Licence Appeal Tribunal

Citation: Sarhadi v. Aviva General Insurance Company, 2026 ONLAT 24-015196/AABS

Licence Appeal Tribunal File Number: 24-015196/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:

Shweta Sarhadi Applicant

and

Aviva General Insurance Company Respondent

DECISION

ADJUDICATOR: Jeff Chatterton

APPEARANCES:

For the Applicant: Bianca Marinescu, Counsel

For the Respondent: Natalie Spinelli, Paralegal

HEARD: In Writing

OVERVIEW

1Shweta Sarhadi, the applicant, was involved in an automobile accident on June 5, 2023, 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:

1. Is the applicant entitled to the assessments/treatment plans proposed by Chinguacousy Physiotherapy and Foot Clinic, as follows: a) $3,010.88 for physiotherapy services, in a treatment plan/OCF-18 (”plan”) submitted January 4, 2024 and denied January 17, 2024? b) $2,672.44 for physiotherapy services, in a plan submitted June 28, 2024 and denied July 12, 2024? c) $793.25 for orthotic devices, in a plan submitted September 11, 2024 and denied September 16, 2024? d) $95.72 ($2595.72 less $2,200 approved) for a driving evaluation assessment, in a plan dated September 12, 2024?
2. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
3. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

3The application is dismissed. The applicant is not entitled to the treatment plans or outstanding balance in dispute.

4Neither interest nor an award are payable.

ANALYSIS

Are the physiotherapy treatment plans (issues 1a and 1b) reasonable and necessary?

5The applicant has not met her onus to demonstrate that the physiotherapy treatment plans are reasonable and necessary.

6To 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.

7The treatment plans are for a combined 24 sessions of physiotherapy recommended by physiotherapist Narwinder Kaur, with goals of increased strength and mobility, in an effort to return to the activities of daily living.

8The applicant argues that she suffered significant physical injuries in the accident, including sprain and strain injuries to the thorax, bilateral calf strains, and ongoing pain, as documented in the OCF-3 completed by physiotherapist Grace Macwan on June 7, 2023. She submits that the physiotherapy provided at Chinguacousy Physiotherapy and Foot Clinic (the “Clinic”) was beneficial, offering short-term pain relief and improved function. She further submits that her pre-existing conditions create barriers to full recovery, necessitating ongoing treatment.

9The respondent relies on the s. 44 insurer examination (IE) report of Dr. Allan Kruger, a musculoskeletal specialist, who directly assessed the applicant on August 5, 2024. Dr. Kruger found a normal physical examination, including normal gait, full range of motion across all joints, and normal strength testing, with reports of pain only at extreme ranges of cervical and lumbar movement. He found no objective neurological or radicular findings. Dr. Kruger concluded the applicant had returned to her pre-accident baseline, her condition had plateaued, and further facility-based treatment was not reasonable and necessary. The respondent further notes the absence of any contemporaneous recommendation by the applicant’s family physician, Dr. Mohan, for physiotherapy for accident-related injuries at the time of either plan.

10I assign more weight to the evidence of the respondent on these treatment plans. I accept, as a general proposition, that pain relief is a legitimate treatment goal and that improvement supports the need for continued care. However, the applicant must still establish that the proposed treatment is necessary and not merely beneficial. The evidence does not support that finding here.

11With respect to the first treatment plan, submitted January 4, 2024, the applicant had not raised the accident with her family physician since the accident occurred more than six months before. At her November 5, 2023 visit with Dr. Mohan, she did not mention the motor vehicle accident. While she reported the accident at her January 25, 2024 visit — shortly after the first plan was submitted — Dr. Mohan did not recommend physiotherapy. He diagnosed acute back pain and prescribed pain medication, but made no referral for physical therapy. The absence of any contemporaneous independent medical recommendation for continued physiotherapy at the time the plan was submitted is significant and supports a finding that it is not reasonable and necessary. I place significant weight on Dr. Mohan’s CNR’s because they are objective and based on a long-term healing relationship with the applicant.

12With respect to the second treatment plan, submitted June 28, 2024, the gap in corroborating medical evidence is even more pronounced. The applicant did not visit Dr. Mohan for accident-related complaints between January 25, 2024 and August 22, 2024 — a period of seven months that encompasses the submission of the second plan. There is no family doctor referral, no specialist recommendation, and no corroborating medical opinion in evidence supporting the need for ongoing physiotherapy at the time of this plan.

13The clinical notes and records from the Clinic reflect the perspective of the treating provider, not an objective source. While they document attendance and subjective reports of improvement, they do not substitute for corroborating evidence connecting the proposed treatment to accident-related impairment. Dr. Kruger’s IE, while post-dating both plans, provides evidence that by August 2024 the applicant had returned to baseline, with a normal physical examination. I find it supports the finding that facility-based physiotherapy was not reasonable and necessary at the time of either plan.

14For these reasons, I find the applicant has not, on the balance of probabilities, met her onus to demonstrate that the physiotherapy treatment plans are reasonable and necessary.

Is the applicant entitled to the plan for orthotic devices (issue 1c)?

15The applicant is not entitled to the treatment plan for orthotic devices.

16The applicant argues that the accident has exacerbated chronic heel pain, and relies on ultrasound imaging, with a diagnosis from General Practitioner Dr. Sumeet Mohan. Dr. Mohan indicates that between January 26, 2023 and August 29, 2024, the left plantar fascia had thickened, and there is a calcaneal spur. He recommended custom orthotics and physiotherapy.

17The respondent argues that Dr. Mohan’s evidence does not indicate that the ankle pain is caused by the accident, or that the accident has exacerbated a prior existing condition.

18Having reviewed the evidence, I agree with the respondent. It is clear that the applicant has a prior history of heel pain before the accident, as evidenced by the Clinical Notes and Records of Dr. Mohan. However, I have not been led to evidence which indicates that the heel pain is accident related, or that the calcaneal spur is due to the applicant’s accident. I further note that there is no mention of, nor diagnosis of foot pain when the applicant met with Dr. Mohan for the first time after the accident, in January 2024.

19For these reasons, I find the applicant has not met her onus to demonstrate, on the balance of probabilities, that she is entitled to orthotic devices as a result of the accident.

Is the applicant entitled to the balance of the plan for a Drivers Evaluation (# issue 1d)

20The applicant is not entitled to the balance of the treatment plan for a Drivers Evaluation

21In the applicant’s submissions, she focused her argument on why an evaluation was necessary.

22The respondent has agreed that the assessment was reasonable and necessary, and reports to the Tribunal that they have approved it, up to the maximum amount of $2,200.00. This leaves an amount in dispute of only $95.75.

23The applicant has not provided submissions on why they would be entitled to the balance in dispute, or why they are entitled to an amount in excess of the maximum as stipulated in s.25(5) of the Schedule.

24For this reason, I find the applicant has not, on a balance of probabilities, established that she is entitled to the balance of the treatment plan in dispute.

Interest

25Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no payments are overdue, no interest is payable.

Award

26The 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.

27As no benefits were unreasonably withheld or delayed, I find no award is payable.

ORDER

28The application is dismissed.

i. The applicant is not entitled to the treatment plans or remaining balance in dispute. ii. Neither interest nor an award are payable.