Citation: Trivedi v. Allstate Insurance Company of Canada, 2026 ONLAT 24-015449/AABS

Licence Appeal Tribunal File Number: 24-015449/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:

Hetvi Trivedi

Applicant

and

Allstate Insurance Company of Canada

Respondent

DECISION

ADJUDICATOR:

Matthew Frontini

APPEARANCES:

For the Applicant:

Nicole Corriero, Counsel

For the Respondent:

Christopher Lupis, Counsel

HEARD:

By way of written submissions

1Hetvi Trivedi, the applicant, was involved in an automobile accident on December 27, 2021, 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, Allstate Insurance Company of Canada, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

2The accident took place in Quebec and the applicant elected to receive benefits administered through Quebec’s public plan, Société de l’assurance automobile du Québec (“SAAQ”) pursuant to s. 59(2) of the Schedule. Québec’s Automobile Insurance Act (chapter A-25) and its regulations govern the procedure and benefits available to the applicant given her election.

ISSUES

3The issues in dispute are:

i. Is the applicant entitled to $2,460.00 for an orthopaedic assessment, proposed by Mississauga Rehab & Sports Injury Clinic (“Mississauga Rehab”) in a treatment plan/OCF-18 (“plan”) dated January 23, 2023?

ii. Is the applicant entitled to $11,359.95 for a chronic pain program, proposed by Mississauga Rehab in a treatment plan dated March 9, 2023?

iii. Is the applicant entitled to $9,707.48 for hospital services, submitted on a claim form (OCF-6) dated July 6, 2023?

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

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

4The applicant confirmed that the issue of a treatment plan for psychological services dated April 13, 2023, is no longer in dispute in this application.

RESULT

5I find that:

i. the applicant is not entitled to $2,460.00 for an orthopaedic assessment, proposed by Mississauga Rehab in a treatment plan dated January 23, 2023.

ii. the applicant is not entitled to $11,359.95 for a chronic pain program, proposed by Mississauga Rehab in a treatment plan dated March 9, 2023.

iii. the applicant is not entitled to $9,707.48 for hospital services, submitted on a claim form (OCF-6) dated July 6, 2023.

iv. the respondent is not liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant.

v. the applicant is not entitled to interest on any overdue payment of benefits.

6The application is dismissed.

ANALYSIS

The applicant is not entitled to $2,460.00 for an orthopaedic assessment, proposed by Mississauga Rehab in an OCF-18 dated January 23, 2023

7I find that the applicant has not established on a balance of probabilities that she is entitled to the treatment plan for an orthopaedic assessment proposed by Mississauga Rehab.

8To receive payment for a treatment and assessment plan under ss. 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. In considering the reasonableness and necessity of an assessment, the applicant bears the onus to demonstrate on a balance of probabilities that there are grounds on which to believe that a condition exists that would warrant further investigation by way of an assessment.

9The applicant submits that the orthopaedic assessment was required to investigate her physical injuries and ongoing pain. Her submissions do not refer to any specific medical evidence to substantiate the referenced physical injuries and pain, nor do they refer to any medical professional, other than the author of the treatment plan in dispute, recommending this assessment or suggesting that investigation into any accident-related injuries was warranted.

10The respondent submits that the applicant has not established that an orthopaedic assessment was reasonable and necessary. It notes that there is no contemporaneous medical evidence in support of a referral for this type of assessment.

11The respondent also submits that the applicant is not entitled to the assessment plan under the SAAQ. The respondent notes that given the applicant’s election to receive benefits under the SAAQ, s. 59(2)(2) of the Schedule provides that the applicant may only receive benefits in the same amounts and subject to the same conditions as a resident of that jurisdiction. The respondent submits that the SAAQ does not have an equivalent provision to s. 25 of the Schedule and consequently, there is no statutory basis for entitlement to this assessment.

12I find that the applicant has not established on balance of probabilities that the orthopaedic assessment is reasonable and necessary. The applicant has not met her onus to demonstrate on a balance of probabilities that there are grounds on which to believe that a condition exists that would warrant further investigation by way of an assessment. Vague references in her submissions to injuries and pain, unsupported by compelling, contemporaneous objective medical evidence, are insufficient to meet her burden.

13Considering the totality of the medical evidence, the applicant has not established that further investigation by way of an orthopaedic assessment is warranted. The applicant’s family doctor, Dr. Murtry, prepared an OCF-3, dated March 20, 2023 – nearly 15 months after the accident. The injuries and impairments listed in the OCF-3 are described in the past tense rather than having a contemporaneous and ongoing impact on the applicant. For example, Dr. Murtry indicated that the applicant was able to return to work in September 2022. He also noted that the applicant was able to resume her regular caregiving duties three to four months after the accident, being March or April of 2022.

14Dr. Murty’s statements in the OCF-3 that the applicant had recovered by September 2022 are consistent with his clinical notes and records. In May 2022, Dr. Murty noted that the applicant’s mastoid injury and accompanying vertigo had recovered but that she had pain and stiffness in her toe. In a follow-up appointment on March 3, 2023, Dr. Murtry indicated that the applicant had no problems walking and that the range of motion in her toe was fine. Dr. Murtry also noted that the applicant did not have headaches or neck pain in an appointment on July 5, 2023.

15The medical evidence of the applicant’s family doctor does not support that a condition existed that would warrant further investigation by way of an assessment when this plan was submitted. On the contrary, the records of the applicant’s family doctor, as well as the OCF-3 he authored, indicate that the applicant’s physical injuries had resolved by this time.

16I also find that the applicant has not established a statutory basis for entitlement to the orthopaedic assessment. Section 59(2) of the Schedule is clear that once an insured elects to receive benefits under the law of another jurisdiction, they may not also claim benefits provided by the Schedule.

17The applicant’s submissions do not identify any statutory basis under Quebec law for an orthopaedic assessment, and she did not dispute the respondent’s position in her reply submissions. As the applicant has not directed the Tribunal to Quebec’s statutory equivalent to s. 25 of the Schedule, if one exists, I find that the applicant has not established that this category of benefit is available to her under the SAAQ.

18I find that the applicant has not established on a balance of probabilities that she is entitled to the treatment plan for an orthopaedic assessment.

The applicant is not entitled to $11,359.95 for a chronic pain program, proposed by Mississauga Rehab in an OCF-18 dated March 9, 2023

19I find that the applicant has not established on a balance of probabilities that she is entitled to the treatment plan for a chronic pain program proposed by Mississauga Rehab.

20In considering the reasonableness and necessity of a treatment plan for goods or services, 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.

21The treatment plan proposes a multidisciplinary program with the bulk of the costs comprising physical therapy ($4,788.16), psychotherapy provided by a psychologist ($2,693.04), and psychotherapy and documentation provided by a social worker ($2,680.00).

22The applicant relies on the orthopaedic assessment report of Dr. Ogilvie-Harris, dated January 23, 2023. Dr. Ogilvie-Harris’ assessment comprised a review of medical records, a clinical interview and physical evaluation of the applicant and the administration of functional scoring questionnaires. In respect of medical documentation reviewed, the assessment references “notes and records of Dr. Murtry” and lists head trauma and dizziness but does not provide any detail regarding the period of time covered by these notes.

23Based on his interview of the applicant, the results of the questionnaires and his review of the medical documentation, Dr. Ogilvie-Harris concluded that the applicant suffers chronic pain syndrome. His assessment goes on to describe general recommendations by the Canadian Pain Task Force to treat chronic pain syndrome with a multi-modal multidisciplinary rehabilitation program. The assessment makes various recommendations of multimodal treatments that could assist the applicant including: physical rehabilitation consisting of core stability, non-impact cardiovascular and respiratory conditioning; spousal counseling; pharmacological interventions; joint injections in her great toe; trigger point and facet joint injections; acupuncture, chiropractic and massage therapy; a functional abilities evaluation; and a vocational assessment.

24The contemporaneous evidence does not establish on a balance of probabilities that the services set out in this treatment plan are reasonable and necessary. The treatment plan states that the applicant has reported continued pain and dysfunction more than 14 months from the date of the accident. For example, the treatment plan lists the applicant’s fractured great toe, as well as indicating that it was unknown if she could return to work on modified duties and also that she could not carry out her activities of daily life.

25However, as described above with respect to the orthopaedic treatment plan, the applicant’s family doctor, Dr. Murtry, had found that these physical conditions had resolved prior to March 2023. Dr. Murtry’s notes and the OCF-3 he authored indicate that the applicant had returned to work and was engaging in her activities of daily life well before this treatment plan was authored. Dr. Murtry’s clinical notes and records also do not support the continued pain and dysfunction over a 14-month period referenced in the treatment plan.

26I am also not persuaded by the applicant’s submission that Dr. Ogilvie-Harris recommended the treatment program outlined in the disputed treatment plan. There is no evidence that Dr. Ogilvie-Harris reviewed this specific treatment plan. Rather, his report describes general recommendations for multidisciplinary treatment of chronic pain syndrome and provides a plethora of possible treatment recommendations that may benefit the applicant. A minority of the types of treatments recommended by Dr. Ogilvie-Harris are proposed in the disputed treatment plan.

27I also place little weight on Dr. Ogilvie-Harris’ conclusions in his assessment report regarding the applicant’s need to treat chronic pain syndrome. The report references Dr. Murtry’s clinical notes and records as part of the medical brief but there is no indication of the period these notes span. This is particularly noteworthy given that Dr. Murtry’s notes do not support that the applicant experienced the dysfunction she reported to Dr. Ogilvie-Harris during her assessment. Dr. Ogilvie-Harris assessment findings are not corroborated by contemporaneous medical evidence. Instead, the dysfunction and impairments reported to Dr. Ogilvie-Harris appeared to be contradicted by contemporaneous medical evidence and his report does not comment on how this evidence affected his analysis.

28Considering the evidence and submissions, I find that the applicant has not established on a balance of probabilities that the treatment plan for a chronic pain program proposed by Mississauga Rehab is reasonable and necessary.

The applicant is not entitled to the expense form for hospital services

29I find that the applicant has not established on a balance of probabilities that she is entitled to the OCF-6 for hospital services dated July 6, 2023. The respondent has established that this benefit is reasonably available from another plan, and the applicant has not demonstrated that this benefit is not reasonably available to her.

30The OCF-6 in dispute encloses a statement of account for hospital services provided by Lemoyne Hospital to the applicant following the accident on December 21, 2021. The applicant’s submissions state that she received the statement of account in late 2022 and it is dated August 17, 2022, nearly 8 months after the accident.

31On July 7, 2023, nearly 11 months after receiving the statement of account, the applicant sought payment from the respondent and submitted the July 2023 OCF-6. On July 10, 2023, the respondent denied the OCF-6 citing section 47 of the Schedule and indicating that this benefit was reasonably available to the applicant by reimbursement from OHIP. The respondent indicated that it would reconsider the disputed charges if the applicant provided a benefit statement or other documentation from OHIP.

32The applicant did not seek reimbursement from OHIP. Five months later, on December 12, 2023, the applicant’s representative wrote to the respondent asking it to reconsider its position in respect of the OCF-6. This correspondence stated that an out-of-province claim needed to be submitted to OHIP within 12 months of the medical services being. Accordingly, the applicant asserted that she was not eligible for reimbursement by OHIP and asked the respondent to reconsider its denial. To be clear, OHIP had not denied reimbursement at this time because the applicant had not applied for it. On January 15, 2024, the respondent maintained its denial and reiterated its request that the applicant provide documentation from OHIP before it would consider the benefit.

33On September 5, 2025, more than three years after the statement of account, and over two years after the respondent requested the applicant contact OHIP, the applicant’s representative wrote to the Ministry of Health. This correspondence asserts that the statement of account was not rendered until April 2023 and requests an exemption from the time limits for submitting out-of-province medical expenses. The applicant’s assertion in the letter regarding the April 2023 date is not corroborated by the evidence in the record. As previously mentioned, the applicant’s own submissions in this application assert that she received the statement of account in late 2022 and the document itself bears a date of August 17, 2022.

34Section 47(2) of the Schedule provides that an insurer is not required to pay for any portion of an expense for which payment is reasonably available to the insured under any insurance plan or law.

35The analytical framework for whether s. 47(2) applies to an expense is set out in G.T. v. Unifund Assurance Company, 2017 CanlII 81567 (ON LAT) and has been consistently applied by the Tribunal. First, the respondent must advance some evidence that, on balance, establishes that the benefit at issue, whether in whole or in part, was reasonably available to the applicant (i.e. the insured) from a collateral provider. Once established, the burden shifts to the applicant to prove that the benefit at issue was not in fact reasonably available.

36The respondent submits that the Province’s legislation, policies and public communications regarding reimbursement of Ontarians’ out-of-province emergency healthcare costs establish that this benefit was reasonably available to the applicant. These submissions are supported by references to the relevant statutory provisions and copies of communications regarding these types of claims. I find that respondent has met its burden to establish that this benefit was reasonably available to the applicant.

37The applicant submits that this benefit was not reasonably available because she had already missed the 12-month deadline for submitting these expenses to OHIP when she submitted the OCF-6 to the respondent on July 7, 2023. She further submits that because the rendering of the statement of account was out of her control, it would be unfair for her to bear these expenses.

38I am not persuaded that the applicant has established on a balance of probabilities that this benefit was not reasonably available to her. In the applicant’s own submissions, she received the statement of account in late 2022. The August 17, 2022 date on the statement of account corresponds to 8 months after the medical services were rendered, i.e. within the 12-month eligibility period established by section 2 of Submission of Accounts, O Reg 22/02 pursuant to the Health Insurance Act, RSO 1990, c H.6. The applicant did not seek reimbursement from OHIP for these expenses during the remainder of the statutory eligibility period, or, for years later.

39The applicant’s submissions do not explain why she waited nearly a year to contact the respondent regarding the statement of account. Her submissions also do not provide an explanation for why, despite repeated requests by the respondent, she waited two more years before contacting the Ministry of Health to seek reimbursement from OHIP. Contrary to the applicant’s submissions, the submission of the statement of account within the statutory time period and for years after was within her control. The applicant did not act reasonably to take the required steps, even when requested, to obtaining this reimbursement from OHIP.

40In any event, there is no evidence in the record that Ministry has responded to the applicant’s request for an exemption by the date of the hearing. The Ministry may grant the applicant’s request despite only receiving it nearly five years after the services were rendered to the applicant. As such, the applicant’s application to the Tribunal to order the payment of this OCF-6 is premature – it will be moot if the Ministry grants the relief requested by the applicant in her September 5, 2025 letter.

41I find that the applicant has not established on a balance of probabilities that she is entitled to the OCF-6 for hospital services dated July 6, 2023. The respondent has established that this benefit was reasonably available from another plan, and the applicant has not demonstrated that this benefit was not in fact reasonably available to her.

Interest

42Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As the applicant is not entitled to the disputed treatment plans, no payments are overdue, and interest does not apply.

Award

43The 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.

44As the respondent did not withhold or delay any payment of benefits, I find that the applicant has not established that she is entitled to an award.

ORDER

45I find that:

i. the applicant is not entitled to $2,460.00 for an orthopaedic assessment, proposed by Mississauga Rehab in a treatment dated January 23, 2023.