Licence Appeal Tribunal File Number: 24-006429/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.
Parties
Between:
Davorka Vujanovic
Applicant
And
Security National Insurance Company
Respondent
DECISION
ADJUDICATOR:
Harry Adamidis
APPEARANCES:
For the Applicant:
Christian Genova, Counsel
For the Respondent:
Eduarda Gouveia, Counsel
HEARD:
In Writing
OVERVIEW
1Davorka Vujanovic, the applicant, was involved in an automobile accident on May 4, 2018, 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, Security National Insurance Company, Insurer, and applied to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
PRELIMINARY ISSUES
2The preliminary issue to be decided is:
i. Is the applicant barred from proceeding to a hearing with respect to the treatment plan/OCF-18 (“plan”) for chiropractic and physiotherapy treatment in the amount of $2,403.72, proposed by 7688750 Canada Inc., because the applicant failed to submit within the 260 weeks after the accident?
ISSUES
3The issues in dispute are:
i. Is the applicant entitled to $2,643.72 for chiropractic treatment, proposed by PhysioMed Brant in a plan submitted May 18, 2022?
ii. Is the applicant entitled to $2,403.72 for chiropractic treatment, proposed by 7688750 Canada Inc. in a plan submitted May 18, 2022?
iii. Is the applicant entitled to $2,403.72 for chiropractic and physiotherapy treatment, proposed by 7688750 Canada Inc. in a plan submitted June 5, 2023?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
4The applicant cannot proceed to a hearing to determine entitlement for a treatment plan costing $2,403.72 for chiropractic and physiotherapy treatment because the limitation in s. 20(1)(a) of the Schedule applies.
5The applicant is entitled to the two treatment plans for chiropractic treatment.
6The applicant is entitled to interest.
ANALYSIS
Preliminary Issue
7The applicant is barred from proceeding to a hearing to determine entitlement for a treatment plan dated June 5, 2023 because the limitation in s. 20(1)(a) of the Schedule applies.
8Section 20(1)(a) of the Schedule states that no incurred rehabilitation benefits are payable 260 weeks after the accident.
9The respondent denied the treatment plan dated June 5, 2023 because it was provided to the insurer outside the 260-week limitation period. The applicant submits that her rehabilitation needs are ongoing, and the delay in submitting the treatment plan should not preclude her from receiving necessary treatment.
10The respondent did not file any submissions with the Tribunal.
11The applicant’s position, that accident benefits are payable after the 260-week limitation period if she continues to need rehabilitation, is inconsistent with the Schedule. The only two exceptions, found in s. 20(2), are for insured persons who are catastrophically impaired or have optional benefits.
12There is no indication that the applicant has been found to be catastrophically impaired (CAT).
13The application to the Tribunal states that she has optional benefits. I also note that the respondent’s denial letter, dated May 24, 2022, states that the insurer has paid $78,652.04 in treatment and attendant care which is a greater than the $65,000.00 non-CAT limit for benefits. This too is an indication that the applicant’s policy may include optional benefits. However, the applicant does not mention having optional benefits in her submissions. She does not point to any evidence of optional benefits or evidence of what those optional benefits may be. In my view, there is an insufficient basis to conclude that she has optional benefits that allow her to receive rehabilitative treatment after 260 weeks. For this reason, I find that the applicant is barred from proceeding to a hearing for this treatment plan as the limitation period applies.
14The applicant is entitled to the two treatment plans for chiropractic services.
15To receive payment for a treatment and assessment plan under s. 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.
16Two treatment plans for chiropractic treatment are in dispute. The applicant notes that the accident caused significant physical injuries, including a right hip labral tear requiring arthroscopy surgery on October 22, 2020 and chronic pain in the neck, back, and shoulders. She submits that the plans address ongoing pain, functional limitations, and rehabilitation needs stemming from the accident.
17An MRI dated August 22, 2018 confirms that the applicant sustained a superior labral tear injury in the accident.
18The clinical notes and records of PhysioMed dated May 26, 2018 confirm that the applicant reported experiencing pain in her neck, shoulders, and hip soon after the accident. The Occupational Therapy in-Home/Functional and Attendant Care Assessment Report dated November 16, 2021 by Joanna Wojcik, occupational therapist, confirms that the applicant was experiencing ongoing pain symptoms in her neck, right shoulder, and right hip. Ms. Wojcik noted limitations such as moderate restrictions with right shoulder flexation and abduction, and hip pain effecting stair mobility, kneeling/squatting, weight bearing on her right heel, prolonged standing and sitting, and walking gait. Regarding functional limitations, Ms. Wojcik found that the applicant is unable to manage the majority of housekeeping tasks.
19The respondent denied the two treatment plans based on a s.44 assessment and the need to obtain another s.44 assessment. The denial letters are in evidence, but the respondent did not file any submissions or a documentary brief. Consequently, there are no s.44 reports supporting the denial.
20Ms. Wojcik determined that the applicant experiences ongoing pain that results functional limitations. As an occupational therapist, she cannot render an opinion on causation. Even so, there is medical evidence showing that the applicant was injured in the accident, that she has consistently made pain complaints in the areas of those injuries, and that she continues to experience the limitations documented by Ms. Wojcik as a result of that pain. In my view, this evidence is sufficient enough to find, on a balance of probabilities, that the applicant’s current pain symptoms and functional limitations are caused by the accident.
21The goals of the treatment, as stated in both plans, are reasonable. These are pain reduction, increased strength, and increased range of motion.
22The treatment is recommended by a chiropractor, Dr. Altaz Madhavji. Her clinical notes from May 29, 2018 to March 1, 2021 show that the plan of care being administered during this period included the type of treatment in the two plans and that there were improvements over the course of time. I find that this evidence shows that the treatment goals would be met to a reasonable degree.
23Each plan covers a documentation fee and 12 sessions of exercise, muscle stimulation, heat therapy, and various sessions of therapy in multiple body sites. In my view, the proposed cost for each plan is reasonable given the quantity of treatment being provided by a medical professionals.
24As such, I find that the two treatment plans are reasonable and necessary as I am satisfied that the treatment goals are reasonable, can be met to a reasonable degree, and also because the costs are reasonable. Consequently, I find that the applicant is entitled to both plans.
Interest
25Interest applies to the payment of any overdue benefits pursuant to s. 51 of the Schedule. I find that the applicant is entitled to interest on the two plans for chiropractic treatment as these benefits are overdue.
ORDER
26The applicant cannot proceed to a hearing to determine entitlement for a plan costing $2,403.72 for chiropractic and physiotherapy treatment because the limitation in s. 20(1)(a) of the Schedule applies.
27The applicant is entitled to the two treatment plans for chiropractic treatment.
28The applicant is entitled to interest.
Released: January 20, 2026
Harry Adamidis
Adjudicator