Citation and Parties
Licence Appeal Tribunal File Number: 25-000662/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:
Deloris Mayne-Morrison Applicant
and
Aviva General Insurance Company Respondent
DECISION
ADJUDICATOR: Jeff Chatterton
APPEARANCES:
For the Applicant: Maria Papadopoulos, Paralegal
For the Respondent: Maggie Morgan, Counsel
HEARD: In Writing
OVERVIEW
1Deloris Mayne-Morrison, the applicant, was involved in an automobile accident on December 2, 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, 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:
Is the applicant entitled to the treatments proposed by Alma Rehab, as follows: a) $4,026.60 for chiropractic services, in a treatment plan/OCF-18 (“plan”) submitted July 19, 2023; b) $3,919.58 for chiropractic services, in a plan submitted October 6, 2023; c) $3,512.56 for chiropractic services, in a plan submitted March 3, 2024; d) $3,630.54 for chiropractic services, in a plan submitted June 19, 2024; e) $448.83 ($1,648,83 less $1,200.00 approved) for psychological services, in a plan submitted June 19, 2024; and f) $843.83 ($1,648,83 less $800.00 approved) for psychological services, in a plan submitted January 8, 2025?
Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The application is dismissed.
4The applicant is not entitled to the treatment plans for physiotherapy (issues 1a, 1b, 1c, and 1d).
5The applicant is not entitled to the balance of the treatment plans for psychological services, identified as issues 1e and 1f.
6Interest is not payable.
ANALYSIS
Is the applicant entitled to physiotherapy (identified as issues 1a, 1b and 1c?)
7The applicant is not entitled to the treatment plans for physiotherapy.
8To 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.
9In dispute are three treatment plans, calling for a total of 54 therapy sessions with a stated goal of pain reduction, increased strength and increased mobility, and all with a functional goal of a return to the activities of normal living. I note that the issues in dispute lists them as chiropractic treatment plans, but for the sake of this hearing I shall refer to them as physiotherapy plans.
10The applicant submits that she has produced ample evidence of objective, third party evidence showing that she was receiving benefit from physiotherapy, and until her benefits were denied she was attending twice a week. She depends on the Clinical Notes and Records (CNRs) of the treatment provider, Alma Rehab, as well as the CNRs of her primary care physicians, Dr’s Zettle and Sequiera. I note from the CNRs that she made complaints of pain improving with physiotherapy on November 9, 2022; December 21, 2022; July 19, 2023; June 19, 2024 and September 25, 2025. There are multiple referrals for physiotherapy, dated December 2022, September 2024 and November 2024.
11The respondent argues that physiotherapy is not reasonable and necessary, and that the applicant has not met her onus. To support its claim, the respondent relies on the s.44 Insurers Examination (IE) report by General Practitioner Dr. Panjak Bansal, who conducted an in-person assessment in February 2023, with a paper review dated August 2023. Dr. Bansal opined that the applicant was suffering from soft tissue sprain and strain type injuries. I note the IE was conducted for the purpose of determining whether the applicant should be removed from the MIG. I further note the applicant has since been removed from the MIG and the respondent has funded $32,000 worth of physiotherapy and psychological services.
12The respondent further argues that the CNR’s submitted by Alma Rehab do not indicate what healing progress is being made by the applicant, and are silent on the issue of efficacy, despite over $20,000 in treatment.
13I am not convinced by the applicant’s evidence because the applicant has not provided objective evidence from her primary care team which clearly indicates that she was receiving benefit, namely reduced pain, from consistent physiotherapy related to accident-caused injuries.
14The reason I make this finding is that upon careful review of the family doctor CNR’s submitted by the applicant, I see a recommendation for physiotherapy dated December 21, 2022. However, there are no further recommendations for physiotherapy until September 2024. I find the evidence does not support a physiotherapy plan which would not have been written for a further 9 months, dated October 6, 2023.
15While other OCF-18’s were submitted (issue 1b and 1c), I have also not been led to further recommendations for physiotherapy from a medical professional.
16Furthermore, I note that the recommendations for physio make multiple references to degenerative conditions such as osteoarthritis, but I have not been led to evidence which states that the physiotherapy in dispute was recommended to treat accident-related injuries.
17I also note that the applicant has not made submissions as to why the treatment plans are not duplicative. For example, I have not been led to any submissions or evidence why treatment plans 1b or 1c may be different in terms of scope or treatment.
18In summary:
i. In the absence of a recommendation for physiotherapy from the family physician, I have not been led to a contemporaneous recommendation for physiotherapy which would justify any of the three separate treatment plans for physiotherapy.
ii. Any recommendation for physiotherapy I have been led to is a) not contemporaneous to the treatment plans in dispute, and b) does not make reference to treating accident-related injuries.
iii. The respondent has provided evidence in the form of Dr. Panjak-Bansal’s report where he opined that the applicant would not be receiving further benefit from facility-based rehabilitation.
19For these reasons, I find the applicant has not met her onus to demonstrate, on the balance of probabilities, that she is entitled to the physiotherapy treatment plans in dispute (identified as issues 1a, 1b and 1c.)
Is the applicant entitled to issue 1d, for physiotherapy services?
20The applicant is not entitled to issue 1d.
21The applicant did not provide any submissions regarding issue 1d. The applicant also referred to the fact a treatment plan dated in June 2024 was paid by the respondent. It is unclear to me if that is the treatment plan in dispute.
22The respondent also does not refer to issue 1d in their submissions.
23In the absence of arguments from either party, I find the applicant has not met their onus, on the balance of probabilities, to establish entitlement to the treatment plan identified in issue 1d.
Is the applicant entitled to the remaining balance of the treatment plan for Psychological Services (issue 1e)?
24The applicant is not entitled to the remaining balance of the Psychological Services treatment plan identified as issue 1e.
25The applicant argues that she is suffering from an ongoing psychological condition and benefits from counseling and ongoing therapy. To support her claim, she relies on the CNRs of Alma Rehab, the treatment provider.
26The respondent argues it approved the treatment plan but did not approve a progress report, since it believes it was not reasonable or necessary. It also asked for information regarding client supervision services, but that to date the applicant has not submitted the requested information.
27The applicant has not addressed whether or not a progress report is reasonable or necessary in her submissions.
28Therefore, I find the applicant has not, on the balance of probabilities, met her onus to demonstrate she is entitled to the amount in dispute on the disputed treatment plan identified as issue 1e.
Is the applicant entitled to the balance of the treatment plan for Psychological Services (issue 1f)?
29The applicant is not entitled to balance of the Psychological Services treatment plan identified as issue 1f.
30The applicant argues that ongoing psychotherapy is reasonable and necessary, and that even the respondent’s experts have identified that she has a psychological condition – specifically, Adjustment Disorder with Mixed Anxiety and Depressed Mood (chronic), as well as Somatic Symptom Disorder with Predominant Pain.
31The respondent argues the applicant has achieved maximal psychological recovery, and that further psychological services will not benefit her or her mental health. To support its claim, the respondent relies on a s.44 IE report conducted by Psychologist Dr. Marco Chiodo, dated March 5 2025. The respondent argues it approved the plan in order to provide conclusory psychotherapy services to the applicant after approving six one-hour sessions with a psychotherapist over the course of the therapeutic relationship.
32The applicant argues that the respondent approving only six sessions is arbitrary and without rationale, and that ongoing treatments are necessary. The applicant states that the decision to only fund six sessions is both arbitrary and medically premature.
33I am convinced by the respondent’s evidence. In his report, Dr. Chiodo noted that the applicant had not shown significant improvement compared to when she was assessed in 2022.
34Although the onus remains with the applicant to demonstrate entitlement, I was not led to progress reports that reflect substantial improvement in the applicant’s condition which would indicate why further treatment was reasonable and necessary. I was also not led to further evidence, such as CNR’s from the primary care physician, to indicate that the applicant was receiving benefit from ongoing psychological services.
35For this reason, I find the applicant has not, on the balance of probabilities, met her onus to demonstrate entitlement to the balance of the treatment plan for psychological services in dispute identified as issue 1f.
Interest
36Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Interest applies on treatment plans 1a, 1b and 1c, as per the Schedule.
ORDER
37The application is dismissed:
i. The applicant is not entitled to treatment plans for physiotherapy, identified as issues 1a, 1b and 1c and 1d.
ii. The applicant is not entitled to the balance of the treatment plans for psychological services, identified as issues 1e and 1f.
iii. Interest is not payable.
Released: May 8, 2026
Jeff Chatterton Adjudicator