010844/AABS
Licence Appeal Tribunal File Number: 24-010844/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:
Jessica Villemaire
Applicant
and
Security National Insurance Company
Respondent
DECISION
ADJUDICATOR:
Estella Muyinda
APPEARANCES:
For the Applicant:
Egor Evsikov, Counsel
For the Respondent:
Uwestina (Tina) Yousif, Counsel
HEARD:
By way of written hearing
OVERVIEW
1Jessica Villemaire, the applicant, was involved in an automobile accident on August 3, 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, Security National 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 $4,080.40 for physiotherapy and massage, proposed by Health Within in a treatment plan/OCF-18 (“plan”) dated March 4, 2024?
Is the applicant entitled to $2,501.54 for Kinesiology services, proposed by Vitality Rehabilitation Group in a treatment plan dated February 20, 2024?
Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant is entitled to $4,080.40 for physiotherapy and massage proposed by Health Within in a treatment plan dated March 4, 2024.
4The applicant is entitled to $2,501.54 for Kinesiology service proposed by Vitality Rehabilitation Group in a treatment plan dated February 20, 2024.
5The applicant is entitled to interest on any overdue payment of benefits.
ANALYSIS
6To receive payment for a treatment and assessment plan under s. 15 and s. 16 of the Schedule, the applicant bears the burden of demonstrating on a balance of probabilities that the benefit is reasonable and necessary because of the accident.
[7]
7To 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.
$4,080.40 for physiotherapy services and massage proposed by Health Within in a treatment plan submitted on March 4, 2024.
8I find that the applicant is entitled to this treatment plan.
9The applicant submits that the treatment plan for physiotherapy services is reasonable and necessary and therefore payable.
10The respondent disagrees and submits that the treatment plan in dispute has been denied because it is not reasonable or necessary.
11The applicant submits that Shawn Fontaine, physiotherapist prepared the treatment plan dated March 4, 2024, for physiotherapy and massage therapy sessions. The goals of treatment include pain reduction, increased strength, improved range of motion, return to work and daily activities, and overall restoration of normal functioning.
12The applicant submits that since the accident she has received care from Dr. Sampa Das, family physician. The applicant asserts that the diagnosis of a concussion and ongoing post concussive symptoms have been confirmed by Dr. Das and s.25 assessor, Dr. Archelle Cortel-Leblanc, neurologist. Both physicians have recommended that this treatment plan is necessary to treat the physical, cognitive and emotional impairments arising from the applicant’s accident-related injury.
13The applicant relies on the clinical notes and records (“CNRs”) of Dr. Das that reveal that the applicant has had significant post-concussion symptoms, including daily headaches, bilateral shoulder pain, radiating neck pain, and sleep disturbance.
14I note that Dr. Das maintained consistent CNRs of the applicant’s post-concussion symptoms from October 2023 to May 2024. The CNRs reveal that on multiple occasions, Dr. Das identified physiotherapy and massage therapy as essential for managing the applicant’s ongoing post-concussion symptoms. Further, Dr. Das opined that the cessation of the service due to lack of insurance coverage resulted in clinical deterioration.
15Dr. Das referred the applicant to a concussion clinic where she was assessed by Dr. Cortel-Leblanc on October 31, 2024. In his report, Dr. Cortel-Leblanc opined that the applicant had persistent post-traumatic headaches and facial pain radiating to the left arm. Dr. Cortel-Leblanc recommended that the applicant have physiotherapy, occupational therapy, massage, and acupuncture for the management of cervicogenic (posttraumatic) headaches.
16The respondent relies on the s.44 IE by Dr. Mohammed Abdul Wahab Khan, physiatrist, dated December 5, 2023. The report reveals that Dr. Khan opined that further treatment would not provide meaningful benefit to the applicant. Additionally, the respondent submits that Dr. Khan opines that the applicant’s complaints were largely subjective with no objective basis to support continued physical intervention.
17Further, the respondent relies on the IE report by Dr. Rhonda Nemeth, psychologist, dated November 20, 2023. Dr. Nemeth opined that there is no evidence that the accident necessitated the proposed services. She diagnosed the applicant as having “other specified trauma and stressor related to disorder consistent with post traumatic stress disorder (PTSD) like symptoms”. Dr. Nemeth opined that the applicant’s pre-accident history of trauma is having a negative impact on her recovery and as a result the accident has caused a resurgence in maladaptive thinking. Thus, Dr. Nemeth opined that it’s the pre-existing trauma that was the significant contributor to the applicant's condition, not physical injuries.
18The respondent submits that the available evidence does not support that the applicant's ongoing physical complaints require further treatment. The respondent states that the applicant has reached maximum medical recovery, and any remaining symptoms are subjective, stable, and better addressed through non-physical modalities.
19I note that Dr. Khan opines in his assessment dated October 25, 2023, that the applicant has not been referred to any specialist. However, I find that the applicant was referred to Dr. Archelle Cortel-Leblanc, neurologist. Additionally, the diagnosis of the applicant’s concussion and ongoing post-concussive symptoms have been confirmed by her healthcare professionals, Dr. Das and Dr. Leblanc.
20Upon review of Dr. Das CNR and Dr. Leblanc’s report-letter. I agree with the applicant that this treatment plan was recommended by treating medical professionals, that indicate that it is necessary to treat the physical, cognitive, and emotional impairments arising from her injury.
21I find that the applicant has submitted contemporaneous corroborating evidence in support of the treatment plan. Thus, I am persuaded by the corroborative reports by Dr. Das and Dr. Leblanc, that the applicant relies on to establish that this treatment plan is reasonable and necessary.
22The records from the two physicians establish that the applicant needs continued physiotherapy and massage therapy. Therefore, it is on that basis that I find that the treatment plan for physiotherapy and massage is payable because it is reasonable and necessary.
$2,501.54 for Kinesiology services, proposed by Vitality Rehabilitation Group in a treatment plan dated February 20, 2024.
23I find that the applicant is entitled to the treatment plan for Kinesiology services in the amount of $2,501.54.
24The treatment plan dated February 20, 2024, submitted by Laura MacKinnon occupational therapist was also signed by Leah Albert, kinesiologist. The goals of the treatment plan are pain reduction, increased strength, improved range of motion, and overcoming physiological limitations.
25The applicant relies on Ms. Albert who opined that the applicant suffered from ongoing and severe symptoms including headaches (rated 8/10), neck pain, tingling on the left side of the face, noise and light sensitivity, and upper body pain.
26Ms. Albert conducted several treatment progress reports dated January 19, 2024; January 26, 2024; February 2, 2024; February 9, 2024; February 16, 2024: February 23, 2024, and May 1, 2024. Ms. Albert opined that Kinesiology services were shown to provide the applicant with relief and functional improvements. She recommended additional kinesiology sessions, and the estimated duration of the treatment plan was 12 weeks.
27The respondent relies on the report by Dr. Mohammed Abdul Khan, physiatrist, dated December 5, 2023, to state that the treatment plan is not reasonable and necessary.
28Dr. Khan opined that the applicant presents with soft tissue complaints, and there is no significant objective accident-related physical impairments or objective ongoing musculoskeletal pathology identified that would necessitate further facility-based therapy for the applicant. The respondent states that any further facility-based treatment beyond what it provided is not expected to provide any subjective or objective cumulative improvement of the applicant.
29Further the respondent relies on Dr. Nemeth’s psychologist, assessment dated November 20, 2023. The respondent submits that Dr. Nemeth opined that pre-existing trauma was the significant contributor to the applicant's current condition, not physical injuries.
30The respondent submits that any ongoing treatment needs relate solely to psychological injuries and are more appropriately addressed through mental health services rather than additional physical interventions.
31Upon review, I place more weight on the s.25 reports because the diagnoses attributed to the applicant are consistent with the accident-related diagnoses made by the applicant’s family physician Dr. Das, who is in a better position to assess the applicant’s psychological injuries related to the accident.
32Additionally, I am persuaded by the corroborative CNR by Dr. Das and the report by Dr. Leblanc that the applicant relies on to establish that this treatment plan is reasonable and necessary. I am further persuaded that the treatment plan is reasonable and necessary because the family physician, who has on numerous occasions recorded and followed up on the applicant’s treatment, in a letter dated May 2, 2024, stated that the applicant should continue physiotherapy/kinesiology for persistent neck pain and headache post accident.
33Further, Ms. Albert opined that because of the kinesiology services, there are improvements in the applicant’s physical activity, and she recommended more sessions of kinesiology for the applicant. I find Ms. Albert’s opinion consistent with the opinion of Dr. Das and Dr. Cortel-Leblanc’s recommendations that the applicant will benefit from more kinesiology sessions. Accordingly, I place more weight on the s. 25 reports because the reports establish that the applicant needs additional sessions of kinesiology therapy.
34For those reasons, I find that the applicant has demonstrated that the treatment plan is reasonable and necessary. The applicant is entitled to the treatment plan.
Interest
35I find that the applicant is entitled to the payment of interest on overdue benefits pursuant to s.51 of the Schedule.
ORDER
36The applicant is entitled to the treatment plan in the amount of $4,080 for physiotherapy and massage.
37The applicant is entitled to the treatment plan in the amount of $2,501.54 for Kinesiology services.
38The applicant is entitled to interest.
Released: May 20, 2026
Estella Muyinda
Adjudicator