Licence Appeal Tribunal File Number: 25-001639/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:
Hanifa Lashkary Applicant
and
Aviva General Insurance Company Respondent
DECISION
ADJUDICATOR: Sarah Guergis
APPEARANCES:
For the Applicant: Christina Trotta, Counsel
For the Respondent: Jordan Hochman, Counsel
HEARD: In Writing
OVERVIEW
1Hanifa Lashkary, the applicant, was involved in an automobile accident on March 13, 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 $4,012.00 for chiropractic services, proposed by In-Motion Rehabilitation and Wellness Centre Inc. in a treatment plan/OCF-18 (“plan”) dated October 9, 2024?
ii. Is the applicant entitled to $2,235.37 for a health coordination and triage assessment, proposed by Red Door Medicare Inc. in a plan dated October 21, 2024?
iii. Is the applicant entitled to $1,155.95 for a health coordination and triage assessment, proposed by Red Door Medicare Inc. in a plan dated October 21, 2024?
iv. Is the applicant entitled to $4,384.00 for chiropractic services, proposed by In-Motion Rehabilitation and Wellness Centre Inc. in a plan dated February 3, 2025?
v. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
vi. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3I find that:
i. The applicant is not entitled to the treatment plans in dispute.
ii. No interest is owing.
iii. No award is owing.
ANALYSIS
Is the applicant entitled to $4,012.00 for chiropractic services, proposed in a plan dated October 9, 2024, and $4,384.00 for chiropractic services, proposed in a plan dated February 3, 2025?
4I find that the applicant has not established entitlement to these plans.
5To 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.
6The applicant submits that both Dr. McCutcheon and Dr. Rahmati diagnosed adjustment disorder with mixed anxiety and depressed mood caused by the accident.
7The applicant does not specify what evidence they are relying on to establish the reasonableness or necessity of these plans specifically. However, the applicant generally relies on a Health Coordination Triage Assessment, by Dr. Gail Wright, chiropractor, dated February 3, 2025.
8In this report, Dr. Wright concludes that the applicant has functional, physical and psychological limitations due to the subject accident. Dr. Wright also opines that the applicant’s “post-concussion syndrome with left ear SNHL, chronic condition and psychological condition” are a direct result of the subject accident. Further, that she continues to suffer with headaches, neck, lower and upper back pain and post concussion symptoms as a result of the subject accident.
9Dr. Wright further opines that the applicant requires “comprehensive rehabilitation” to “address vestibular disorder, ocular, headaches, and medication to reduce pain”.
10The applicant also relies on clinical notes and records from her family doctor, Dr. Ines Sadek. The applicant submits that Dr. Sadek recommends she continue with physical treatment to address her ongoing concerns of pain to her neck, shoulders and back. However, the applicant does not point me to these specific entries. Upon review of the CNRs, there is one entry from March 21, 2024, where the applicant reports neck pain after the subject accident. Dr. Sadek writes “her x rays were N in ER, starting physio in 3 d.”
11In CNRs dated May 2, 2024, it appears the applicant was seen by Daniel Shogliev, MD, at Trillium Health Partners emergency room. The applicant was evaluated for neck swelling/ pain and an upper extremity injury. Dr. Shogliev’s notes conclude with “Canadian head CT negative, nexus C-spine negative.”
12The applicant further submits that the x-ray of her cervical spine confirms a spinal alignment issue which causes neck and shoulder pain, limited movement and neurological symptoms, which are all symptoms she has been reporting consistently since the date of the accident. However, upon review of the diagnostic imaging completed on March 13, 2024, it revealed “no definite bony abnormality or fracture can be identified”. I was not pointed to the entry referred to by the applicant in her written submissions.
13The respondent submits that the Health Coordination and Triage Assessment authored by Gail Wright, chiropractor, should be afforded significantly diminished weight, because Dr. Wright is the applicant’s proposed treatment provider in all of the treatment plans in dispute, which at the very least creates a financial interest for Dr. Wright to make certain findings.
14The respondent further relies on an insurer’s examination (“IE”) report and General Practitioner Addendum Report by Dr. Eric Silver, dated December 19, 2024, which noted that further treatment of this type was not reasonable or necessary as it would not provide additional benefit.
15In the applicant’s reply submissions, she writes that the medical evidence clearly establishes multiple chronic pain indicators, and the respondent’s submissions are inconsistent with the medical records. Further, the applicant argues that she meets five of the six AMA Guides criteria for establishing chronic pain, therefore satisfying a Chronic Pain Syndrome diagnosis.
16I considered both parties submissions and find that the applicant has not met her onus to demonstrate the reasonableness and necessity of these two chiropractic treatment plans in dispute. I acknowledge the general assessment of Dr. Wright; however, this report seems to focus on the applicant’s removal from the MIG. It is not clear from this report why the chiropractic plans in dispute are reasonable or necessary, how the goals of this treatment would be met to a reasonable degree and that the overall costs of achieving them are reasonable. This report refers to “comprehensive rehabilitation” and pain medication but does not refer to chiropractic or physical treatment.
17Further, I acknowledge the applicant’s submissions regarding Dr. Sadek’s CNRs referencing the injuries related to the subject accident. However, I was not pointed to the specific entries where this was mentioned.
18The applicant references the CNRs citing chronic back pain, however, she has not directed me to specific CNR entries where chronic pain is diagnosed or discussed. An isolated complaint of back pain is not compelling evidence to establish the reasonableness and necessity of these plans. The applicant has further not directed me to any CNR entry where Dr. Sadek recommended chiropractic services.
19I acknowledge the applicant’s submissions regarding tinnitus, adjustment disorder with mixed anxiety and depressed mood caused by the accident, however, it is not clear how the chiropractic treatment in dispute is reasonable or necessary based on these injuries.
20Therefore, on a balance of probabilities, I find that the applicant has not met her onus to prove that the chiropractic plans are reasonable and necessary.
Is the applicant entitled to $2,235.37 for a health coordination and triage assessment, proposed in a plan dated October 21, 2024, and to $1,155.95 for a health coordination and triage assessment, proposed in a plan dated October 21, 2024?
21I find that the applicant has not established entitlement to these plans.
22The purpose of an assessment is to determine whether a condition still exists. For an insured, they bear the onus to demonstrate that there are grounds on which to believe that a condition exists that would warrant further investigation by way of an assessment.
23The applicant submits that she underwent a Health Coordination Triage Assessment by Dr. Gail Wright of Red Door Medicare Inc for the purpose of addressing her accident-related injuries and outlining how she should not be confined within the Minor Injury Guideline.
24The respondent submits that the applicant is not entitled to this benefit as the assessment is not reasonable and necessary and is not payable pursuant to Sections 25 and 47(2) of the Schedule. Further, that because the health coordination and triage assessment at issue does not fall under any of the enumerated categories in s. 25, it is not payable.
25The respondent further submits that an assessment is similarly not payable under s. 47 of the Schedule. The law is clear that, pursuant to s. 47(2) of the Schedule, if an expense would be covered under OHIP, then it is not payable by an insurer.
26The applicant bears the onus to demonstrate that there are grounds on which to believe that a condition exists that would warrant further investigation by way of an assessment. However, the applicant has not clarified in her submissions what these assessments entail, what specific conditions they would be clarifying, or why they are reasonable and necessary. The applicant has further not directed me to any CNR entry from Dr. Sadek, that identified why these assessments were needed.
27Additionally, the applicant does not address the respondent’s submissions regarding s. 25 or s. 47, or whether these assessments would be covered by the applicant’s OHIP, or whether they could be permissible under s. 25.
28Therefore, on a balance of probabilities, I find that the applicant has not established that the proposed assessments are reasonable and necessary.
Interest
29As no plans are payable, no interest is owing.
Award
30As no benefits have been unreasonably withheld or delayed, no award is owing.
ORDER
31For the reasons stated above I find that:
i. The applicant is not entitled to the treatment plans in dispute.
ii. No interest is owing.
iii. No award is owing.
32The application is dismissed.
Released: June 15, 2026
Sarah Guergis Adjudicator