Licence Appeal Tribunal File Number: 25-000768/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:
Arslan Koksal
Applicant
and
TD General Insurance Company
Respondent
DECISION
ADJUDICATOR: Roderick Walker
APPEARANCES:
For the Applicant: Ken Singh, Counsel
For the Respondent: Ali Samhat, Counsel
HEARD: By Way of Written Submissions
OVERVIEW
1Arslan Koksal, the applicant, was involved in an automobile accident on February 17, 2024, 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, TD 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 $5,380.00 for Plates Rich Plasma, (PRP) injections, proposed by All Health Medical Centre in a plan dated February 27, 2025?
ii. Is the applicant entitled to $21,732.75, (partial paid $ 8,395.59) for a chronic pain program, proposed by Dr. Mikhail Shteynberg in a plan dated February 27, 2025?
iii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant is not entitled to $5,380.00 for PRP injections as well as the plan for $13,337.16, the disputed amount of the chronic pain plan. No interest or award is payable.
ANALYSIS
4To 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.
The applicant is not entitled to PRP injections.
5I find the plan is not reasonable and necessary.
6The applicant argues that PRP injections are justified because of ongoing chronic pain, including chronic low back pain and other muscle and joint complaints. PRP injections involve using the patient’s own blood to promote healing. To support this claim, the applicant relies on several sources, including an OCF‑3 dated May 21, 2024, completed by Dr. Baharanchi, Chiropractor, which lists various soft tissue injuries as, headaches,WAD 2 whiplash with neck pain, shoulder and upper arm pain, sprain and strain of shoulder girdle, thoracic spine, lumbar spine elbow, confusion of elbow, dorsalgla and sleep disorders. The applicant also relies on a disputed treatment plan, a physiatry report by Dr. Wildeman, and a CADTH Health Technology Review published in July 2023, which suggests that PRP injections may help chronic low back pain in the general population.
7The respondent disagrees and argues that the applicant did not sustain a chronic or structural back injury from the accident. Instead, the respondent states the applicant suffered soft tissue injuries, which do not justify PRP injections. The respondent relies on a section 44 insurer’s examination performed by Dr. Ko,Physiatrist, who stated that PRP injections are experimental and not medically necessary for this case. Dr. Ko also referenced research, including Cochrane Database of Systematic Reviews, showing insufficient and inconsistent evidence to support PRP injections for soft tissue injuries.
8I find that the applicant did not meet the burden of proof on a balance of probabilities. While the applicant has shown that pain continues, I am not persuaded by the individualized medical evidence explaining how PRP injections would specifically improve the applicant’s injuries or chronic low back condition.
9The evidence also does not show how the PRP injections would lead to measurable or functional improvement in the applicant’s daily life. General claims that PRP may help some conditions or may work for the general population are not enough to prove medical necessity for this specific applicant.
10The CADTH review from July 2023 only discusses possible benefits at a population level and does not address the applicant’s exact diagnosis, treatment history, or prognosis. Although Dr. Wildeman supports the injections, the report does not clearly link the applicant’s symptoms to a specific, measurable outcome from PRP treatment, nor does it explain how success would be evaluated.
11In contrast, the respondent’s medical evidence raises valid concerns about the experimental nature of PRP injections and the lack of solid clinical evidence supporting their use for injuries like those suffered by the applicant.
12I find because there is no clear medical rationale in the evidence and that being an article from the Cochrane Database of Systematic Reviews, showing that PRP injections are reasonably required and medically necessary as a result of the accident.I find that the treatment plan is not reasonable or necessary. As a result, on a balance of probabilities, the applicant is not entitled to the proposed PRP injection treatment plan.
The applicant is not entitled to $13,337.16, the disputed amount of the chronic pain plan.
13I find that the outstanding balance of the chronic pain treatment plan is not reasonable or necessary.
14The applicant submits that his ongoing chronic pain syndrome, chronic back pain, shoulder pain, anxiety, and depression justify entitlement to the remaining portion of the partially approved plan. He relies on the clinical notes and records of his family physician, Dr. A. Hoca, to support his claim.
15The respondent submits that the partially approved amount of $8,395.56 is sufficient and that the remaining components of the plan including additional physical rehabilitation, chiropractic treatment and work conditioning, medical visits, psychological progress reporting, delivery, a TENS unit, transdermal compound cream, and lumbar support—are not reasonable or necessary. The respondent relies on the insurer’s examination conducted by Dr. Yong‑Kyong Michael Ko, Physiatrist, dated April 23, 2025, who concluded that the applicant sustained soft tissue injuries and that no further physical treatment was medically required.
16The respondent relies on of Violi v. General Accident Assurance Co. of Canada, FSCO A98-000670, 2000 ONFSCDRS 177, which establishes that an insured person must demonstrate that treatment goals are reasonable, that the goals are being met to a reasonable degree, and that the overall cost of achieving those goals is reasonable in light of available treatment alternatives.
17While I accept that the applicant continues to experience physical and psychological symptoms, ongoing symptoms alone do not establish entitlement to additional benefits. I find that the applicant has not explained how the remaining portion of the chronic pain plan would benefit him or why the partially approved amount was insufficient. There is no persuasive medical evidence demonstrating that the additional proposed treatment would address accident‑related impairments or result in meaningful functional improvement.
18The treatment plan lists proposed services and goods but does not clearly link them to defined treatment goals or explain how the applicant’s functioning is expected to improve as a result. I find the evidence does not support the plan is reasonable and necessary.
19I accept Dr. Ko’s opinion dated April 23, 2025, that the applicant’s physical injuries are soft tissue in nature and that the additional physical components of the chronic pain plan are not medically required. Although psychological conditions have been identified, the applicant has not established that the denied portion of the plan is necessary to achieve outcomes beyond those already addressed through the approved plan.
Interest
20Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. No interest is awarded because no benefits are payable.
Award
21Pursuant to section 10 of Regulation 664, the Tribunal may award up to 50% of the total benefits payable plus interest if it determines that the insurer unreasonably withheld or delayed the payment of benefits. I find that since no benefits are payable, the respondent is not liable to pay for an award.
ORDER
22On the totality of the evidence, I find that:
a The applicant is not entitled to $5,380.00 for PRP injections.
b The applicant is not entitled to$13,337.16, the disputed amount of the chronic pain plan.
c No interest or award are payable.
d The application is dismissed.
Released: May 15, 2026
Roderick Walker
Adjudicator