Licence Appeal Tribunal File Number: 25-000446/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:
Ali Vahdati
Applicant
and
Allstate Insurance Company of Canada
Respondent
DECISION
VICE-CHAIR:
Amanda Marshall
APPEARANCES:
For the Applicant:
Adesina C John, Paralegal
For the Respondent:
Greg Specht, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Ali Vahdati (the “applicant”) was involved in an automobile accident on March 19, 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 Allstate Insurance Company of Canada (the “respondent”) and applied to the Licence Appeal Tribunal-Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
2A prior decision found that the applicant’s injuries are predominantly minor as defined in s. 3 of the Schedule and therefore subject to treatment within the $3,500.00 Minor Injury Guideline (“MIG”) limit. The applicant filed another application on January 14, 2025. The Case Conference Report and Order (“CCRO”) dated April 17, 2025 identified two preliminary issues:
i. Whether the applicant is barred from proceeding to a hearing by the doctrine of res judicata pertaining to the issue of whether the applicant’s injuries are predominantly minor as defined in s. 3 of the Schedule; and
ii. Whether the applicant is barred from proceeding to a hearing for three treatment plans because the applicant failed to dispute their denial within the 2-year limitation period.
3In a correspondence sent to the Tribunal on May 6, 2025, the applicant withdrew the issue of whether his injuries are predominantly minor as defined in s. 3 of the Schedule and therefore subject to treatment within the $3,500.00 Minor Injury Guideline (“MIG”) limit.
4A preliminary issue decision was issued on July 11, 2025. The applicant sought a reconsideration of the decision. The reconsideration was granted. The preliminary issue decision was cancelled, pursuant to Rule 18.4 of the Licence Appeal Tribunal Rules, 2023.
5The preliminary issue was reheard as part of the reconsideration decision. The respondent’s request to bar the applicant’s application from proceeding to a substantive issues hearing based on the doctrine of res judicata was denied, because the applicant had withdrawn the issue of whether the applicant’s injuries were subject to treatment within the MIG.
6The reconsideration decision ordered the remaining preliminary issue and the substantive issues to proceed to a written hearing as ordered in the April 17, 2025 CCRO, with some variations with respect to the timelines for submissions.
PRELIMINARY ISSUE
7The preliminary issue to be decided is:
i. Is the applicant barred from proceeding to a hearing for the following benefits: substantive issues 1(i), (ii) and 2 below, because the applicant failed to dispute their denial within the two-year limitation period?
SUBSTANTIVE ISSUES
8The substantive issues in dispute are:
- Is the applicant entitled to the services proposed by Mackenzie Medical Rehabilitation Center, as follows:
i. $2,635.40 for chiropractic services, in a treatment plan/OCF-18 (“treatment plan”) dated May 20, 2021; and
ii. $2,229.50 for chiropractic services, in a treatment plan dated February 28, 2022?
Is the applicant entitled to $1,999.01 for a chronic pain assessment, proposed by Unison Medical Assessments in a treatment plan dated July 12, 2021?
Is the applicant entitled to the services and assessments proposed by Baskakova Psychology Professional Corp., as follows:
i. $2,400.00 for a psychological assessment, in a treatment plan dated May 5, 2023;
ii. $4,912.81 for psychological services, in a treatment plan dated July 31, 2023; and
iii. $1,997.33 for a driving evaluation, in a treatment plan dated July 31, 2023?
- Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
9I find that:
i. The applicant is barred from proceeding to a hearing for the two chiropractic treatment plans and the chronic pain assessment as he did not dispute the denials within two years of receiving the valid denials.
ii. The psychological assessment, psychological services treatment plan and the driving evaluation are not payable pursuant to s. 38(11) of the Schedule.
iii. The applicant is not entitled to interest because there is no overdue payment of benefits.
PRELIMINARY ISSUE ANALYSIS
10I find the applicant is barred from proceeding to a hearing for the two chiropractic treatment plans and the chronic pain assessment as he did not dispute the denials within two years of receiving the valid denials.
11Section 56 of the Schedule provides that an application to the Tribunal in respect of a benefit shall be commenced within two years after the respondent’s refusal to pay the amount claimed. However, pursuant to s. 7 of the Licence Appeal Tribunal Act, 1999, S.O. 1999, c. 12, Sched. G (the “LAT Act”), the Tribunal has the authority to extend the limitation period beyond the two-year mark outlined by s. 56 of the Schedule.
12Section 38(8) of the Schedule, relied on by the applicant and which pertains to medical and rehabilitation benefits, states that within 10 business days of receiving a treatment plan, the insurer shall give the insured person notice outlining the medical reasons and all other reasons why the insurer considers any goods, services, assessments and examinations, or the proposed costs of them, not to be reasonable and necessary.
13The respondent submits that the applicant is statute-barred from proceeding with his claim for the two chiropractic treatment plans and the chronic pain assessment, because the denials were valid, and the application was filed outside of the two-year limitation period set out in s. 56. Further, the respondent submits that the Tribunal should not exercise its discretion to extend the limitation period as the applicant has not satisfied his onus to establish reasonable grounds for an extension.
14The applicant does not dispute that his application was filed outside of the two-year limitation period. However, the applicant argues that all three treatment plans are deficient, citing the absence of meaningful medical or other reasons supporting their denial and the failure to indicate whether additional documentation was attached. His submissions are as follows:
i. The $2,635.40 plan states only that the fee exceeds the permitted maximum, without explanation.
ii. The $2,229.50 plan indicates that the “MIG applies is appropriate,” without identifying the relevant diagnosis.
iii. The third plan concludes that the treatment is not reasonable and necessary but provides no supporting medical rationale or evidentiary basis.
15Here, in order for the denials to trigger s. 56, they must comply with the principles set out in Smith v. Co-operators General Insurance Co., 2002 SCC 30 (“Smith”). According to Smith, the information in a denial must be provided in straightforward and clear language, directed towards an unsophisticated person. The information should also include a description of the most important points of the dispute resolution process, and the relevant time limits that govern the process.
16I find that each denial was clear and unequivocal, set out medical and other reasons for the refusal, and included notice of the applicable two‑year limitation period as well as information about the dispute resolution process.
17For the $2,635.40 chiropractic treatment plan, I find that the denial identifies the proposed treatment, the amount claimed, and that no benefits are payable. It relies on the April 13, 2021 physiatry report of Dr. Alborz Oshidari, which concludes that the applicant’s injuries fall within the MIG and that no further physical intervention is required. Although attachments were not expressly noted, the denial includes page references and directs the applicant to the April 13, 2021 report, which had been provided on April 19, 2021. I find that this denial complies with the principles set out in Smith.
18The denial for the $2,229.50 chiropractic treatment plan similarly identifies the treatment sought, the amount claimed, and that no benefits were payable. As above, while attachments were not expressly noted, the comments page references the April 13, 2021 physiatry examination report and confirms the MIG determination. I find this denial also complies with the principles set out in Smith.
19I find the remaining denial likewise complies with the principles in Smith. The denial identifies each treatment item, the associated costs, and that no benefits were payable on the basis that the treatment was not reasonable and necessary. The comments page refers to the April 13, 2021 physiatry examination report, confirms the MIG determination, and indicates that no further physical intervention is required. Considering the existing medical opinion, the plan was not referred for a s. 44 examination.
20I find that all three denials were clear, straightforward, and directed to an unsophisticated person, and provided medical and other reasons as required by 38(8). Further, each set out the dispute resolution process and the applicable time limits.
21I turn now to s. 7 of the LAT Act which allows the Tribunal to extend a limitation period for filing an appeal. In considering whether to exercise its discretion to extend the limitation period, the Tribunal must consider the following four factors set out in Manuel v. Registrar, 2012 ONSC 1492:
i. The existence of a bona fide intention to appeal within the limitation period;
ii. The length of delay;
iii. The prejudice to the other party; and
iv. The merits of the appeal.
22The onus is on the applicant to establish reasonable grounds for an extension under s. 7 of the LAT Act.
23I decline to exercise my discretion under s. 7 of the LAT Act. The applicant made no submissions requesting or supporting the exercise of this discretion. Instead, the applicant reiterated the position that the notices are deficient. In the absence of submissions explaining why discretion should be exercised, the applicant has not met his onus, and there is no basis upon which to grant s. 7 relief.
SUBSTANTIVE ISSUES ANALYSIS
Two psychological treatment plans and the driving evaluation
24The applicant advances two sets of arguments about the treatment plans for the psychological assessment, the psychological treatment and the driving evaluation. He argues that he is entitled to the treatment plans under s. 40(7) of the Schedule. He also argues that they are payable pursuant to s. 38(11). I will consider each of these arguments in turn.
Section 40(7) arguments
1The applicant withdrew the MIG issue for this hearing; it is not before me. Despite this, the applicant submits that the three treatment plans are payable on the basis that his injuries are not predominantly minor, relying on s. 40(7) to argue that the MIG does not apply to treatment sought beyond the initial 12-week period. This same argument was previously rejected by the Tribunal, and the applicant advances it again here.
2The respondent contends that the applicant was found to be within the MIG and therefore, the treatment plans are not payable.
3Section 40(7) does not confer an entitlement to benefits or exempt treatment from the MIG. It governs the procedural requirement for submitting treatment plans outside the initial 12‑week MIG period, requiring an OCF‑18 rather than an OCF‑23. It does not establish that impairments arising outside that period are excluded from the MIG. This interpretation was upheld on reconsideration. Although prior decisions are not binding, I see no basis to depart from the previous Tribunal findings on the applicant’s arguments pursuant to s. 40(7). Further, while the applicant asserts that his injuries are not predominantly minor and that the proposed treatments are reasonable and necessary, the issue of continued MIG applicability has been withdrawn and is therefore not properly before me.
4Therefore, as the applicant was found to be within the MIG, it is unnecessary to determine whether the treatment plans in dispute are reasonable and necessary.
Section 38
5I find that the treatment plans are not payable pursuant to s. 38(11) of the Schedule.
6While the applicant asserts that the respondent’s denials for the three treatment plans do not comply with s. 38(8) of the Schedule, the applicant has not identified how the denials are deficient. In the absence of reasons upon which to assess non‑compliance, I am unable to find that the respondent failed to comply with s. 38(8) for the psychological assessment, psychological treatment and the driving evaluation. Therefore, the shall pay provisions of s. 38(11) are not triggered, and the treatment plans are not payable.
Interest
7Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As I have found no benefits are overdue, no interest is payable.
ORDER
8For the above reasons, I find:
i. The applicant is barred from proceeding to a hearing for the two chiropractic treatment plans and the chronic pain assessment as he did not dispute the denials within two years of receiving the valid denials.
ii. The psychological assessment, psychological services treatment plan and the driving evaluation are not payable pursuant to s. 38(11) of the Schedule.
iii. The applicant is not entitled to interest because there is no overdue payment of benefits.
Released: May 15, 2026
Amanda Marshall
Vice-Chair