Licence Appeal Tribunal File Number: 24-012320/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:
Kapilraj Thangarajah
Applicant
and
Aviva General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Greg Witt
APPEARANCES:
For the Applicant:
Maria Papadopoulos, Paralegal
For the Respondent:
Marim Hadi, Counsel
HEARD: In Writing
OVERVIEW
1Kapilraj Thangarajah, the applicant, was involved in an automobile accident on October 11, 2020, 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, Aviva General Insurance Company, 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. Is the applicant entitled to $5,076.60 for chiropractic services, proposed by Alma Rehab in a treatment plan/OCF-18 (“plan”) submitted April 9, 2024, and denied April 17, 2024?
ii. Is the applicant entitled to $4,594.58 for chiropractic services, proposed by Alma Rehab in a plan submitted July 17, 2024, and denied July 17, 2024?
iii. Is the applicant entitled to $3,512.56 for chiropractic services, proposed by Alma Rehab in a plan submitted September 20, 2024, and denied October 2, 2024?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant is entitled to the treatment plan for $5,076.60 for chiropractic services.
4The applicant is not entitled to the treatment plan for $4,594.58 for chiropractic services.
5The applicant is not entitled to the treatment plan for $3,512.56 for chiropractic services.
6The respondent is liable to pay interest in accordance with s. 51 of the Schedule with respect to the treatment plan for $5,076.60 for chiropractic services.
ANALYSIS
7To 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.
8I find that the treatment plan for physiotherapy services completed by Dr. Singh of Alma Rehab, is reasonable and necessary. The treatment plan consists of physical therapy, functional exercises, spine manipulation, a personalized home exercise program, manual therapy and shockwave therapy. The stated goals of treatment include: pain reduction, improved range of motion, increased strength, improved muscular endurance, and a return to activities of normal living.
9The applicant submits that he began experiencing neck and back pain within days following the October 11, 2020 motor vehicle accident. He sought treatment at a walk-in clinic where he was examined by Dr. Rizwan Shaikh, General Practitioner, who prescribed the applicant pain medication. The clinical notes and records (“CNRs”) of Dr. Shaikh dated October 26, 2020, November 9, 2020, November 28, 2020, December 16, 2022 document ongoing complaints of neck and back pain. The applicant further submits the pain was ongoing, and relies on the CNR’s dated November 6, 2023 of Dr. Tejedin Getahun Orthopedic Surgeon; which diagnoses the applicant with chronic myofascial strains of the cervical spine, the lumbosacral spine, left shoulder strain and bicipital tenosynovitis.
10The applicant also relies on the CNRs from Dr. Victor Figurado, Family Physician, and these records demonstrate a consistent pattern of musculoskeletal dated between the date of the accident and July 25, 2023 complaints associated with the neck and back following the accident that persisted as evidenced by the applicant’s regular reports of back pain.
11The respondent submits that the applicant sustained only minor soft tissue injuries as a result of the accident and relies on the Insurer’s Examination report of Dr. Howard Platnick, General Practitioner, dated May 29, 2024. Dr. Platnick opined that the applicant’s accident-related impairments were limited to soft tissue strains and sprains and had largely resolved.
12I find that the contemporaneous medical documentation supports that the applicant experienced neck and back pain following the accident. These complaints were recorded shortly after the accident and persisted in the months that followed as well as regular and consistent reports of back pain since that time. The proposed treatment plan is directed toward addressing those accident-related impairments and includes treatment modalities commonly used for musculoskeletal injuries of this nature.
13While some of the medical records also reference the applicant’s right knee complaints – which will be addressed below - I find that this treatment plan is directed broadly toward the applicant’s musculoskeletal recovery, and recovery as a whole, including treatment of his neck and back symptoms which I accept were caused by the accident. The respondent does not address causation in their submission with respect to the neck and back pain.
14On the evidence before me, I am satisfied that the proposed chiropractic treatment is reasonable and necessary to address the applicant’s accident-related impairments.
15Accordingly, the applicant is entitled to the treatment plan in the amount of $5,076.60.
16I find that the applicant is not entitled to the treatment plan in the amount of $4,594.58.
17Based on the submissions that were provided and the documentation before me that could be reasonably interpreted, this treatment plan appears directed toward rehabilitation of the applicant’s right knee condition. The functional goals of the treatment plan include strengthening and conditioning of the right knee and improving functional mobility following surgical intervention. However, the applicant’s submissions address the treatment plans collectively and since it is not the role of the adjudicator to decipher or parse submissions on behalf of the parties; rather, parties are expected to provide clear and distinct submissions for each item being sought, accordingly, I am unable to consider any portions of the treatment plan relating to or that might relate to rehabilitation of the applicant’s neck and back conditions.
18On May 13, 2021 the applicant visited Dr. Figurado and reported right knee pain and then reported persisting pain in the right knee on June 23, 2021, August 12, 2021, and December 2, 2021, which the applicant reported led to difficulty walking and with mobility. Dr. Figurado referred the applicant to Orthopedic Surgeon, Dr. Vikram Venkateswaran, where the applicant reported swelling of the knee gradually and the CNRs reveal the applicant experienced an ACL tear, and osteoarthritis. Dr. Figurado also referred the applicant to Dr. Nirmala Kodali, Physiotherapist, for the applicant’s persistent knee issues, where the applicant self reported a 3-year traumatic history of his right knee pain as a result of the motor vehicle accident. The applicant also self-reported the knee pain and injuries to Dr. Khal Efala, Orthopedic Surgeon on December 29, 2022. Dr. Tajedin Getahun, Orthopedic Surgeon, further assessed the applicant on November 6, 2023 and diagnosed him with right knee internal derangement including an ACL tear.
19The respondent submits that the applicant has not established that his right knee condition was caused by the motor vehicle accident. The respondent relies on the Insurer’s Examination report of Dr. Howard Platnick dated May 29, 2024. Dr. Platnick opined that there was no indication that the applicant sustained any injury or trauma to the right knee as a result of the October 11, 2020 accident. Dr. Platnick further noted that the MRI findings of the right knee demonstrated long-standing degenerative changes rather than an acute traumatic injury.
20I find the respondent’s submissions and evidence persuasive.
21The onus is on the applicant to prove that in this case, the applicant’s knee injury was caused by the accident, and I find the applicant led insufficient evidence to do so. In my view, if the applicant had sustained a traumatic knee injury as a result of the accident, it would reasonably be expected that complaints of knee pain would have been reported and documented much closer in time to the accident. The absence of any reference to knee symptoms in the immediate post-accident medical documentation weighs against a finding that the accident caused the knee condition. Moreover, the applicant does not address in their submissions the reason why there is a gap in reporting of the knee injury.
22As such, the contemporaneous medical records do not support that the applicant sustained a knee injury as a result of the accident. The evidence shows the accident occurred on October 11, 2020, however the first documented reference to right knee pain appears in the clinical notes of Dr. Figurado dated May 13, 2021, approximately seven months after the accident.
23In addition, the MRI findings referenced by Dr. Platnick indicate degenerative changes in the right knee rather than evidence of an acute traumatic injury. This further supports the respondent’s position that the knee condition is unrelated to the accident. I place added weight to Dr. Platnick’s findings as they are based on objective testing and imaging.
24I also note that in section 7(b) of the OCF-18 form dated July 16, 2024, which asks whether the applicant has developed any condition not related to the accident, the applicant indicated “right knee surgery.” This notation further supports that the knee condition was not considered to be accident related.
25While I accept that the applicant experiences right knee pain, the evidence before me does not establish, on a balance of probabilities, that the knee condition was caused by the motor vehicle accident.
26As this treatment plan is primarily directed toward rehabilitation of the right knee condition, I find that it is not reasonable and necessary as a result of the accident within the meaning of section 15 of the Schedule.
27Accordingly, the applicant is not entitled to the treatment plan in the amount of $4,594.58.
28I find that the applicant is not entitled to the treatment plan in the amount of $3,512.56.
29Similar to the previous treatment plan, the evidence before me indicates that this plan is directed toward rehabilitation and recovery of the applicant’s right knee following surgery. The functional goals of the treatment plan include strengthening and conditioning of the right knee and improving functional mobility following surgical intervention.
30The respondent submits that this treatment is not reasonable or necessary because the underlying knee condition was not caused by the accident.
31For the reasons outlined above, I accept the respondent’s position.
32I have already found that the applicant has not established that his right knee condition arose as a result of the October 11, 2020 motor vehicle accident. The medical documentation demonstrates that complaints of knee pain first appear several months after the accident, and the MRI findings support a degenerative knee condition rather than an acute traumatic injury.
33Moreover, I note that in section 7(b) of the OCF-18 form dated September 17, 2024, which asks whether the applicant has developed any condition not related to the accident, the applicant again indicated “right knee surgery.” This notation further supports that the knee condition was not considered to be accident related.
34Given these findings, I am not satisfied that treatment directed toward rehabilitation of the applicant’s right knee surgery is related to injuries sustained in the accident.
35Accordingly, I find that the proposed treatment is not reasonable and necessary as a result of the accident within the meaning of section 15 of the Schedule.
36The applicant is not entitled to the treatment plan in the amount of $3,512.56.
Interest
37As I find that the applicant is entitled to the amount of $5,076.60 for chiropractic services, I therefore find that the applicant is entitled to interest for the overdue payment of this benefit pursuant to s. 51 of the Schedule.
ORDER
38For the reasons outlined above, I find that:
i. The Tribunal orders the respondent to pay $5,076.60 for chiropractic services and interest for the overdue payment of this benefit; and
ii. The applicant is not entitled to the remaining treatment plans in dispute.
Released: May 14, 2026
Greg Witt
Adjudicator