance, making decisions, scheduling, completing tasks and interacting with others.

73As noted, the applicant has not worked since her previous motor vehicle accident in 2008, and has remained on long-term disability.

74Dr. Parekh opined that the applicant’s injuries are interfering with her ability to cope. He found that she would have difficulty maintaining a pace for employment or activities based on her performance at the assessment, and that she is likely to experience problems with attendance and punctuality in the presence of pain symptoms.

75For his report, Dr. Parekh considered the fact that the applicant did not participate in the community task or a household cleaning/vacuuming task during Mr. Madan’s assessment. As previously noted, Dr. Parekh and Mr. Madan did not have the benefit of observations of the applicant in the community, including the July 2024 situational assessment conducted by Ms. Oh, as part of their respective assessments. I find the observations from those activities to be relevant to the domain of adaptation as they show some functioning in work-like settings. I prefer Dr. Phillips’ opinion on adaptation, as his report considered such situational assessment in opining that the applicant is capable of making decisions and problem-solving, that her social skills and ability to establish rapport are preserved. He also noted that increased stress appeared to increase somatic symptoms such as increased pain, leading to his rating of the applicant as having a mild impairment in the domain of adaptation.

76I find that the examples discussed above in the other areas of function, demonstrate an ability for several years post-accident to engage in activities that suggest a reasonable ability to adapt and manage stressors in work-like settings. She continues to care for her family and access the community by driving. Her choice to drive and shop during the week at less busy times, demonstrates a level of adaptation.

77There were significant differences in how the applicant reported her level of activity to the assessors. She described to the applicant assessor, Mr. Madan, that her activity level on a typical day was somewhat sedentary; she watches TV or takes a nap, goes for short walks and performs light home chores. In contrast, she reported to Ms. Oh in the IE assessment that occurred in July 2024 that she goes out for coffee, picks up some food, plans lunch, goes to No Frills with someone, hangs out by the TV while her son plays video games. Further, she tries to have lunch with whoever is at home, preparing something simple or going out to get something. Based on the examples noted in the sections above, I find the level of activity documented in the IE assessment to be more representative of the applicant’s daily activities and functioning.

78None of these activities, which required sustained ability to adapt, suggest an applicant that is significantly impeded in useful functioning in the area of adaptation.

79Accordingly, I find the applicant has not met her onus to establish that she sustained a marked impairment under the domain of adaptation.

CAT Criterion 8 Conclusion

80Without at least three marked or one extreme impairment, the applicant cannot meet the minimum required to be found catastrophically impaired.

81Accordingly, for the reasons set out above, I find that the applicant has not proven on a balance of probabilities that she sustained a catastrophic impairment under Criterion 8 in accordance with the Schedule as a result of the accident.

The applicant is not entitled to ACB for the time periods claimed

82I find the applicant has not established entitlement to ACB in any of the disputed amounts claimed for any of the periods in dispute.

83Section 19 of the Schedule states that an insurer shall pay for all reasonable and necessary expenses incurred by or on behalf of an insured person as a result of an accident for ACBs provided by an aide or attendant.

84Section 20(1) provides that for a non-CAT impaired person, no ACBs are payable for expenses incurred more than 260 weeks after the accident. Such limitation does not apply if the person has sustained a CAT impairment, or if the person has optional benefits. The parties acknowledge that the applicant has optional benefits, as is also indicated in the application to the Tribunal.

85Section 3(7)(e) provides that to meet the definition of incurred the following three criteria must be satisfied:

i. The applicant received the service to which the expense relates;

ii. The applicant paid the expense or promised to pay the expense or is legally obligated to pay the expense; and

iii. The person who provided the service:

a. did so in the course of his or her employment, occupation, or profession in which he or she would ordinarily have been engaged, but for the accident; or

b. sustained an economic loss as a result of providing the goods or services to the insured person.

86I find the applicant has not established that any ACBs are payable for the periods in dispute because she did not direct me to evidence that ACB expenses in the amounts in dispute have been incurred by her to the date of the hearing. In her closing submissions, the applicant referred to an account activity summary of Advanta that had been entered as an exhibit, but did pinpoint anything within the summary from me to consider. The applicant did not refute the respondent’s submission that she has not incurred the monthly ACB of $851.74 since it was approved in July 2023. As well, the applicant did not provide submissions as to whether ACBs are reasonable and necessary pursuant to s.19 of the Schedule, specify what amount of ACBs had been incurred and when, or direct me to specific evidence in the exhibit to demonstrate incurred. 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.).

87In addition, for the period of May 15, 2023 to July 19, 2023, the applicant relies on the Form-1 completed by Mr. Varun Madan, OT, dated May 3, 2023 which assessed monthly ACB of $1,950.82, and Mr. Madan’s s. 25 attendant care assessment report dated May 15, 2023. I am not persuaded by Mr. Madan’s report as he testified he made his recommendations without reviewing any pre-accident records. Further, he did not review records of the family doctor or prescription summaries, either pre or post-accident. He placed significant reliance on the applicant’s self-reporting. As well, he made his recommendations for attendant care needs with limited testing or observing. For participation in self-care, he only performed a single test of having the applicant don on/off socks to test her ability, which she was able to complete independently, although she reported aggravated pain. As such, I give little weight to Mr. Madan’s recommendations for attendant care needs.

88For the period from July 20, 2023 to ongoing, the applicant relies on the Form-1 completed by Ms. Cristyn Franic, OT, dated June 15, 2023 which assessed monthly ACB of $2,688.36 of which $851.74 was approved, leaving $1,836.62 in dispute, and Ms. Franic’s s. 25 attendant care assessment report dated June 27, 2023. No explanation was provided as to why this second Form-1 for the applicant was completed just over one month after the Form-1 prepared by Mr. Madan. As well, Ms. Franic’s Form-1 recommended basic supervisory care, which had not been recommended by Mr. Madan. Ms. Franic testified that she included this as she felt the applicant needed custodial care due to changes in her behaviour, specifically high levels of anxiety and depression symptoms found in questionnaires that were completed. Ms. Vanessa Dwyer, the IE OT assessor who completed a Form-1 dated July 20, 2023 and assessment of attendant care needs report dated July 31, 2023, testified that she was of the opinion that the applicant had the physical and cognitive capabilities to be self-sufficient in an emergency situation and did not demonstrate the criteria to require supervisory care. I find the explanation provided by Ms. Dwyer to be consistent with the findings of Mr. Madan, and as such prefer this over the recommendations of Ms. Franic, all of which were assessed within a period of two months. As such, I give little weight to Ms. Franic’s attendant care needs recommendations.

89Accordingly, I find on a balance of probabilities that the applicant has not established entitlement to ACB in any of the disputed amounts claimed for any of the periods in dispute. This finding does not interfere with any ongoing entitlement to monthly ACB of $851.74 as approved by the respondent in July 2023, if incurred subsequent to the hearing in compliance with the Schedule.

The applicant is not entitled to housekeeping benefits

90Section 23 of the Schedule provides that housekeeping and home maintenance benefits are only available to those who have sustained a CAT impairment. Since I have determined that the applicant is not CAT impaired, she is not entitled to this benefit.

91To 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.

92It is well established that applicants to the Tribunal are obligated to make their own case, and as part of this obligation, applicants must adduce all evidence which they need or intend to rely on. The Tribunal may not satisfy their evidentiary burden for them.

93The respondent noted that the OCF-18s were not made part of the record and therefore the Tribunal has no basis to say that any of the plans are reasonable and necessary. I do not agree. Although the OCF-18s were not entered into evidence by the applicant, I do have them before me through the parties’ filings with the Tribunal and find that the applicant is relying on them. The respondent denied the OCF-18s which form the basis of this dispute and as such, it was aware of the case against it. In order to fully and properly assess the reasonableness and necessity of the disputed plans, I must consider them as it forms the basis of the parties’ dispute: see: J.R. v. Certas Home Insurance Company, 2018 CanLII 13161 at para. 21 (Tribunal reconsideration decision). However, I will be guided by the parties’ submissions in the context of my review of the plans.

The applicant is not entitled to the plans proposed by Dr. Rick Thompson/Thompson Optometry

94I find the applicant has not proven on a balance of probabilities that the plans for ophthalmology/optometric services are reasonable and necessary.

95Issue vii: The plan dated May 3, 2023 prepared by Dr. Rick Thompson, optometrist, sought funding of $1,435.00 for a neuro-optical assessment.

96Issue v: The plan dated October 28, 2024 prepared by Dr. Thompson, sought funding of $4,823.00 for various services, including vision therapy, prism eyeglasses and an oculo-visual reassessment.

97Issue viii: The CCRO identifies a plan dated October 28, 2024 proposed by Thompson Optometry seeking funding of $4,823.00 for an oculo-visual reassessment. This appears to be a duplicate of issue v, as it has the same date, amount, same clinic and substantially the same services. A second plan of same date was not found in the parties’ filings.

98A treatment plan in and of itself is insufficient to establish entitlement to a benefit. The applicant did not provide any submissions or direct me to any evidence to support entitlement to the plans. 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. In addition, the plan identified in issue viii appears to be a duplication of the plan listed as issue v.

99Accordingly, I find on a balance of probabilities that the applicant has not met her onus of demonstrating that these plans are reasonable and necessary.

The applicant is not entitled to the plan for a neurological assessment

100I find the applicant has not proven on a balance of probabilities that the plan for a neurological assessment is reasonable and necessary.

101Issue vi: The January 19, 2023 plan prepared by Dr. Vincenzo Basile, physician, sought funding of $2,486.00 for a neurological assessment, inclusive of $200.00 for documentation support, plus tax. The goal of the plan is to determine if there is an accident-related neurological impairment and to provide recommendations for recovery. Additional Comments indicate that a neurological consultation is recommended to explore further treatment options, given the positive MRI and EMG/NCS findings.

102The applicant did not provide any submissions or direct me to any evidence to support entitlement to this plan. In addition, in the April 12, 2023 IE report of Dr. Verity John, neurologist, Dr. John was of the opinion that the applicant should be examined by a neurosurgeon due to signs of L5-S1 radiculopathy. He noted that there are several attempts since 2021 for referrals to a neurosurgeon from her family doctor, Dr. Grant Shechtman. Dr. John reviewed the medical records, including pre- and post-accident MRIs and an EMG report of Dr. Dinesh Kumbhare dated November 15, 2022, which shows chronic left L5-S1 nerve root injury. Given the need to see a neurosurgeon, he was of the opinion that a neurological consultation with Dr. Basile, a neurologist, was not reasonable or necessary, as she has a diagnosis and would likely require surgery. He found that she was in need of a consultation with a neurosurgeon. I am persuaded by Dr. John’s report as he based his opinion on his examination of the applicant and a review of her medical history, including medical imaging. The recommendation for a consultation with a neurosurgeon was also confirmed by Dr. Farhadi, neurosurgeon, in his s. 25 assessment report dated May 24, 2024.

103Accordingly, I find on a balance of probabilities that the applicant has not met her onus of demonstrating that this plan is reasonable and necessary.

The applicant is not entitled to the plans for assessments in physiatry, speech and language therapy or functional driver/passenger/pedestrian

104I find the applicant has not proven on a balance of probabilities that the plans for assessments are reasonable and necessary.

105Issue ix: The May 5, 2023 plan prepared by Dr. Milan Unarket, physician, sought funding of $2,200.00 for a physiatry assessment. The breakdown of the services is $400.00 for completion of OCF-18, $400.00 for assessment and advice on treatment, $400.00 for assessment and examination, $400.00 for file review and report preparation, and $800.00 for medical report preparation. The goals of the plan are to coordinate medical care from a physiatry perspective, assess nature and severity of the impairments, and assist the case manager/multidisciplinary team with appropriate course of rehabilitation.

106Issue x: The May 18, 2023 plan prepared by Ms. Kathleen Arnold, speech-language pathologist, sought funding of $2,200.00 for a speech-language and cognitive-communication assessment, inclusive of $200.00 for documentation support. The goal of the plan is to investigate cognitive-communication challenges to better understand the applicant’s communication profile and make recommendations for treatment.

107Issue xi: The June 8, 2023 plan prepared by Ms. Carol Kelly, OT, sought funding of $2,200.00 for a functional driver/passenger/pedestrian assessment, inclusive of $200.00 for documentation support. The goal of the plan is to reduce fear/anxiety as a driver/passenger/pedestrian.

108The applicant did not provide any submissions or direct me to any evidence to support entitlement to these plans for assessments. The denial letters/explanation of benefits cite Dr. John’s April 12, 2023 IE report which found that the applicant should be examined by a neurosurgeon and did not make any other recommendations for assessments or examinations.

109Accordingly, I find on a balance of probabilities that the applicant has not met her onus of demonstrating that these plans are reasonable and necessary.

The applicant is not entitled to the plans proposed by Cristyn Franic/Therapy Connections for assessments or services

110I find the applicant has not proven on a balance of probabilities that the following plans proposed by Ms. Cristyn Franic/Therapy Connections (including Mr. Brenton Mitchell, OT) are reasonable and necessary.

111Many of these plans identified as separate issues appear to be the same or similar plan resubmitted by Ms. Franic subsequent to the initial plan being denied, as discussed herein.

Assessments

a. Social work assessments

112Issue xii (xii): The plan dated May 3, 2023 prepared by Ms. Franic, OT, sought funding of $2,200.00 for a social work assessment, inclusive of $200.00 for documentation support. The goal of the plan is to outline the applicant’s counselling needs. The assessment is proposed to be conducted by Ms. Jennifer Robyn, social worker.

113Issue xii (v): The plan dated September 4, 2024 prepared by Ms. Franic sought funding of $2,200.00 for a social work assessment, inclusive of $200.00 for documentation support. The goal of the plan is to outline the applicant’s counselling needs. The assessment is proposed to be conducted by Ms. Jessica Helm, social worker.

114The applicant did not provide any submissions or direct me to any evidence to support entitlement to these plans for social work assessments, the substance of which appear to be identical, other than proposing the services of a different social worker. Additional Comments in the September 4, 2024 plan confirms that Ms. Franic is requesting reconsideration of the plan for the social work assessment.

115Accordingly, I find on a balance of probabilities that the applicant has not met her onus of demonstrating that these plans are reasonable and necessary.

b. OT assessments

116Issue xiii (ii): The plan dated May 9, 2023 prepared by Ms. Franic, sought funding of $1,200.00 for an OT assessment, inclusive of $200.00 for documentation support. The goal of the plan is to evaluate the applicant’s current level of motor and processing skills. The comments indicate the plan was originally submitted on May 15, 2023 and resubmitted on September 12, 2024, and that the assessment was needed to identify the applicant's post-accident impairments, personal care needs and functional abilities.

117Issue xii (iii): The plan dated May 12, 2024 prepared by Ms. Franic, sought funding of $1,200.00 for an OT assessment, as set out in the CCRO. Per comments on above issue, the September 17, 2024 denial letter/explanation of benefit advised the applicant that the plan is a duplicate of the May 9, 2023 plan which was denied on May 15, 2023.

118The applicant did not provide any submissions or direct me to any evidence to support entitlement to these plans for OT assessments. In addition, the September 17, 2024 denial letter/explanation of benefit plan indicate that these plans are duplicates, with the original plan dated May 9, 2023 being denied on May 15, 2023 and then resubmitted by Ms. Franic and denied on September 17, 2024.

119Accordingly, I find on a balance of probabilities that the applicant has not met her onus of demonstrating that these plans are reasonable and necessary.

c. OT assessment of attendant care needs

120Issue xii (ii): The plan dated May 12, 2023 prepared by Ms. Franic, sought funding of $2,200.00 for an assessment of attendant care needs, inclusive of $200.00 for documentation support. The goal of the plan is to assess current attendant care needs.

121Issue xiii (i): The plan dated “9, 2024” (month missing) prepared by Ms. Franic, sought funding of $2,200.00 for an OT assessment, as set out in the CCRO. This error was not addressed by the parties and I was unable to reconcile it with the documents filed. The CCRO indicates this is one of several issues the applicant requested to add. In reviewing the applicant’s Schedule A to her case conference summary, there is no issue listed of a 2024 plan prepared by Ms. Franic in this amount. There is an issue listed as submitted on May 9, 2023 and denied on May 16, 2023, however, I have I have no information on this or any basis to determine if this was the plan dated “9, 2024” (month missing).

122The applicant did not provide any submissions or direct me to any evidence to support entitlement to these plans for assessments. In addition, the September 12, 2024 denial letter/explanation of benefit indicates another plan for an assessment of attendant care needs was approved for Downsview Healthcare on May 10, 2023 and that it considers this to be a duplication of services.

123Accordingly, I find on a balance of probabilities that the applicant has not met her onus of demonstrating that these plans are reasonable and necessary.

Services

124Issue xii (xi): The plan dated April 27, 2023 prepared by Mr. Brenton Mitchell, OT, sought funding of $2,658.99 for occupational therapy services. The goal of the plan is to coordinate medical and rehabilitation needs. The majority of the funding relates to brokerage and planning services, with $786.91 for documentation support ($495.95) and provider travel time ($290.96). The May 12, 2023 denial letter/explanation of benefit cites Dr. John’s April 12, 2023 IE report.

125Issue xii (xiii): The CCRO refers to a plan dated June 29, 2023 (to which I find the correct date to be June 15, 2023) prepared by Ms. Franic, sought funding of $3,716.80 for rehabilitation support services. The goal of the plan is to provide home and community support. Most of the funding relates to cognition and learning skills training of $1,396.56 and provider travel time of $931.04. The June 28, 2023 denial letter/explanation of benefit cites Dr. John’s April 12, 2023 IE report.

126Issue xii (i): The plan dated May 28, 2024 prepared by Ms. Franic, sought funding of $3,415.19 for occupational therapy services. The goal of the plan is to coordinate medical and rehabilitation needs. The breakdown of the plan is $2,007.53 for brokerage and planning services, $523.71 for provider travel time, and $490.95 for documentation support, plus tax. I note this is similar to the denied plan of April 27, 2023 above.

127Issue xii (iv): The plan dated September 4, 2024 prepared by Ms. Franic, sought funding of $3,716.90 for occupational therapy services. The goal of the plan is to provide home and community support. This is substantially the same as the above denied plan of June 15, 2023, with $1,396.56 relating to cognition and learning skills training and $931.04 for provider travel time. The September 18, 2024 denial letter/explanation of benefit notes this duplication and requests an IE for the applicant.

128Issue xii (viii): The plan dated November 13, 2024 prepared by Ms. Franic, sought funding of $240.00 ($3,631.98 less $3,391.98 approved) for occupational therapy services. The goal of the plan is to provide ongoing occupational therapy treatment to increase safety, engagement and independence in ADLs. The November 29, 2024 denial letter/explanation of benefit shows that the plan was approved, other than $240.00 for provider mileage to treatment, noting that authorized transportation expenses are intended to apply to expenses the insured person incurs for their (or their aide or attendant) travel to and from treatment sessions. The applicant made no submissions to support entitlement to provider mileage. I find the respondent’s explanation is consistent with the definition of authorized transportation expense in s. 3(1) of the Schedule.

129Issue xii (ix): The plan dated November 18, 2024 prepared by Ms. Franic, sought funding of $3,513.80 for case management services. The goal of the plan is to coordinate medical and rehabilitation needs. The breakdown of the plan is $2,094.90 for brokerage and planning services, $523.71 for provider travel time, and $490.95 for documentation support, plus tax. I note this is similar to the denied plans of May 28, 2024 and April 27, 2023 above.

130The applicant did not provide any submissions or direct me to any evidence to support entitlement to any of these plans for services or the remaining balances for those plans that have been partially approved. A treatment plan in and of itself is insufficient to establish entitlement to a benefit. The denial letters/explanation of benefits outline the basis for each denial.

131Accordingly, I find on a balance of probabilities that the applicant has not met her onus of demonstrating that these plans or the remaining balances for those plans that have been partially approved are reasonable and necessary.

The applicant is not entitled to the plans proposed by Cristyn Franic for assistive devices and home modifications

132I find the applicant has not proven on a balance of probabilities that the remaining balances for the following plans proposed by Ms. Franic are reasonable and necessary.

Issues xii (vi) and xii (vii)

133Issue xii (vi): The plan dated August 8, 2024 prepared by Ms. Franic, sought funding of $5,907.98 ($7,583.69 less $1,675.71 approved) for other assistive devices. The goal of the plan in recommending 35 assistive and pain management devices is to increase safety and engagement in ADLs, and minimize symptoms. The plan included a Golden Infinite lift/recline chair in the amount of $2,899.00. The September 26, 2024 denial letter/explanation of benefit addresses this plan. The respondent denied various devices in reliance on the September 19, 2024 IE OT paper review report of Ms. Dwyer.

134Issue xii (vii): The plan dated August 12, 2024 prepared by Ms. Franic, sought funding of $6,820.67 ($7,102.67 less $282.00 approved) for other assistive devices. The goal of the plan in recommending a walker, adjustable bed and supportive mattress, is for safe mobility and to improve sleep quality. The September 26, 2024 denial letter/explanation of benefit also partially approves this plan. The respondent approved the walker and documentation support, but denied the adjustable bed and supportive mattress in reliance on the September 19, 2024 IE OT paper review report of Ms. Dwyer.

135In support of these plans, the applicant relies on Ms. Franic’s October 7, 2024 OT letter for further justification, which was prepared in response to Ms. Dwyer’s IE report. Ms. Franic testified that her recommendations were based on her observations as the applicant’s treating OT as well as her previous assessments. She indicated that the applicant still has ongoing physical, cognitive and psychological symptoms, and reduced mobility. Ms. Franic’s testimony was focussed on certain of the recommended assistive devices, primarily relating to sit/stand transfers, including the adjustable bed and supportive mattress, recline chair and sit/stand stool.

136The respondent submits that the denied devices in the plans are not reasonable and necessary, and relies on the Ms. Dwyer’s IE report. Ms. Dwyer’s finding was informed by the applicant reporting that she is independent in sitting to standing, transfers, bed mobility and shower transfers. Ms. Dwyer testified that when she assessed the applicant in July 2023, and again in June 2024, she was able to maintain balance while on the stairs with a reciprocal gait pattern, including observing the applicant going up and down the stairs, from upstairs down to the basement. She was able to complete transfers and do some functional movements, while maintaining balance and stability.

137I find the applicant has not satisfied her onus of demonstrating that the remaining assistive devices are reasonable and necessary. In Ms. Dwyer’s July 4, 2024 report, she notes the applicant reported that she is independent in sitting to standing transfers, bed mobility and shower transfers, which Ms. Dwyer observed the applicant performing slowly and cautiously. As examples, due to such independence in transfers, Ms. Dwyer found that devices such as the adjustable bed and supportive mattress, lift/recline chair and sit/stand stool, were not reasonable or necessary. I am persuaded by Ms. Dwyer’s report and findings, as they are based on both the applicant’s reported ability and her observations during two assessments over the period of July 2023 to June 2024.

138While the applicant suggested that greater weight should be given to Ms. Franic as she is the treating OT and would therefore have more detailed observations, she acknowledged in cross-examination that she began seeing the applicant virtually starting July 30, 2024 and had only seen the applicant once in-person in 2024 (August 6, 2024), prior to submitting these two plans for assistive devices. As such, I am not persuaded by the applicant’s argument.

139Accordingly, I find on a balance of probabilities that the applicant has not met her onus of demonstrating that the remaining balances for these plans are reasonable and necessary.

Issues xiii (iii) and xii (x)

140Issue xiii (iii): The plan dated November 12, 2024 prepared by Ms. Franic, sought funding of $4,361.31 ($5,329.71 less $968.40 approved) for home modifications. The goal of the plan for handrails and aids is to increase home accessibility and safety, reduce pain and increase ADL. The March 29, 2025 denial letter/explanation of benefit addresses this plan. The respondent approved or partially approved some of the home modifications and denied the remainder of the plan in reliance on the March 17, 2025 IE OT assessment of Ms. Dwyer.

141Issue xii (x): The CCRO refers to plan dated January 17, 2025 prepared by Ms. Franic, sought funding of $5,239.71. I find there is no plan in that amount before me. Item 15 of the application lists a plan for other assistive devices (handrails) prepared by Ms. Franic in the amount of $5,329.71 (not $5,231.79) submitted November 13, 2024 and denied November 28, 2024. In the absence of any other explanation, I find that this is duplicative (the same plan) as issue xiii (iii) above, which was an added issue in the CCRO.

142The applicant did not provide any submissions or direct me to any evidence to support entitlement to these plans. A treatment plan in and of itself is insufficient to establish entitlement to a benefit.

143Accordingly, I find on a balance of probabilities that the applicant has not met her onus of demonstrating that these plans or the remaining balances for those plans that have been partially approved are reasonable and necessary.

OCF-6 Expense Claims – Issues xv-xviii

144The onus is on the applicant to demonstrate that she is entitled the expenses claimed. Pursuant to s.15 and 16 of the Schedule, the insurer shall pay for all reasonable and necessary expenses incurred by or on behalf of the insured person for medical and rehabilitation benefits.

145Section 38(2) states that an insurer is not liable to pay an expense in respect of a medical or rehabilitation benefit that was incurred before the insured person submits a treatment and assessment plan (OCF-18), unless: (a) the insurer gives the insured person notice stating that it will pay the expense; (b) the expense is for an ambulance or other goods and services provided on an emergency basis not more than five business days after the accident; (c) the expense is reasonable and necessary as a result of the impairment for drugs or goods listed with a cost of $250 or less per item; or (d) the insurer agrees that the expense is essential for the treatment or rehabilitation of the insured person for the goods or services listed with a cost of $250 or less.

Assistive devices

146Issue xvii: The OCF-6 dated November 6, 2024 claimed $3,051.55 for other assistive devices. It lists a single expense, being a lift/recline chair, and attaches an invoice dated October 30, 2024. A receipt was also attached, showing an initial payment of $1,602.55 on October 31, 2024, with a note that the balance of $1,449.00 is to be paid as to $250.00 per month.

147The denial letter dated January 8, 2025 notes that this item had been previously submitted in a plan and denied on September 26, 2024 based on the September 19, 2024 IE report of Ms. Dwyer.

148The applicant did not provide any submissions or direct me to any evidence to support entitlement to this plan. No explanation was provided as to why the OCF-6 was submitted after the plan was denied. I find this appears to be the same item (Golden Infinite lift/recline chair) that was denied in the plan found at issue xii (vi), as addressed above.

149Accordingly, I find on a balance of probabilities that the applicant has not met her onus of demonstrating that this benefit claimed on the OCF-6 for assistive devices is reasonable and necessary.

Medical services

150Issue xiv: The OCF-6 dated August 9, 2024 claimed $497.20 for medical services. It lists four receipts for massage therapy, each in the amount of $124.30, covering the period of April 19 to August 9, 2024. The service provider is Ms. June Ng, RMT, and receipts are attached for each 60 minute sessions showing paid. The denial letter dated September 9, 2024 notes that the applicant failed to submit an OCF-18 before incurring the expense, therefore triggering the consequences of s.38(2).

151Issue xv: The OCF-6 dated October 23, 2024 claimed $372.90 ($625.38 less $252.48 approved) for massage therapy. It attaches two receipts, each in the amount of $124.30, dated August 30 and September 20, 2024, from Ms. Ng, each for 60 minute sessions and showing paid. The denial letter dated November 25, 2024 notes that the applicant failed to submit an OCF-18 before incurring the expense, therefore triggering the consequences of s.38(2).

152Issue xvi: The OCF-6 dated December 16, 2024 claimed $1,226.90 for medical services. It lists three receipts for massage therapy, each in the amount of $124.30, covering the period of November 2 to December 13, 2024, from Ms. Ng, and attaching receipts for each 60 minute sessions showing paid. There is also a December 14, 2024 receipt in the amount of $854.00 from Pearle Vision, along with an accompanying credit card payment slip. It is not clear from the photo of the receipt as to what was purchased from Pearle Vision, nor is it described in the OCF-6. The denial letter dated January 8, 2024 (which should be January 8, 2025) notes that the applicant failed to submit an OCF-18 before incurring the massage therapy expense, therefore triggering the consequences of s.38(2). Further, it denies the Pearle Vision expense on the basis of there being no supporting documentation on how the expense is reasonable and necessary.

153Issue xviii: The OCF-6 dated January 17, 2025 claimed $124.30 for one 60 minute massage therapy session on January 3, 2025 from Ms. Ng, and attached a receipt showing paid. The denial letter dated January 23, 2024 (which should be January 23, 2025 as the applicant noted in her document brief) notes that the applicant failed to submit an OCF-18 before incurring the expense, therefore triggering the consequences of s.38(2).

154The applicant did not provide any submissions or direct me to any evidence to support entitlement to any of these plans for medical services, or why such massage services were reasonable and necessary for her accident-related impairments. Further, no explanation was provided as to why the applicant did not submit an OCF-18 treatment plan before she incurred the services claimed on the OCF-6s. I note that each of these OCF-6s claim for massage therapy. In addition, for issue xvi, the OCF-6 also includes the Pearle Vision expense to which the respondent advised that there was no supporting documentation on how the expense is reasonable and necessary.

155I have not been directed to any evidence that OCF-18s were submitted prior to incurring the costs in the OCFs for medical services. This triggers the consequences under s.38(2) meaning that the insurer is not liable to pay the expenses.

156Accordingly, I find on a balance of probabilities that the applicant has not met her onus of demonstrating that these benefits claimed on the OCF-6s for medical services are reasonable and necessary.

Interest

157Interest 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

158For the reasons outlined above, I find that:

a. The applicant has not sustained a catastrophic impairment as defined by the Schedule under Criterion 8;

b. The applicant is not entitled to ACB in any of the disputed amounts claimed for any of the periods in dispute;

c. The applicant is not entitled to housekeeping benefits;

d. The applicant is not entitled to the plans in dispute, the remaining balances for those plans that have been partially approved, the expenses claimed on OCF-6s or interest; and

e. The application is dismissed.