Licence Appeal Tribunal File Number: 24-014699/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:
Eva Bohusova
Applicant
and
Certas Home and Auto Insurance Company
Respondent
AMENDED DECISION
ADJUDICATOR:
Nadia Mauro
APPEARANCES:
For the Applicant:
David Gardiner, Counsel
For the Respondent:
Lori Marzinotto, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Eva Bohusova, the applicant, was involved in an automobile accident on June 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 the respondent, Certas Home and Auto 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 $1,153.17 for assistive devices, proposed by Function Ability Rehabilitation Services in a treatment plan (“OCF-18”) submitted on October 23, 2024, and denied on November 29, 2024?
ii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
iii. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant is not entitled to the proposed treatment plan for assistive devices, interest, or an award.
ANALYSIS
The applicant is not entitled to the proposed treatment plan for assistive devices
4The applicant has not demonstrated, on a balance of probabilities, that the proposed treatment plan for assistive devices is reasonable and necessary.
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.
6The OCF-18 completed by occupational therapist, Brianna Whitteker, dated October 23, 2024, sought funding for the following assistive devices:
| Line | Description | Quantity | Amount |
|---|---|---|---|
| 1. | Completing claim form | 1 | $200.00 |
| 2. | Other supplies (cost adjustment) | 1 | $50.00 |
| 3. | Prescription, support activity | 1.5 | $87.29 |
| 4. | Other supplies (Non-slip bath mat and aids for daily living) | 1 | $80.00 |
| 5. | Other supplies (Assista-Rail (bed rail), round raised toilet seat, transfer bath bench with curtain control, stainless steel grab bar, grab bar service visit) | 1 | $598.00 |
| 6. | Other supplies (Suction holder for handheld shower head) | 1 | $14.53 |
| 7. | Other supplies (long handled loofah) | 1 | $13.69 |
7The goals of the treatment plan are to increase safety, return to activities of daily living, improve safety with activities of daily living, functional mobility, and transfers using the recommended equipment.
8The applicant submits that the treatment plan is reasonable and necessary, and the assistive devices are required for her safety to help protect her in her recovery. The applicant relies on the s. 25 occupational therapy (OT) report of Brianna Whitteker, dated October 18, 2024, and s. 25 orthopedic assessment report of Dr. Michael Kliman, dated January 16, 2025.
9The OCF-18 indicates that Line 2: other supplies (cost adjustment) is with respect to the fact that online pricing frequently changes after the OCF-18 is submitted and approved for items at a specific price, and to avoid time required to request small price adjustments later, this OCF-18 includes the additional line item as a buffer in the event of the adjustment. The OCF-18 also indicates that Line 3: prescription, support activity is time required to order, ship, and arrange the correct purchase of the items. The applicant does not make specific submissions with respect to these line items. Given the further explanation of these proposed goods and services within the OCF-18, I agree with the respondent’s position with respect to Line 2 and 3 and find that neither of these items are payable under the Schedule, nor has the applicant established that they are reasonable and necessary.
10With respect to Line 5 through 7, Ms. Whitteker reports these proposed goods and services are to facilitate the applicant’s independence with bed, toilet, and shower mobility and transfers. Nonetheless, Ms. Whitteker in her OT report, dated October 18, 2024, reports the applicant demonstrated independence using slow movements with transferring into bed. This is supported in the s. 44 occupational therapy in-home evaluation report of Ms. Vinita Tandon, dated August 2, 2024. As such, I find the bed rail listed under Line 5 to not be reasonable and necessary considering the applicant already demonstrates independence in bed transfers.
11With respect to the toilet seat, tub transfer bench, grab bar, bathmat, and long-handled loofah, Ms. Whitteker in her report indicates that the applicant displays difficulties with getting into the tub and transferring to the toilet. Ms. Whitteker provides an explanation for the recommended devices in the OCF-18 as follows:
a. Raised toilet seat: for independence with toilet transfers
b. Tub transfer bench: for safety with shower transfers and seated bathing tasks.
c. Grab bar: for safety when standing to rinse her body
d. Bathmat: current mat in poor condition, impacting its efficacy for fall prevention
e. Long handled loofah: to facilitate washing of harder to reach areas due to range of motion limitations
12While the applicant submits that it would be “hugely unjust, unfair and unsafe to maintain the denial of the assistive devices in the circumstances and, therefore, a clear breach of the law and the overall standard to protect consumers,” relying on the Divisional Court decision in Botbyl v. Heartland Farm Mutual Inc., 2025 ONSC 3349, the applicant does not make specific submissions with respect to any of these line items.
13Conversely, s. 44 OT assessor, Ms. Tandon, reports the applicant demonstrated adequate functional abilities to complete all transfers independently. Ms. Tandon also reports that the applicant demonstrated functional abilities, including right and left-hand gross function, to manage bathing independently. While I note that the applicant has consistently reported to assessors such as Dr. Kliman and s. 44 orthopedic assessor, Dr. Alex Rabinovich, that she completes personal care albeit with increased pain and done slowly and carefully, the applicant has not directed me to contemporaneous evidence that would indicate that these items are needed for safety. Despite the fact that the central treatment goal identified in the OCF-18 was improving the applicant’s safety, the applicant has further not directed me to any corroborating medical opinion that recommends the proposed items for her safety. I note that the OCF-18 does not indicate a goal of pain reduction. As such and keeping in mind the goals of the proposed treatment plan, I find that the applicant has not established, on a balance of probabilities, that these proposed goods and services are reasonable and necessary.
14I find that the applicant has not proven, on a balance of probabilities, that the proposed treatment plan for assistive devices is reasonable and necessary.
Interest
15As there are no overdue benefits, the applicant is not entitled to interest pursuant to s. 51 of the Schedule.
Award
16The 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.
17As there are no overdue benefits, the applicant is not entitled to an award.
ORDER
18I find that:
a. The applicant is not entitled to the treatment plan for assistive devices;
b. The applicant is not entitled to interest pursuant to s. 51 of the Schedule;
c. The respondent is not responsible to pay an award; and
d. The application is dismissed.
Released: June 17, 2026
Nadia Mauro
Adjudicator