Citation: Gunes v. Aviva General Insurance Company, 2026 ONLAT 24-015289/AABS

Licence Appeal Tribunal File Number: 24-015289/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:

Muzafer Gunes

Applicant

and

Aviva General Insurance Company

Respondent

DECISION

ADJUDICATOR:

Harouna Saley Sidibé

APPEARANCES:

For the Applicant:

Ken Singh, Counsel

For the Respondent:

Kevin H. Griffiths, Counsel

HEARD:

By way of written submissions

1Muzafer Gunes, the applicant, was involved in an automobile accident on March 22, 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, 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:

i. Is the applicant entitled to $2,618.13 ($4,015.23 less $1,397.00 approved) for psychological services, proposed by Global Health Recovery in a treatment plan/OCF-18 (“plan”) submitted August 8, 2024?

ii. Is the applicant entitled to $3,284.96 for chiropractic services, proposed by RehabOne Plus in a plan submitted September 5, 2024?

iii. Is the applicant entitled to $2,169.29 ($4,015.13 less $1,845.84 approved) for psychological services, proposed by Global Health Recovery in a plan submitted November 26, 2024?

iv. Is the applicant entitled to $21,818.59 for a chronic pain program, proposed by All Health Medical Centre in a plan submitted November 28, 2024?

v. Is the applicant entitled to $2,169.30 ($4,015.13 less $1,845.83 approved) for psychotherapy services, proposed by Global Health Recovery in a plan submitted March 9, 2025?

vi. Is the applicant entitled to the assessments proposed by All Health Medical Centre, as follows:

$2,670.00 for a Neurological Assessment, in a treatment plan submitted June 24, 2024; and
$2,410.00 for a Chronic Pain Assessment, in a treatment plan submitted September 23, 2024?

vii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?

viii. Is the applicant entitled to interest on any overdue payment of benefits?

3The Case Conference Report and Order (“CCRO”) dated March 26, 2025, records, for the most part, the dates the respondent received the disputed treatment plans rather than the dates shown on the plans. For consistency, I have relied on and retained the dates set out in the CCRO.

RESULT

4For the reasons below, I find that:

i. The applicant is entitled to the outstanding amounts of $2,618.13; $2,169.29 for the plans covering psychological services and $2,169.30 for psychotherapy services, plus interest.

ii. The applicant is entitled to the chiropractic treatment plan for $3,284.96, the neurological assessment for $2,670.00, and the chronic pain assessment for $2,410.00, plus interest.

iii. The applicant is not entitled to the treatment plan for the chronic pain program.

iv. The applicant is not entitled to an award.

ANALYSIS

Is the applicant entitled to the disputed treatment and assessment plans?

5I find that the applicant has, in part, established the reasonableness and necessity of the disputed treatment and assessment plans. Specifically, the applicant is entitled to the outstanding amounts of $2,618.13 and $2,169.29 for psychological services, $2,169.30 for psychotherapy services, $3,284.96 for the chiropractic treatment plan, $3,284.96 for the neurological assessment, and $2,410.00 for the chronic pain assessment.

6To 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.

Outstanding Amounts for Psychological and Psychotherapy Services

7I find that the applicant is entitled to payment of the outstanding balances under the plans submitted on August 8, 2024; November 26, 2024; and March 9, 2025.

8The dispute before me does not concern entitlement to psychological treatment generally but is limited to whether the applicant is entitled to payment of the outstanding balances arising from the respondent’s application of a lower hourly rate to the psychological and psychotherapy services proposed in the treatment plans submitted on August 8, 2024, November 26, 2024, and March 9, 2025.

9To receive payment for the disputed portions of these treatment plans, the applicant bears the burden of establishing, on a balance of probabilities, that the proposed costs are reasonable and necessary under Superintendent’s Guideline No. 03/14 (the “Guideline”). The Guideline governs fees for services listed in the Schedule by prescribing maximum payable amounts. For example, it sets a maximum hourly rate for psychologists but not for all provider categories, including psychotherapists. Where no capped rate is prescribed, the parties must determine an appropriate fee, and the applicant must demonstrate that any proposed rate, particularly when it exceeds comparable regulated rates, is justified. This assessment requires consideration of the treatment goals, how those goals are to be achieved, the nature of the services, the qualifications and role of the service providers, and whether the claimed costs reasonably reflect those factors.

The plan dated August 8, 2024

10The August 8, 2024, plan requests payment of $4,015.23 for psychological and psychotherapy services. The respondent approved $1,397.00, leaving an outstanding balance of $2,618.13, primarily due to a dispute over the applicable hourly rate and session length. The plan is signed by Dr. Hadi Bahiraei, a psychologist, and Mr. Mehdi Mohammadi Kaji, a registered psychotherapist.

11The stated treatment goals are to reduce psychological symptoms associated with adjustment‑related and somatic conditions, facilitate a return to pre‑accident functioning and work activities, assist the applicant in coping with physical conditions, and support functional recovery. The plan proposes a structured course of cognitive behavioural therapy (“CBT”), delivered by Mr. Kaji under the clinical supervision of Dr. Bahiraei, along with associated preparation, documentation, testing, and reporting services.

12The respondent partially approved the plan on September 12, 2024, agreeing to fund psychotherapy at $99.75 per hour for one‑hour sessions, and denying the balance on the basis that the proposed psychotherapy rate exceeded what it considered reasonable for a psychotherapist under the Guideline, that 90‑minute sessions were unjustified, and that test, mental health, preparation, brokerage, and planning services were unnecessary or duplicative.

The plans dated November 26, 2024, and March 9, 2025

13The treatment plans dated November 26, 2024, and March 9, 2025, request funding for substantially the same services, with nearly identical goals, providers, and treatment structure. After partial approvals at the same $99.75 hourly rate, the outstanding balances are $2,169.29 and $2,169.30, respectively. The respondent maintained its position that psychotherapy delivered by a psychotherapist should be reimbursed at the lower rate and that the additional time and ancillary services were not justified.

14The respondent’s position rests on the premise that psychotherapy must be reimbursed at a fixed, reduced hourly rate solely because the service is delivered by a registered psychotherapist rather than a psychologist. The respondent did not dispute that the services were clinically required but took issue with the quantum and the rate applied.

Analysis

15I agree with the applicant’s submission that the reasonableness of the claimed rate cannot be determined solely by reference to the professional title of the individual providing the treatment. While the Guideline sets maximum hourly rates for certain identified providers, it does not prescribe a specific rate for psychotherapists. The applicant relies on prior Tribunal decisions in which adjudicators considered the nature and complexity of the services provided, as well as the provider’s credentials and experience, when determining a reasonable rate. For example, in J.V. v. Intact Insurance Company, 2019 CanLII 130366 (ON LAT), upheld on reconsideration, and A.S. v. Aviva Insurance Company, 2020 CanLII 12787 (ON LAT), the Tribunal accepted that a registered psychotherapist could be compensated at a rate equivalent to that of a psychologist where the evidence supported comparable qualifications and services. Similarly, in Pauvif v. Aviva General Insurance, 2020 CanLII 122614 (ON LAT), rates for psychological services were found reasonable where they were tied to approved treatment. I find this approach persuasive in the circumstances. Consistent with these authorities, the assessment of reasonableness in this case is more appropriately grounded in the substance of the services provided and the provider’s qualifications and experience, rather than the professional title alone.

16The applicant has identified clear treatment goals across all three plans and has outlined how those goals will be met through a structured CBT‑based intervention that addresses trauma‑related symptoms, mood disturbance, anxiety, and functional impairment. The proposed services are not generic supportive counselling but rather targeted psychological treatment that requires clinical formulation, treatment planning, ongoing evaluation, and professional supervision.

17The CV of Mehdi Kaji indicates that he is a registered psychotherapist regulated by the College of Registered Psychotherapists of Ontario, with training in CBT, and that he provided services within a structured clinical framework under the supervision of Dr. Bahiraei, a registered psychologist who conducted the initial psychological assessment and maintained clinical oversight. The applicant also relies on professional regulatory materials indicating that registered psychotherapists are regulated health professionals who undergo formal training and operate under comparable professional obligations and overhead.

18The Guideline establishes fixed maximum rates for certain categories of professional services, and in most cases, those rates apply as prescribed. However, it does not specify a maximum hourly rate for services provided by registered psychotherapists. By contrast, it sets a rate of $58.19 per hour for unregulated providers, such as counsellors and psychometrists. In the absence of a specified rate for psychotherapists, the parties must determine an appropriate fee, and the applicant must establish, on a balance of probabilities, that any proposed rate, particularly when it exceeds comparable Guideline rates, is reasonable.

19In these circumstances, the applicant has demonstrated that the psychotherapy services form part of an integrated psychological treatment plan, clinically supervised by a psychologist and directed at complex accident‑related psychological impairments. The evidence establishes that Mr. Kaji is a registered psychotherapist regulated by the College of Registered Psychotherapists of Ontario, with training in CBT and experience providing psychotherapy within a structured clinical setting. The treatment is delivered pursuant to a psychological assessment and under the ongoing clinical oversight of Dr. Bahiraei, a registered psychologist, which further supports the characterization of the services as psychological in nature. Having regard to these factors, including the provider’s regulatory status, therapeutic training, and role within a supervised, assessment‑driven treatment framework, I am satisfied that the proposed hourly rate of $149.61 is reasonable given the nature and scope of the services.

20I also accept that the proposed 90‑minute CBT sessions, along with the time required for clinical preparation, progress monitoring, and reassessment, are reasonable and necessary in the circumstances. The evidence indicates that the applicant’s psychological presentation, characterized by ongoing symptoms identified in the psychological assessment, requires a structured, goal‑oriented intervention consistent with CBT. Such an intervention may reasonably require longer sessions to deliver core therapeutic components, review progress, and adjust treatment strategies within a single sitting. The session length is therefore supported by the clinical framework set out in the assessing psychologist’s report and the treatment plan.

21Regarding the additional time for preparation, documentation, and progress reporting, I acknowledge that the Guideline generally contemplates that such activities are captured within the prescribed hourly rates and cautions against duplicative billing that would effectively increase those rates. However, on the evidence before me, the impugned items are sufficiently connected to the delivery and monitoring of treatment goals, rather than purely administrative or overhead functions, to constitute integral components of the therapeutic process. They cannot be characterized as duplicative merely because similar categories of work appear across successive plans, particularly where ongoing reassessment and adjustment are inherent to CBT.

22On balance, I find that the applicant has met his burden of proving that the outstanding balances claimed under each of the three treatment plans are reasonable costs for achieving the identified treatment goals and are consistent with the intent and application of the Guideline.

23The applicant is therefore entitled to payment of the outstanding amounts as follows: $2,618.13 for psychological and psychotherapy services proposed in the plan dated August 8, 2024; $2,169.29 for psychological services proposed in the plan dated November 26, 2024; and $2,169.30 for psychotherapy services proposed in the plan dated March 9, 2025.

Chiropractic Services

24I find that the applicant is entitled to the chiropractic treatment plan.

25The treatment plan in dispute, dated September 5, 2024, seeks $3,284.96 in funding for chiropractic services and is signed by Dr. Maliheh Zakeri Mehr, a Chiropractor. The goals of the proposed treatment are to reduce pain, improve strength, restore functional abilities necessary for activities of daily living, and support a return to pre-accident work activities. The plan recommends 16 chiropractic treatment sessions, 16 mobilization sessions involving multiple body regions, 16 muscle-stimulation sessions to the back, and related documentation of supportive activities.

26On October 4, 2024, the respondent denied the plan. The denial was based on the position that the applicant had already received $3,500 in treatment under the Minor Injury Guideline (“MIG”) and that the medical evidence showed only minor soft-tissue injuries. The respondent maintained that further chiropractic treatment was neither reasonable nor necessary. In support, the respondent relied primarily on the insurer’s examination report by Dr. Howard Platnick, dated September 16, 2024, in which he concluded that the applicant sustained minor, uncomplicated soft-tissue injuries that had resolved and required no further rehabilitation.

27The applicant relies on the clinical notes and records (“CNRs”) of the family physician, Dr. Asim Hoca, and submits that these records document ongoing accident-related symptoms, including neck and back pain and headaches, that persisted beyond the initial post-accident period.

28The respondent relies on Dr. Platnick’s report and submits that the early post-accident medical records show limited, resolving soft-tissue complaints, a largely normal range of motion, and minimal objective findings. On this basis, the respondent argues that the September 5, 2024, treatment plan has not been shown to be reasonable or necessary.

29In reply, the applicant submits that the respondent’s characterization of the medical evidence is incomplete and fails to account for relevant clinical documentation, including entries by the family physician dated August 21, 2024, and thereafter.

30In the CNRs dated August 21, 2024, approximately five months after the accident, Dr. Hoca records the applicant’s primary complaints as headaches, neck pain, back pain, and anxiety, along with associated symptoms of insomnia, stiffness, and tenderness, and continued use of pain medication.

31On September 11, 2024, Dr. Hoca documented that, since the accident, the applicant continued to report pain, primarily in the neck and back, along with intermittent headaches. The applicant was managing symptoms with Tylenol and naproxen as needed and was undergoing physiotherapy. Dr. Hoca diagnosed post-accident musculoskeletal pain.

32On February 25, 2025, Dr. Hoca noted that since the accident, there has been tenderness in the paraspinal muscles of the cervical and lumbar spines, along with stiffness and a reduced range of motion.

33I assign less weight to Dr. Platnick’s insurer examination report because it does not address the full scope of the applicant’s ongoing symptoms documented in the family physician’s CNRs. In particular, Dr. Platnick reviewed records only through June 4, 2024, and did not consider subsequent clinical documentation showing continued impairment.

34Based on the totality of the evidence, I am satisfied that the applicant continued to experience accident‑related musculoskeletal symptoms that warrant further conservative treatment. Notably, in his CNRs dated April 15, 2024, Dr. Hoca advised the applicant to pursue physical therapy and chiropractic treatment, supporting the medical necessity of these modalities early in the post‑accident period. The clinical record also reflects ongoing pain over time, with some response to prior treatment but without full resolution of symptoms. In these circumstances, the proposed chiropractic care is reasonably directed toward pain management, functional improvement, and the restoration of daily activities, and represents a continuation of conservative treatment consistent with the applicant’s presentation.

35Accordingly, I find, on a balance of probabilities, that the proposed chiropractic treatment is reasonable and necessary.

Chronic Pain Program

36I find that the applicant is not entitled to the chronic pain program.

37The treatment plan dated November 28, 2024, requests $21,818.59 for a multidisciplinary chronic pain program proposed by Dr. Shteynberg, a chiropractor. The plan includes physiotherapy, chiropractic care, massage therapy, psychotherapy, social work services, assistive devices, and transportation, with the stated goal of reducing pain, improving function, and facilitating a return to daily activities.

38On December 11, 2024, the respondent denied the plan in its entirety. In doing so, it relied primarily on the insurer’s musculoskeletal examination report by Dr. Platnick, dated September 16, 2024, which concluded that the applicant sustained minor injuries that had resolved and that the applicant had reached maximum medical improvement.

39The applicant relies primarily on the chronic pain assessment dated November 15, 2024, by Dr. Igor Portnoi, a family physician accredited by the College of Physicians and Surgeons of Ontario and the Canadian Association of Chronic Pain, who diagnosed the applicant with chronic pain syndrome and recommended a comprehensive multidisciplinary program. I accept that Dr. Portnoi is qualified to provide such an opinion. However, his conclusions must be assessed in light of the totality of the evidentiary record.

40The respondent submitted that certain diagnoses referenced in Dr. Portnoi’s chronic pain assessment, such as tendonitis, epicondylitis, and carpal tunnel syndrome, were not supported by diagnostic imaging or other objective medical evidence. In addition, the respondent denied the psychological and social work components of the program on the basis that the applicant was already receiving psychotherapy elsewhere, characterizing these services as duplicative and unnecessary.

41Dr. Portnoi reports that the applicant experiences severe, persistent pain, including daily headaches, constant neck and back pain rated as high as 9/10, and significant functional limitations affecting work and daily activities. He also cites a Pain Disability Index score of 45/70, indicating a significant degree of impairment.

42However, aspects of Dr. Portnoi’s opinion are not fully supported by the broader medical record. The family physician’s clinical notes document ongoing musculoskeletal complaints following the accident, but they consistently reflect conservative management with medication and physiotherapy. As of September 11, 2024, the treatment plan remained focused on continuing these measures and pursuing general pain management. While a formal diagnosis of chronic pain syndrome or a referral to a specialist is not required, the records do not otherwise show indicators, such as worsening symptoms, functional decline, or increasing intensity of treatment, that would make it more likely than not that the applicant’s condition had progressed to a chronic pain presentation of the severity described by Dr. Portnoi.

43Although the applicant continued to report symptoms, the longitudinal clinical record indicates that these complaints were managed conservatively, with routine follow‑up, medication, and limited intervention, rather than more intensive treatment. The records do not document frequent exacerbations, significant functional decline, or repeated changes in treatment approach that would typically indicate a severe and refractory pain condition requiring a comprehensive, multidisciplinary chronic pain program.

44In addition, certain aspects of Dr. Portnoi’s report rely heavily on the applicant’s self-reported symptom severity and functional limitations, including statements that the applicant has experienced “debilitating pain” and has shown minimal improvement despite treatment. These assertions are not consistently reflected in the contemporaneous clinical records. While those records do document ongoing complaints, they generally describe stable symptoms over time and do not indicate a pattern of worsening function, increasing intensity of care, or repeated treatment changes that would typically be expected if the applicant’s condition were deteriorating or unresponsive to treatment.

45The applicant has already been approved for and is receiving psychological treatment and chiropractic care during the relevant period. The proposed chronic pain program includes substantial additional sessions of similar modalities, such as psychotherapy and social work services, without sufficient evidence to explain why these services are required beyond those already approved or how they differ in therapeutic purpose.

46Similarly, the plan proposes a high volume of overlapping physical modalities, including physiotherapy, chiropractic care, and massage therapy. The applicant has not established why this combination, at the proposed frequency, is necessary rather than a continuation or modification of existing conservative treatment.

47The plan also includes assistive devices, such as a TENS unit, a cervical pillow, and other supports, as well as transportation expenses. Although Dr. Portnoi recommends some of these items, the record contains limited objective evidence showing that they are medically necessary or required to achieve the stated treatment goals.

48I also note that the program was proposed by a chiropractor. While a chiropractor may recommend treatment for musculoskeletal conditions, opinions on complex chronic pain and psychological components should be evaluated cautiously, particularly when those aspects extend beyond the provider’s primary scope of expertise.

49While I have accepted that the applicant experiences ongoing physical and psychological symptoms warranting continued treatment and further assessment, this alone does not establish that a comprehensive and costly multidisciplinary chronic pain program is required. Such a program requires clear evidence of significant severity, functional impairment, and an insufficient response to existing treatment, none of which is established in this record.

50Finally, although the respondent’s reliance on maximum medical improvement is not determinative, the broader evidentiary record, including the lack of clear treatment escalation, overlap with already-approved services, and limited objective support for several components of the plan, does not establish the proposed program’s necessity.

51Accordingly, on a balance of probabilities, the applicant has not established that the chronic pain program proposed in the November 28, 2024, treatment plan is reasonable and necessary.

Is the applicant entitled to the disputed assessments?

52I find that the applicant is entitled to the disputed neurological and chronic-pain assessments.

53In determining whether an assessment is reasonable and necessary, it must be borne in mind that assessments, by their nature, are investigative. The purpose of an assessment is to determine if a condition exists. Notwithstanding their speculative nature, the applicant still bears the onus of establishing, on the balance of probabilities, that an assessment is reasonable and necessary. To do so, the applicant must point to objective evidence that there are grounds to suspect the applicant has the condition for which he seeks the assessment.

Neurological Assessment

54I find that the applicant is entitled to the neurological plan.

55The plan dated June 24, 2024, seeks $2,670.00 for a neurological assessment and is signed by Dr. Vincenzo Basile, a neurologist. The stated purposes of the assessment are to identify impairments, provide treatment recommendations, and facilitate maximum recovery. The plan includes a neurological examination, file review, report preparation, completion of the OCF‑18, transportation, and interpretation services. It identifies symptoms such as dizziness, headaches, nervousness, sleep disturbance, and cognitive concerns that affect daily functioning.

56On July 8, 2024, the respondent denied the plan, stating that the available medical evidence did not support the need for a neurological assessment. The respondent relied on family physician records from April and May 2024, which documented neck and back pain but did not note neurological deficits. The respondent further submitted that the symptoms listed in the plan did not warrant neurological investigation.

57On September 24, 2024, the respondent reaffirmed its denial, again relying on the early clinical records and the insurer’s examination report by Dr. Platnick dated September 16, 2024, which concluded that the applicant had no ongoing neurological impairment and had reached maximum medical improvement.

58The applicant submits that the denial was unsupported and lacked adequate medical reasoning. In particular, the applicant argues that the respondent failed to address relevant clinical information, including reports of dizziness and family physician records documenting headaches and psychological symptoms.

59The applicant further submits that the respondent improperly relied on the opinion of Dr. Platnick, who is not a neurologist, to deny an assessment recommended by a neurologist.

60In addition, the applicant argues that the respondent failed to consider updated medical evidence, including clinical records beyond September 2024, and instead relied on an earlier report that did not reflect the applicant’s ongoing condition.

61The respondent maintains that there was no evidence before September 2024 supporting the need for a neurological assessment.

62The applicant disagrees and relies on the August 21, 2024, family physician note and the August 29, 2024, OCF‑3. These documents identify headaches, dizziness, sleep disturbance, nervousness, and cognitive concerns, which the applicant submits reasonably warrant neurological investigation.

63I agree with the applicant. The respondent’s position rests largely on the assertion that neurological symptoms arose only after the applicant’s viral illness in September 2024. This assertion is not supported by the record. The August 21, 2024, CNR lists headaches as a primary complaint, and the August 29, 2024, OCF‑3 also documents headaches and related symptoms.

64In these circumstances, the applicant has established reasonable grounds to believe that an accident-related neurological condition may exist and that further investigation is warranted. I find that this is sufficient to establish entitlement to an assessment.

65Accordingly, the applicant is entitled to the neurological assessment proposed in the plan dated June 24, 2024.

Chronic Pain Assessment

66I find that the applicant is entitled to the chronic pain assessment.

67The treatment and assessment plan dated September 23, 2024, seeks $2,410.00 and is signed by Dr. Igor Portnoi, a General Practitioner. The plan proposes a chronic pain assessment, including a total-body assessment, support‑activity documentation, transportation, and interpretation services. Its stated goals include reducing pain, improving range of motion and strength, and enhancing functional capacity.

68On October 4, 2024, the respondent denied the plan, asserting that it did not sufficiently explain the need for the assessment, questioning whether Dr. Portnoi conducted a direct assessment, and relying on Dr. Platnick’s opinion that no accident-related impairments requiring further investigation were present.

69The applicant submits that the denial was based on an incomplete and inaccurate understanding of the medical evidence. The applicant relies on Dr. Portnoi’s findings, which document widespread pain, objective signs of tenderness and restricted range of motion, and significant functional limitations. The applicant further notes that a diagnosis of chronic pain syndrome was made and that a multidisciplinary approach was recommended.

70The applicant argues that the respondent’s reasons for denial were factually incorrect. The plan indicates that a clinical history was obtained, contrary to the respondent’s suggestion that no consultation occurred. The applicant also submits that the family physician records clearly document ongoing accident-related symptoms, including pain, headaches, and psychological difficulties.

71The applicant further submits that the respondent improperly relied on Dr. Platnick’s report, which did not address the chronic pain assessment in question and therefore does not directly support the denial.

72The respondent maintains that the need for the assessment was not substantiated. It adds that the applicant began complaining of increased neck pain and severe headaches only after he was admitted in late September 2024 for a viral infection and underwent a lumbar puncture.

73The applicant replies that the plan, including the detailed description of symptoms, functional limitations, and accident history, demonstrates that a clinical history was obtained.

74I agree with the applicant. The plan identifies ongoing symptoms, including neck and low-back pain, headaches, anxiety, sleep disturbance, and reduced participation in daily activities. The level of detail in the report supports the conclusion that Dr. Portnoi obtained a direct clinical history before recommending the assessment.

75In addition, the family physician’s CNRs document ongoing pain complaints well before the proposed assessment and prior to the October 1, 2024, viral illness, undermining the respondent’s suggestion that the applicant’s symptoms are attributable to that intervening condition. The applicant reported neck and back pain as early as April 15, 2024, with continued back pain noted on May 6, 2024, and further complaints of headache, neck pain, and back pain on August 21, 2024, and September 11, 2024. These consistent, contemporaneous reports provide objective evidence of persistent symptoms that began after the accident and contradict the respondent’s position that the complaints only emerged following the illness. Moreover, the respondent has not provided persuasive medical evidence establishing a causal link between the viral infection and the applicant’s pain presentation, nor does Dr. Platnick’s report address or reconcile these earlier documented complaints. I therefore find that the respondent’s evidence does not meaningfully weaken the applicant’s claim. On the totality of the evidence, the proposed chronic pain assessment serves a valid diagnostic purpose and meets the relatively low threshold for establishing entitlement.

76Accordingly, the applicant is entitled to the chronic pain assessment outlined in the plan dated September 23, 2024.

Interest

77Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As the applicant is entitled to the disputed benefits, interest is payable on any overdue amounts.

Award

78The applicant seeks an award under section 10 of Regulation 664. Under section 10, the Tribunal may grant an award of up to 50 percent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits. The Tribunal has determined that an award is justified where the delay or withholding of benefits by the insurer is unreasonable conduct, meaning “behaviour which is excessive, imprudent, stubborn, inflexible, unyielding or immoderate.” [ See, for e.g., 17-006757 v. Aviva Insurance Canada, 2018 CanLII 81949 (ON LAT); and S.M. v. Unica Insurance Inc., 2020 CanLII 61460 (ON LAT Reconsideration]. The onus is on the applicant to prove, on a balance of probabilities, that the respondent’s conduct meets this threshold.

79The applicant submits that the respondent acted in a high‑handed and capricious manner by failing to meaningfully engage with significant medical evidence, including the August 21, 2024, family physician note, and by relying on insurer examination reports that were inconsistent and outcome‑oriented.

80The respondent disputes this characterization and submits that its conduct was reasonable throughout the claim. The respondent notes that it removed the applicant from the MIG upon receipt of medical documentation identifying psychological concerns, denied certain physical treatment plans based on insurer examination findings that the applicant’s soft‑tissue injuries had resolved, and approved psychotherapy services at a rate it asserts is consistent with Tribunal jurisprudence.

81While I agree that the respondent’s denial rationale and submissions did not fully address key evidence, particularly the August 21, 2024, clinical note and other evidence of pre‑September headache symptoms, the threshold for an award under section 10 is high.

82On the whole of the evidence, I am not satisfied that the respondent’s conduct amounts to unreasonable behaviour contemplated by the regulation. The respondent obtained insurer examinations, approved certain benefits, and advanced positions that, although ultimately unsuccessful, were not excessive, inflexible, or immoderate.

83Accordingly, the applicant’s claim for an award under Ontario Regulation 664, section 10, is dismissed.

ORDER

84For the above reasons, it is ordered that: