Licence Appeal Tribunal File Number: 25-002003/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:
Mohafizali Merali
Applicant
and
Security National Insurance Company
Respondent
DECISION
ADJUDICATOR:
Melanie Malach
APPEARANCES:
For the Applicant:
Yalini Yogeswaran, Paralegal
For the Respondent:
Hilary Doyle, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Mohafizali Merali, the applicant, was involved in an automobile accident on August 30, 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:
i. Is the applicant entitled to the services proposed by Mackenzie Medical Rehabilitation Centre, as follows:
(a) $3,622.31 for chiropractic services, in a treatment plan dated September 16, 2023;
(b) $2,023.03 for chiropractic services, in a treatment plan dated January 30, 2024; and
(c) $1,525.84 for chiropractic services, in a treatment plan dated June 24, 2024?
ii. Is the applicant entitled to the services and assessments proposed by E Clinic United Healing, as follows:
(a) $1,463.80 for chiropractic services, in a treatment plan dated November 29, 2024;
(b) $2,132.60 for chiropractic services, in a treatment plan dated November 29, 2024; and
(c) $1,050.00 for a nutritional assessment, in a treatment plan dated November 29, 2024?
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?
3The Case Conference Report and Order lists issue 6(i) as, “Is the applicant entitled to $1,850.00 for a Psychological Assessment, in a treatment plan proposed by E Clinic United Healing, dated November 29, 2024?”. The applicant and the respondent confirm that this treatment plan has now been approved and is no longer in dispute. I therefore have not included it in the issues in dispute.
RESULT
4The applicant is not entitled to the treatment plans in dispute, interest or an award.
ANALYSIS
Entitlement to Medical and Rehabilitation Benefits
5To receive payment for a treatment and assessment plan under sections 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. In the context of an assessment, while the applicant does not need to prove the condition exists, he must prove with persuasive evidence that there is some accident-related condition that warrants investigation via the proposed assessment.
Entitlement to the treatment plans prepared by Mackenzie Medical Rehabilitation Centre proposing chiropractic treatment
6The applicant submits that he is entitled to the following treatment plans proposed by Mackenzie Medical Rehabilitation Centre, recommending chiropractic services:
i. $3,622.31 for chiropractic services, in a treatment plan dated September 16, 2023;
ii. $2,023.03 for chiropractic services, in a treatment plan dated January 30, 2024; and
iii. $1,525.84 for chiropractic services, in a treatment plan dated June 24, 2024.
7The applicant submits that the treatment plans proposing chiropractic services dated September 16, 2023, January 30, 2024 and June 24, 2024, are reasonable and necessary based on the medical evidence in the Clinical Notes and Records (“CNRs”) of her family physician, Dr. Sadaf Sawar; Mackenzie Medical Rehabilitation Centre; E Clinic United Healing; Q Medical, All Health Medical and Dr. Devanshi Sharma. The applicant submits that he continues to experience persistent cervical, thoracic and lumbar pain with associated muscle tightness, stiffness, and functional limitations despite years of compliant physiotherapy, home exercise and massage therapy. The applicant submits that the chronicity of his symptoms and ongoing postural imbalance indicate that