Licence Appeal Tribunal File Number: 24-010607/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:
Thomas Brooks
Applicant
and
The Dominion of Canada General Insurance Company
Respondent
DECISION
VICE-CHAIR:
Robert Maich
APPEARANCES:
For the Applicant:
Sherilyn Pickering, Counsel
For the Respondent:
James Armstrong, Counsel
HEARD: In Writing
OVERVIEW
1Thomas Brooks, the applicant, was involved in an automobile accident on June 30, 2021, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”). The applicant was denied benefits by the respondent, The Dominion of Canada General Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
2The applicant was driving on Highway 141 when his vehicle collided with a trailer. He was impaled with a 5 cm x 5 cm, 1-meter-long piece of aluminum framing from the trailer. His vehicle flipped over the guardrail and rolled down an embankment, before coming to rest on its roof. When his vehicle came to rest, the applicant was inside his vehicle, laying semi prone, face down, on the roof, with his left shoulder and arm underneath him and a 30 cm length of aluminum protruding from the back of his shoulder. The driver’s side door was cut off by the fire department, and the applicant was placed in a cervical collar on a stretcher with the impaled object secured in place. The applicant was taken by air ambulance from the scene to Sudbury Regional Hospital.
3On June 23, 2025, the applicant filed a Notice of Motion to convert the format of the hearing from a videoconference hearing to a written hearing. The respondent consented to the motion. The motion was granted by order dated June 26, 2025.
ISSUES
4The issues in dispute are:
Is the applicant entitled to attendant care benefits (“ACB”) in the amount of $5,546.07 per month from January 5, 2023 to date and ongoing?
Is the applicant entitled to $1,200.00 for optometric services, proposed by Radhika Chawla, in a treatment plan submitted on May 30, 2023 and denied on May 31, 2023?
Is the applicant entitled to $5,552.53 for physiotherapy, and medications, submitted on a claim form (OCF-6) dated August 31, 2022?
Is the applicant entitled to $1,193.83 for mileage, travel expenses, medication, assistive devices, and counselling, submitted on a claim form (OCF-6) dated September 22, 2022?
Is the applicant entitled to $1,599.73 for hospital expenses, parking, counselling, and prescriptions, submitted on a claim form (OCF-6) dated September 22, 2022?
Is the applicant entitled to $2,934.54 for Physiotherapy, and medication, submitted on a claim form (OCF-6) dated September 22, 2022?
Is the applicant entitled to $3,635.90 for optometry services, prescriptions, and visitors’ expenses, submitted on a claim form (OCF-6) dated September 22, 2022?
Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
Is the applicant entitled to interest on any overdue payment of benefits?
5The applicant has withdrawn the treatment plans proposed by Rehab First listed as issues [4]4i though xiii inclusive, and the following issues: [4]6, [4]7, [4]8, [4]10, [4]11 and [4]15 as listed in the Case Conference Report and Order (“CCRO”) dated February 28, 2025.
RESULT
6The applicant is entitled to ACB in the amount of $3,000.00 per month from January 5, 2023 to July 18, 2023.
7The applicant is entitled to $1,200.00 for optometric services, proposed by Radhika Chawla, in a plan submitted on May 30, 2023.
8The applicant is entitled to $141.40 for prescription medications of the $5,552.53 claimed for physiotherapy, and medications, submitted on a claim form (OCF-6) dated August 31, 2022.
9The applicant is not entitled to $1,193.83 for mileage, travel expenses, medication, assistive devices, and counselling, submitted on a claim form (OCF-6) dated September 22, 2022.
10The applicant is entitled to $45.00 for ambulance expense out of the $1,599.73 submitted on a claim form (OCF-6) dated September 22, 2022.
11The applicant is not entitled to $2,934.54 for physiotherapy, and medication, submitted on a claim form (OCF-6) dated September 22, 2022.
12The applicant is entitled to $976.00 for optometry and prescription glasses in addition to the amount of $1,601.29 previously paid by the respondent of $3,654.90 submitted on a claim form (OCF-6) dated September 22, 2022.
13The respondent is not liable to pay an award under s. 10 of Reg. 664.
14The applicant is entitled to interest on any overdue payment of benefits.
ANALYSIS
Is the applicant entitled to ACB in the amount of $5,546.07 per month from January 5, 2023 to date and ongoing?
15The applicant is entitled to ACB of $3,000.00 per month from January 5, 2023 to July 18, 2023.
16Section 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 attendant care services provided by an aide or attendant. The amount of a monthly ACB is determined in accordance with the approved version of the document entitled Assessment of Attendant Care Needs (“Form 1”) that is required to be submitted under s. 42. ACB’s are only payable for non-minor injuries. The maximum payable for ACB under the Schedule is $3,000.00 per month for non-catastrophically impaired insured persons, and $6,000.00 per month for catastrophically impaired insured persons.
17An expense in respect of goods or services referred to in the Schedule is incurred by an insured person under s. 3(8):
(8) If in a dispute described in subsection 280 (1) of the Act, the Licence Appeal Tribunal finds that an expense was not incurred because the insurer unreasonably withheld or delayed payment of a benefit in respect of the expense, the Licence Appeal Tribunal may, for the purpose of determining an insured person’s entitlement to the benefit, deem the expense to have been incurred.
18The onus is on the applicant to demonstrate that he required the care of an aide or attendant as a result of his accident-related injuries, and that he incurred the expense of hiring one. The applicant may still be entitled to ACB despite not hiring an aide or attendant if he can show that the expense was not incurred because the respondent unreasonably withheld or delayed payment of the benefit.
19The applicant submitted he requires supervision and assistance with walking, to ensure comfort, safety and security in the home, supervisory care, and assistance with coordination of care. He requires supervision and assistance with walking due to balance impairments having fallen while climbing stairs, and difficulties with transferring due to his injuries. He requires assistance to ensure comfort safety and security because he is reliant on his parents for assistance with cleaning, cooking, laundry, and pet care. He requires supervisory care as he would require assistance in an emergency, due to fatigue, dizziness, visual impairments, cognitive impairments, headaches, fall risk, and extra time required for transfers. If there were an emergency at night, he would require verbal prompts to help him understand what was happening and what he should do, as he would be easily distracted when attempting to exit the home. He requires assistance coordinating care due to difficulties with concentration, memory, fatigue, and pain which impact on his ability to plan and coordinate care.
20The applicant submitted he is entitled to $3,000.00 per month in ACB as a non-CAT applicant and conceded the claimed amount of $5,546.07 per month in ACB exceeds his entitlement. The applicant relies upon the s. 25 Occupational Therapy and Assessment of Attendant Care Report by Ms. Hubbard, OT, dated January 5, 2023 (“Hubbard report”). I have reviewed the Hubbard report and note that in respect to Level 1 ACB, it was determined the applicant did not require assistance for dressing/undressing or feeding and required only 10 minutes per week for one aspect of personal grooming (toenail trimming), although his mobility issues require 420 minutes. Level 2 ACB identified a need for assistance with hygiene totalling 1680 minutes per week and basic supervisory care of 3360 minutes per week plus 30 minutes for coordination of ACB needs. Level 3 ACB was not identified as required. I find the total identified ACB needs in the Hubbard report was $5,546.07 per month and that the Hubbard report is sufficient evidence that the ACB need was reasonable and necessary at the date of the assessment.
21The respondent submitted the applicant is not entitled to ACB as claimed, and that he has failed to prove that he meets the requirements under s. 19 and 3(7)(e) of the Schedule. The applicant has never submitted any expenses for ACB by way of an OCF-6 or invoices from a provider, or any other evidence that ACB were incurred.
22The respondent submitted the applicant was advised by correspondence dated July 8, 2021 that ACB may be available and an OCF-18 for an attendant care assessment was approved by letter dated September 1, 2022. However, a Form 1 dated October 21, 2022 was submitted on January 5, 2023, approximately a year and a half after the accident. The respondent advised that insurer’s examinations were required to assess entitlement to attendant care benefits but agreed to pay for all incurred attendant care expenses in the interim (up to $3,000.00 per month) from January 5, 2023 until a determination had been made. The respondent subsequently denied ACB as of July 18, 2023 citing the reports of its IE assessors, Dr. Mansour Alvi, orthopedic surgeon, Dr. Brandon Kucher, neurologist, Dr. Sadiq Hasan, psychiatrist and Munirah Quraishi, OT, who all opined that attendant care was not needed. Further, the respondent contends that the applicant also reported to the assessors that he was independent with his activities of daily living.
23In reply, the applicant submitted that not paying ACBs does not mean that it was not needed. The lack of paid ACB reflects the applicant’s inability to afford to pay the benefit. The applicant submitted there is no expectation that an applicant pay significant costs to validate the need for treatment or care; an expectation to pay a benefit without it being approved on the hope that it might get approved is simply unrealistic. The applicant relies upon Landoy v Wawanesa Mutual Insurance Company, 2022 CanLII 20143, para 25, Averkin v Scottish & York, 2024 CanLII 49089, para 22 and Viran v Aviva General Insurance Company, 2021 CanLII 28692, para 24. I have reviewed the authorities cited by the applicant and find the caselaw supports that there is no expectation or requirement of an insured to incur or pay significant expenses in hope that the insurer will find it reasonable and necessary.
24I note that the applicant’s claim for ACB is from January 5, 2023, the same date as the respondent approved ACB in the amount of $3,000 per month. I note that the applicant conceded that because he was not designated CAT, his maximum entitlement for ACB is $3,000 per month. Further, I note that the respondent’s approval for ACB was withdrawn July 18, 2023 based upon the findings of its IE assessors. I note my previous finding that the applicant’s demonstrated ACB needs was $5,546.07 per month as of January 5, 2023; however, I also find that the applicant’s maximum ACB was $3,000.00 per month due to the maximum set under the Schedule for the applicant as he was not designated CAT.
25I find that the Hubbard report was based in part upon an interview of the applicant on October 21, 2022 approximately six months prior to the s.44 OT assessors’ interview of March 18, 2023 for the Occupational Therapy In-Home Report by Munirah Quraishi, OT, dated June 26, 2023 (“Quraishi report”); I find the six months between the Hubbard report and the Qurashi report to be a significant passage of time in relation to a potential change in circumstances.
26I find the Quraishi report did not identify any Level 1 ACB needs as the grooming tasks no longer required assistance for toenail trimming and mobility was assessed to be independent, including transfers to washroom and bed transfers. In respect to Level 2 ACB, the applicant was assessed to have functional ability in hygiene, albeit with difficulty in some areas, especially tasks requiring bending that could be overcome with assistive devices; fatigue was also noted to be a problem that could be addressed with pacing. Basic supervisory care was also assessed to be unnecessary as the applicant was deemed independent in his mobility and observed to negotiate a flight of stairs independently and able to leave the home to attend appointments independently. I find both assessor OTs were in agreement that no Level 3 ACB needs were required at the time of the respective assessments.
27I find the evidence of both the s.25 OT Hubbard report dated January 5, 2023 and s.44 OT Qurashi dated June 26, 2023 to have equal substantive weight as the reports both contained a review of the applicant’s medical history, interview of the applicant and an assessment of the applicant including objective testing; accordingly, I find that the applicant’s condition was as assessed at each respective assessment date. Specifically, the applicant’s ACB needs were as described in the Hubbard report as of January 5, 2023 and his ACB needs were as described in the Qurashi on July 18, 2023 when the insurer cut off ACB. Accordingly, I conclude that the applicant was entitled to ACB benefits between January 5, 2023 when it was claimed based on the Hubbard report, and July 18, 2023 when it was terminated by the respondent based upon the Qurashi report.
28I note that the parties agreed no ACB invoices have been paid or submitted for payment. The insurer submitted because nothing was incurred during the period, nothing is payable. The applicant submitted incurred ACB expenses are not a realistic reflection of need and he could not pay for the ACB needed. I find the absence of professional invoices is not a bar to recovery of ACB as per my previous finding at para. [23]. I find that based upon the Hubbard report and absent any evidence to the contrary, that the insurer unreasonably withheld payment of ACB benefit and deem the ACB incurred by the provisions of the Schedule under s. 3(8) for the period January 5, 2023 until July 18, 2023. I find as of July 18, 2023 the respondent had reasonable grounds to withhold payment of ACB based upon the Qurashi report.
29I find the applicant is entitled to ACB of $3,000.00 per month from January 5, 2023 to July 18, 2023. However, the applicant has not established entitlement to ACBs after July 18, 2023.
Is the applicant entitled to $1,200.00 for optometric services, proposed by Radhika Chawla, in a plan submitted on May 30, 2023?
30The applicant is entitled to $1,200.00 for optometric services, proposed by Radhika Chawla, in a plan submitted on May 30, 2023.
31Pursuant to section 15 of the Schedule, the respondent is liable to pay for all reasonable and necessary expenses incurred by or on behalf of the insured person a result of an accident. It is the applicant’s responsibility to prove the medical benefits claimed are reasonable and necessary on a balance of probabilities.
32The applicant submitted he is entitled to $1,200.00 for optometric services, proposed by Dr. Radhika Chawla, optometrist, in a plan submitted on May 30, 2023. Dr. Chawla proposed to assess the function of the two eyes as a team and the efficiency of the visual system, including assessing binocularity, accommodation, oculomotor function, primitive reflexes, peripheral awareness, fine and gross motor skills, spatial relations, form constancy, figure ground, and visual closure. The applicant also submitted that the respondent denied the plan incorrectly on the basis of there being no evidence of vision impairments or a brain injury from the accident.
33The applicant relies upon the report of Dr. Neilank Jha, neurosurgeon, dated January 11, 2024. Although cranial diagnostic imagining was negative, Dr. Jha advised that a concussion does not necessarily involve a loss of consciousness and 10% may have persistent symptoms beyond two weeks, as in the case of the applicant. Various symptoms differing between individuals correspond to injury of the frontal, temporal, parietal and occipital lobe, cerebellum, brain stem and cranial nerves; Dr. Jha recommended follow up with his primary care physician.
34Dr. Makary, the applicant’s primary care physician, documented vision changes, blurry vision, pain behind the eyes, photophobia, impairments of depth-perception and headaches exacerbated by light; Dr. Makary diagnosed the applicant with suspected post-concussive syndrome post-accident. Dr. Malary recommended an oculo-visual assessment and the Hubbard report also recommended vison therapy assessment. The s.44 assessors also recommended similar investigation, for example, Dasha Poronik, RN, recommended neuro-ophthalmologist referral to investigate the applicant’s blurred vision.
35The applicant submitted the s.25 Neuro-Optometric Visual Assessment by Dr. Quaid, PhD vision science, (“Quaid report”) dated June 11, 2023 for the purposes of assessing whole person impairment, demonstrated significant vision impairments, including abnormal near point convergence, vergence infacility, saccadic function impairment, reduced stereopsis, reduced reading efficiency, symptoms of diplopia, symptoms of photophobia, and visual motion sensitivity and misperceiving visual cues. The Neuro-Optometric Rehabilitation Assessment by Dr. Rayman, optometrist, (“Rayman report”) dated May 20, 2025 demonstrated deficits in functional vision, visual information processing, oculomotor skills, visual memory, visual motor integration, and laterality and directionality. Dr. Rayman diagnosed the applicant with post trauma vision syndrome, general binocular dysfunction, oculomotor dysfunction, hyperopia, astigmatism, presbyopia, photophobia, headache, visual-vestibular dysfunction, visual motor dysfunction, and visual information processing disorder; Dr. Rayman recommended optometric vision therapy.
36The respondent submitted the applicant had not reported any vision injuries/eye injuries in the accident; there were no complaints by the applicant regarding his vision until Dr. Makary was contacted on May 17, 2023 from Rehab First that reported the applicant’s vision complaint. The respondent also submitted the applicant has also undergone optometric assessments with Dr. Quaid and Dr. Rayman and it would be a duplication or triplication of services for the optometric assessments the applicant has already undergone since 2021.
37I find the proposed treatment plan would not be a duplication of services as a solution to the applicant’s condition has not been discovered and further treatment and investigation is warranted. I find the previous assessments addressed other areas that may have explained the vision loss; I find the applicant has been examined in a process of ruling out potential causes to discover the root cause of his vision loss as it is not readily apparent. I note the majority of assessors, whether s.25 or s.44 assessors, also recommended further investigation and/or treatment is warranted. I find the applicant has met his onus on a balance of probabilities that the treatment plan is reasonable and necessary.
38The applicant is entitled to $1,200.00 for optometric services, proposed by Radhika Chawla, in a plan submitted on May 30, 2023.
OCF-6s
OCF-6 dated August 31, 2022 of $5,552.53 for physiotherapy and medications
39I find that the applicant is entitled to $141.40 for prescription medications as claimed under the OCF-6 for $5,552.53 and dated August 31, 2022.
40The applicant limits this OCF-6 to prescriptions only as follows: Cephalexin - $8.92, prescribed by Vanessa 13 Mawashi, filled July 9, 2021; Hydromorphone - $8.06, prescribed by Vanessa Mawashi, filled July 9, 2021; Hydromorphone - $7.21, prescribed by Dr. Hayward, filled August 3, 2021; Hydromorphone - $7.21, prescribed by Dr. Puri, filled August 16, 2021; Naproxen + Esomeprazole - $34.25, prescribed by Dr. Puri, filled August 16, 2021. The applicant does not dispute the remaining balance relating to physiotherapy services.
41Cephalexin and Hydromorphone were prescribed by a Nurse Practitioner at Health Sciences North upon the applicant’s discharge from the hospital; Cephalexin is an antibiotic given the risk of infection and Hydromorphone is an analgesic meant to control pain due to the severity of his injuries as a result of the accident; hydromorphone was repeated several times. Naproxen + Esomeprazole are an anti-inflammatory, given due to the extent of the applicant’s injuries.
42The respondent submitted that pursuant to s.38(2) of the Schedule, an insurer is not liable to pay for a medical benefit that was incurred before the insured person submits a treatment and assessment plan, with the exceptions of prescribed medications by a regulated health professional as a result of the accident.
43The respondent also submitted pursuant to s. 47(2) of the Schedule, payment for a medical, rehabilitation or attendant care benefit is not required for the portion of an expense for which payment is available to the insured under any insurance plan or any other benefits. The respondent relies upon Zhang v. TD, 2022 CanLII 23404 at para. 19 where the Tribunal found that once the insurer advised that the insured would need to submit the expense to the extended health benefit provider first, that the cost is not payable where the insured has not provided documentation showing the costs were submitted to the extended health care provider.
44I agree with the reasoning in Zhang v. TD. However, I find the applicant has demonstrated that the medication was prescribed by regulated health professionals and his onus is discharged If the respondent wishes to raise other extended healthcare coverage as a bar to recovery of the benefit, then it has the onus to prove that the applicant had existing extended healthcare coverage. I find the respondent has not met its onus in this regard as no proof of coverage was demonstrated in its submissions.
45I find the applicant is entitled to $141.40 for prescription medications as claimed under the OCF-6 for $5,552.53 and dated August 31, 2022.
OCF-6 dated September 22, 2022 of $1,193.83 for mileage, travel expenses, medication, assistive devices and counselling
46I find the respondent has paid the visitor expenses in dispute; the applicant is not entitled to any further sum than that already paid by the respondent.
47The applicant submitted the items in dispute are limited to visitors’ expenses, specifically hotel room expenses for his parents while visiting with him in Sudbury during his recovery (July 12-13, 2021). These expenses were incurred within the first 104 weeks by eligible family members to reasonably visit with the applicant.
48The respondent submitted the OCF-6 was partially approved by letter dated October 19, 2022 in the amount of $877.66. Visitor’s expenses for food, gas and lodging (totaling $705.53) and medications of Benadryl and a massage machine (totaling $175.13) were approved. The amounts denied were $17.18 for a medication at Guardian (unspecified, with no prescription receipt), $60.94 from Shoppers Drug Mart (unspecified), $18.00 from Carpark (unspecified what it was related to), $170.00 from Anora Counseling (submitted prior to submission/approval of OCF-18), and $50.03 for a form relating to unspecified medical equipment.
49I find the respondent has paid the visitor expenses in dispute; the applicant is not entitled to any further payments beyond the amounts previously paid by the respondent.
OCF-6 dated September 22, 2022 of $1,599.73 for hospital expenses, parking, counseling and prescriptions
50I find the applicant is entitled to $45.00 for the ambulance call.
51The applicant submitted the parking expenses include parking at Health Science North Sudbury while the applicant was in hospital; the prescription expenses include Ciprofloxacin prescribed by Dr. Lee and filled July 19, 2021 ($9.89), Lenoltec No.3 prescribed by Dr. Lee and filled on July 19, 2021 ($7.29); and Ketorolac prescribed by Dr. Lee and filled on August 16, 2021 ($14.75). Dr. Lee was the applicant’s treating orthopaedic surgeon for his accident related shoulder injuries. Both Lenoltec No. 3 and Ketorolac are pain relievers, prescribed for pain, Ciprofloxacin is an antibiotic prescribed for ongoing concerns of infection. All of the medications prescribed by Dr. Lee were to treat accident related injuries.
52The respondent submitted the OCF-6 was partially approved by letter dated October 19, 2022, in the amount of $41.82 for prescription ciprofloxacin and ketorolac. Other amounts listed were denied, as there were insufficient details to determine what the expenses pertained to, or how it related to the accident. Specifically, there was a $45.00 ambulance bill that was denied, as it had not been submitted to an alleged third party insurer. Parking amount of $25.00 was denied, as it was not clear what it related to. $370.00 for nutrition coaching was denied as it was incurred prior to submission of an OCF-18 Treatment and Assessment Plan. $56.21 of prescriptions from King City Pharmacy were denied, as there was no indication what medications the expenses pertained to. $16.98 from Guardian was denied as prescription details were not provided and $84.72 for probiotics were denied.
53I find the applicant is entitled to $45.00 for the ambulance call for the same reasons above as the respondent did not meet his onus that the applicant had extended healthcare coverage. The applicant did not meet his onus on the balance of the items claimed on this OCF-6 as his submissions were limited to medications previously approved and the ambulance payment issue was plain on the face of the respondent’s submissions.
OCF-6 dated September 22, 2022 of $2,934.54 for physiotherapy, medication
54The applicant is not entitled to any further payment in respect of this OCF-6.
55The applicant submitted the OCF-6 was for multiple expenses, with those in dispute being for food for his parents while they visited him in hospital. The “Independent” receipts and “Smith’s Markets” receipts are from food purchases while his parents were in Sudbury visiting him.
56The respondent submitted the OCF-6 was partially approved by letter dated October 19, 2022, in the amount of $91.43 totaling: $30.50 for back medicine, $60.93 for groceries for visitor expenses; other amounts listed were denied, as there were insufficient details to determine what the expenses pertained to, or how it was accident related. Specifically, a $2,472.50 invoice from the Ministry of Transportation (for fire rescue from the Township of Seguin), as the respondent advised there was no coverage through the Schedule for the expense, $170.00 from Meadowbrook counseling, $140.00 from York County Physiotherapy, $205.00 from Honsberger Physiotherapy and $55.00 from Unionville Family Wellness were denied, as all were incurred prior to submission of an OCF-18.
57I find the respondent has previously paid the amounts for groceries that the applicant submitted were in dispute. The applicant is not entitled to any further payment in respect to this OCF-6.
OCF-6 dated September 22, 2022 of $3,654.90 for optometry, prescriptions and visitors’ expenses
58I find the applicant is entitled to a total sum of $976.00 for optometry and prescription glasses in addition to the amounts previously paid by the respondent.
59The applicant submitted the OCF-6 is for multiple expenses, with those in dispute being hotel expenses for his parents and replacement glasses and clothing. The hotel expenses were for the applicant’s parents to visit him in Sudbury while in hospital, during his recovery (July 1 to 6, 2021). The applicant’s glasses were broken in the motor vehicle accident and the respondent is required to reimburse for prescription eyewear and clothing damaged in the accident.
60The respondent submitted by letter dated October 19, 2022, this OCF-6 was partially approved in the amount of $1,601.29 for replacement clothing ($201.07) and visitor expenses ($1,209.14). The Respondent mistakenly over-paid these expenses by $191.08, as it listed replacement clothing as $392.15 instead of $201.07. The amounts denied included $179.00 for replacement glasses, with the respondent claiming third party coverage. Prescription medication of $58.00, groceries of $864.44, Shoppers Drug Mart expenses of $60.94, Harvey’s expense of $26.30 were denied as details of these expenses were not provided, and it was not clear how they related to the accident. The expense of $797.00 from King City Optometry was denied, as the respondent alleged third party coverage.
61I find the applicant is entitled to $179.00 and $797.00 for optometry services and prescription glasses for the same reasons as previously stated as the respondent did not meet its onus that the applicant had extended healthcare coverage. I find the respondent previously paid $1,601.29 in respect to items in dispute and the applicant did not meet his onus on the balance of the items in the OCF-6 and other than optometry services and eyewear. I find the applicant is entitled to a total sum of $976.00 for optometry and prescription glasses in addition to the amounts previously paid by the respondent.
Interest
62Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. The applicant is entitled to interest on the payment of any overdue benefits.
Award
63The applicant sought an award under s. 10 of Reg. 664. Under s. 10, the Tribunal may grant an award of up to 50 per cent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits. The applicant made no submissions in respect to award and absent any submissions I find an award is not appropriate in the circumstances.
ORDER
64The Tribunal’s final Orders:
i. The applicant entitled to ACB in the amount of $3,000.00 per month from January 5, 2023 to July 18, 2023.
ii. The applicant is entitled to $1,200.00 for optometric services, proposed by Radhika Chawla, in a plan submitted on May 30, 2023.
iii. The applicant entitled to $141.40 for prescription medications of the $5,552.53 claimed for physiotherapy, and medications, submitted on a claim form (OCF-6) dated August 31, 2022.
iv. The applicant is not entitled to $1,193.83 less $91.43 approved for mileage, travel expenses, medication, assistive devices, and counselling, submitted on a claim form (OCF-6) dated September 22, 2022.
v. The applicant entitled to $45.00 for ambulance expense of the $1,599.73 submitted on a claim form (OCF-6) dated September 22, 2022.
vi. The applicant is not entitled to $2,934.54 less $91.43 approved for physiotherapy, and medication, submitted on a claim form (OCF-6) dated September 22, 2022.
vii. The applicant entitled to $976.00 for optometry and prescription glasses in addition to the amount of $1,601.29 previously paid by the respondent of $3,654.90 on a claim form (OCF-6) dated September 22, 2022.
viii. The respondent is not liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant.
ix. The applicant entitled to interest on any overdue payment of benefits.
Released: May 5, 2026
Robert Maich
Vice-Chair