Licence Appeal Tribunal File Number: 25-002288/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:
Reagan Francis-Newman
Applicant
and
Co-operators General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Bernard Trottier
APPEARANCES:
For the Applicant:
Renata Szady, Paralegal
For the Respondent:
Suzanne Armstrong, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Reagan Francis-Newman, the applicant, was involved in an automobile accident on July 9, 2022, 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 Co-operators General Insurance Company, the respondent, and applied to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
2The applicant had pre-accident scoliosis, diagnosed in 2010, for which she received chiropractic treatment before the accident. She was also involved in a prior motor vehicle accident on December 24, 2019, requiring physical therapy.
3On the date of the accident, the applicant was a front-seat passenger in a vehicle when it was struck perpendicularly by another vehicle, deploying the airbags. Although first responders attended the accident, the applicant declined transportation to the hospital. Subsequently, the applicant reported physical and psychological impairments to her family physician and other service providers. The parties agreed that the Minor Injury Guideline (“MIG”) is not an issue in dispute for this matter. The parties dispute whether the hourly rates charged for psychological services are appropriate in the circumstances, and whether the proposed treatment and assessment plans are reasonable and necessary.
ISSUES
4The issues in dispute are:
Is the applicant entitled to $2,294.14 ($4,688.38 less $2,394.24 approved) for psychological services, proposed by A&B Medical Assessments in a treatment and assessment plan/OCF-18 (“OCF-18”) dated March 20, 2023?
Is the applicant entitled to $2,486.00 for a chronic pain assessment, proposed by A&B Medical Assessments in an OCF-18 dated May 5, 2023?
Is the applicant entitled to $2,200.00 for an attendant care assessment, proposed by Oshawa Physiotherapy & Rehabilitation Centre in an OCF-18 dated August 2, 2023?
Is the applicant entitled to $2,200.00 for an orthopaedic assessment, proposed by Oshawa Physiotherapy & Rehabilitation Centre in an OCF-18 dated August 2, 2023?
Is the applicant entitled to $3,222.40 for physiotherapy, massage therapy and chiropractic services proposed by Oshawa Physiotherapy & Rehabilitation Centre in an OCF-18 dated March 13, 2024?
Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
5The applicant is entitled to the disputed chronic pain assessment, plus interest.
6The applicant is not entitled to the disputed amount for psychological services.
7The applicant is not entitled to the disputed attendant care assessment, orthopaedic assessment, or further physical therapy services.
8The applicant is not entitled to an award.
ANALYSIS
Legal test and onus for “reasonable and necessary” under the Schedule
9To 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 the psychologist rate for her psychotherapist
10On March 20, 2023, A&B Medical Assessments (“A&B”) submitted the disputed OCF-18 to the respondent, proposing that the services would be provided by Vida Jabloo, psychotherapist, under the supervision of Dr. Manreet Singh, psychologist.
11The OCF-18 requested funding for the following:
Proposed Item
Proposed Amount
Approved Amount
16 sessions, 1.5 hours each at $149.61 per hour
$3,590.72
$2,194.24
Documentation to support activity
$448.83
$0
Documentation to support activity
$200.00
$200.00
Assessment (total body)
$448.83
$0
Total
$4,688.38
$2,394.24
12The respondent partially approved the OCF-18 on the basis that it confirmed with A&B that the services would be provided by Ms. Jabloo, and therefore the psychologist rate of $149.61 per hour, from the Financial Services Commission of Ontario Professional Services Guideline, September 2014 (the “PSG”), would not apply.
13The respondent submits that psychotherapists are not listed as health care providers in the PSG, and therefore it needs to agree on a rate before it will approve an OCF-18. The respondent submits that it agreed with A&B that the services would be approved at a rate of $91.43 per hour, commensurate with the PSG rate for a registered nurse or a nurse practitioner.
14The applicant argues, citing A.S. v. Aviva Insurance Company, 2020 CanLII 12787 (ON LAT) (“A.S.”), that a psychotherapist working under the direct supervision of a psychologist is entitled to the PSG rate for a psychologist of $149.61 per hour.
15The applicant made no submissions on the denied amounts for documentation and for a total body assessment.
16The respondent argues that A.S. is distinguishable from the present matter, because in A.S., the psychotherapist had additional training and was providing cognitive behavioral therapy specific to their training, justifying the higher rate. The respondent argues that, in the present matter, Ms. Jabloo was still qualifying to become a registered psychotherapist, as evidenced by her signature in her clinical notes and records (“CNRs”). The respondent argues that A.S. has been considered in 21 subsequent Tribunal decisions, and in 20 of those, the adjudicators found that psychotherapist services should not be charged at the same rate as that for a psychologist.
17While I am not bound by other Tribunal decisions, as each must be considered on the merits of the specific circumstances, I am persuaded that a qualifying psychotherapist cannot be charged at the same rate as the supervising psychologist. In this matter, I accept that the respondent and A&B had agreed on a rate for Ms. Jabloo. For this reason, I find that the proposed cost of achieving the treatment goals is not reasonable, and the applicant is not entitled to compensation at the higher rate. I find, also, that the applicant has not demonstrated that she is entitled to the denied line items for documentation and a total body assessment. Therefore, I find that the applicant is not entitled to the disputed amount of the OCF-18 for psychological services.
The applicant is entitled to the proposed chronic pain assessment
18The applicant submits that she suffers from pain in her back, neck, chest, shoulder and arm that has become chronic in nature and that her family physician, Dr. Smita Sauvé, diagnosed her with chronic pain. She submits that her reports of ongoing, persistent pain are documented in the CNRs of Dr. Sauvé and in those of her treating rehabilitation practitioners.
19The applicant submits further that, since the accident, she has been taking prescription pain medicine including Cyclobenzaprine, Celebrex, Advil and Baclofen to help manage her pain.
20The applicant submits that the progress report of Dr. Stephen Lewis, orthopaedic surgeon (referred by Dr. Sauvé), dated February 12, 2024, indicates that her pain was aggravated following the accident and that her pain was getting worse over time. Dr. Lewis notes that the applicant was not taking any analgesics for her pain while she was receiving chiropractic, physiotherapy and naturopathic services.
21The applicant argues that she exhibits the symptoms described in the six criteria in the American Medical Association Guides, 6th Ed. (the “AMA Guides”) for assessing chronic pain. The applicant argues that a chronic pain assessment is reasonable and necessary to confirm whether she suffers from chronic pain syndrome, to develop an appropriate pain management strategy, and to explore treatment options.
22The respondent argues that the applicant refers vaguely to the CNRs of Dr. Sauvé to indicate that she reported ongoing, severe pain. The respondent argues that submissions are not medical evidence, and that the CNRs of Dr. Sauvé do not support the contention that she suffered from severe, persistent chronic pain symptoms.
23The respondent argues that the applicant’s intermittent use of prescription pain medication does not support her claim of chronic pain as described in the AMA Guides. The respondent argues, further, that the applicant does not point to any specific evidence that she is dependent on health care providers.
24In addition, the respondent submits that the applicant returned to work as a construction field inspector nine days after the accident, and she resumed her full-time studies at Durham College in September of 2022. The respondent argues that her post-accident work and educational activity do not support her claim that she withdrew from social milieu or that her post-accident function made her unable to pursue work, family or recreational needs. The respondent argues that a chronic pain assessment is not reasonable and necessary in the circumstances.
[25]
25I find that the medical note from Dr. Sauvé, dated August 29, 2025 does not provide a diagnosis of chronic pain, or chronic pain syndrome, as stated by the applicant. However, I find that Dr. Sauvé’s note provides a provisional diagnosis, that the applicant has reported ongoing and worsening musculoskeletal pain since the accident, that has affected her daily function and quality of life. Dr. Sauvé states, further, that the therapies provided to the applicant to date (physiotherapy, psychotherapy, chiropractic care, massage therapy, aquatherapy and structured exercise programs) are consistent with approaches commonly used to help patients manage chronic pain and mental health symptoms.
26I assign weight to the opinion of Dr. Sauvé, as the applicant’s physician before and after the accident, that the applicant suffered chronic pain symptoms.
27Generally, the Tribunal has found that an injured person does not need to prove that they suffer from a condition, before receiving funding for an assessment to determine whether they suffer from that condition. (See, for example, F.H. v. Certas Direct Insurance Company, 2018 CanLII 39445 (ON LAT) and Pottayya v. Unica Insurance Inc., 2021 CanLII 28673 (ON LAT)). I must consider whether there is sufficient, compelling medical evidence that would demonstrate that the assessment is reasonable and necessary to advance the applicant’s recovery. In this case, I find that there is compelling evidence, from Dr. Sauvé and Dr. Lewis, that the applicant suffers accident-related pain that has endured beyond the normally expected recovery time.
28For this reason, I find that a chronic pain assessment is reasonable and necessary, on a balance of probabilities, and payable by the respondent.
The applicant is not entitled to the proposed attendant care assessment
29The applicant submits that she continues to be impacted physically, cognitively and psychologically by the accident. The applicant argues that an attendant care assessment is reasonable and necessary to assess the applicant’s functional abilities in relation to home and social demands, and to identify barriers, establish goals and develop treatment options.
30The applicant submits, further, that she has difficulties walking, transferring between standing and sitting, and lifting, making it difficult to perform personal care and housekeeping.
31The respondent argues that the applicant has provided only vague self-reports of self-care and housekeeping difficulties, and that she has not provided any documented evidence of these difficulties. The respondent argues, also, that the applicant’s return to work and full-time studies demonstrate that the applicant has achieved a level of function that would indicate that attendant care is not required.
32The respondent submits that the progress report of Dr. Lewis, dated February 12, 2024, indicated that the applicant could continue with full activities as tolerated.
33In her reply submissions, the applicant directed me to a physiotherapy update report, dated July 24, 2025 (over three years post-accident), where Bindu Jacobs, physiotherapist, noted that the applicant’s activities of daily living (“ADLs”) questionnaire indicated difficulty in performing multiple daily tasks.
34The onus lies with the applicant to demonstrate, on a balance of probabilities that the proposed attendant care assessment is reasonable and necessary. I find that the applicant has not met that onus. I find that the applicant has not directed me to specific evidence, other than a brief mention in the physiotherapy update report, that the applicant was suffering from an inability to manage her ADLs because of the accident. I find that the applicant’s return to work and full-time studies are indicators that the applicant’s basic household ADLs were manageable, and that an attendant care assessment is not reasonably necessary.
35For these reasons, I find that an attendant care assessment is not reasonable and necessary in the circumstances, and therefore not payable.
The applicant is not entitled to the proposed orthopaedic assessment
36The applicant submits that her pre-existing conditions, including her scoliosis, may affect her recovery from her accident-related injuries. She argues that an orthopaedic assessment is required to evaluate whether her injuries may be more serious than suspected and not fully resolving through her conservative rehabilitation. She argues, further, that undiagnosed orthopaedic injuries may contribute to chronic pain and long-term disability. For these reasons, the applicant argues that an orthopaedic assessment is reasonable and necessary.
37The respondent submits that the applicant was referred by Dr. Sauvé for a consultation with Dr. Lewis on February 12, 2024. The respondent submits that Dr. Sauvé has not made any orthopaedic referrals since then. The respondent argues that if such a referral were necessary, it could be arranged through the Ontario Health Insurance Plan (“OHIP”). The respondent argues that the applicant has not adduced evidence that such an assessment was not reasonably available through OHIP.
38The respondent argues that the Tribunal has held, citing G.T. v. Unifund Assurance Company, 2017 CanLII 81567 (ON LAT), that OHIP is an “insurance plan or law” for purposes of s. 47(2) of the Schedule, which states that an insurer is not required to pay for medical and rehabilitation benefits that are covered by another benefits plan. The respondent argues that the applicant’s referral to Dr. Lewis is evidence that the services are reasonably available through OHIP.
39I find that the applicant has not demonstrated that an assessment by an orthopaedic specialist is not reasonably available through OHIP, because she has been referred to at least one OHIP-funded orthopaedic specialist recently.
40For this reason, I find that the proposed orthopaedic assessment is not reasonable and necessary, and therefore not payable.
The applicant is not entitled to further physiotherapy, massage therapy and chiropractic services
41The applicant submits that the goals of the proposed treatment, as identified on the OCF-18 dated March 13, 2024, are to reduce pain, increase range of motion, increase strength, return to activities of normal living and return to pre-accident work activities. The applicant argues that the goals are reasonable based on the recommendations of Dr. Sauvé on multiple occasions, including as recently as August 26, 2024, and August 29, 2025.
42The applicant contends that she was not discharged from the treatment facility, and that she continued to attend treatment despite being denied funding from the respondent. The applicant argues that she requires further treatment in light of chronic pain in the lower back and shoulder, in addition to her pre-existing scoliosis.
43The applicant argues that the overall costs of achieving the goals of the treatment are reasonable because the rates are aligned with those of the PSG.
44The respondent denied the proposed treatment plan on March 26, 2024, noting that the applicant had sustained soft tissue injuries and had received treatment for such. The respondent arranged an insurer’s examination with Dr. Edwin Urovitz, orthopaedic surgeon, who opined in his report dated June 19, 2024 that the applicant did not demonstrate any objective signs of accident-related orthopaedic impairment. Dr. Urovitz opined, further, that the applicant’s pre-accident scoliosis had not been exacerbated by the accident.
45The respondent argues, citing I.K. v. Allstate Canada, 2020 CanLII 37667 (ON LAT) (“I.K.”), that it is not enough to show that only one goal will be met by the proposed treatment. The respondent argues that the applicant must demonstrate that all the identified goals will be met to a reasonable degree.
46Based on the opinion of Dr. Urovitz, the respondent argues that the proposed treatment plan is not reasonable and necessary, because of the time passed since the accident, the nature of the injuries, the treatment received to date, and the lack of objective sign of any accident-related orthopaedic impairments.
47The respondent argues that Dr. Lewis noted that the applicant reported that physiotherapy was not helpful in treating her back pain. Dr. Lewis opined, further, that the applicant was managing her scoliosis well and that he recommended that she continue with full activities as tolerated.
[48]
48I am persuaded by the opinion of Dr. Urovitz, that the applicant no longer demonstrated signs of accident-related orthopaedic impairment, other than some pain. I find that Dr. Urovitz’s findings of full, unrestricted mobility in the applicant’s upper extremities indicates her shoulder injury had resolved by then. I note that Dr. Urovitz indicated that the applicant occasionally took extra strength Motrin for pain relief.
49I find that Dr. Sauvé’s note of August 29, 2025, endorsed further facility-based interventions, but was vague as to whether these interventions would address, primarily the applicant’s musculoskeletal or psychological symptoms.
50The progress report of Dr. Lewis dated February 12, 2024, to which both parties directed me, does not make any recommendation for further facility-based treatment. Dr. Lewis notes that the applicant has had multiple treatments for her back including massage, acupuncture, cupping and chiropractic treatment, which the applicant reported she found somewhat helpful, and that the physiotherapy she received worsened her back pain.
51I find that, of the stated goals of the proposed treatment plan, pain reduction is the only one that appears to be unresolved at that point in her recovery. I find that the medical notes of Dr. Sauvé, Dr. Lewis and Dr. Urowitz indicated that the applicant’s range of motion, strength, activities of daily living and work activities were back to her pre-accident levels. While I am not bound by the decision in I.K., I find it instructive that if only one of the goals of the proposed treatment is met, and only partially, that is not enough to satisfy the reasonable and necessary test. I find that this is the case in the present matter.
52Based on the evidence before me, I find that the applicant has not demonstrated that further physiotherapy, massage therapy and chiropractic treatment are reasonable and necessary at that point in her recovery from her soft tissue injuries. I find that the applicant reported to Dr. Lewis that physiotherapy was not helpful, and that massage therapy and chiropractic treatment were only somewhat helpful. I find that the cost of achieving the stated goal of pain reduction, through facility-based interventions, in not reasonable in light of other modalities that might achieve more cost-effective results. For these reasons, I find that the proposed OCF-18 for physiotherapy, massage therapy and chiropractic services is not reasonable and necessary, and therefore not payable.
Award
53The applicant sought an award under s. 10 of Reg. 664. Under s. 10, the Tribunal may grant an award of up to 50 per cent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits.
[54]
54The respondent submits that the Case Conference Report and Order, dated June 20, 2025 (the “CCRO”) ordered the applicant to provide the respondent with particulars of the award claim within 30 calendar days after receipt of the adjusters’ log notes. The respondent submits that it served log notes on the applicant within the time frame ordered in the CCRO, but that the applicant did not provide any particulars of the award claim prior to her written submissions on this matter.
55The respondent argues, citing Gordan v. Certas Direct, 2025 CanLII 15990 (ON LAT) that it would be a breach of procedural fairness to allow the applicant to proceed with an award claim without the particulars being provided in accordance with the CCRO.
56The applicant argues, in her hearing submissions, that the respondent is liable to pay an award because it failed to give any weight to the records of Dr. Sauvé, referrals and specialist consultation reports, deliberately disregarding the diagnosis of chronic pain and chronic pain syndrome.
57I find the applicant’s claim for an award is dismissed because the particulars of the award claim were not produced to the respondent as ordered in the CCRO. I find the applicant has breached Rule 9.4 in not submitting the basis for the award ahead of the hearing. Each of the parties is entitled to know the case it needs to meet. I find it would be a breach of procedural fairness to the respondent to allow the applicant to proceed with the award claim without the particulars being produced in advance of the hearing. Therefore, the claim for an award is dismissed.
Interest
58Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. I find that the payment for the chronic pain assessment should have been made when the OCF-18 was submitted to the respondent on May 5, 2023. I find that the applicant is entitled to interest at a rate of 1% per month, compounded monthly, on amounts then owing.
59No interest is payable for the disputed amount for psychological services, the attendant care assessment, the orthopaedic assessment, or the physical therapy services, because I have found that those OCF-18s are not payable.
ORDER
60The applicant is entitled to the dispute chronic pain assessment, with interest.
61The applicant is not entitled to the disputed amounts for psychological services.
62The applicant is not entitled to the disputed attendant care assessment, orthopaedic assessment, or the physiotherapy, massage therapy and chiropractic treatment.
63The applicant is not entitled to an award under s. 10 of Reg. 664.
Released: June 11, 2026
Bernard Trottier
Adjudicator