Licence Appeal Tribunal File Number: 25-002071/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:
Yun Na
Applicant
and
TD General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Jeff Chatterton
APPEARANCES:
For the Applicant:
Andrew Bergel, Counsel
For the Respondent:
Sandra L White, Counsel
HEARD: In Writing
OVERVIEW
1Yun “Maggie” Na, the applicant, was involved in an automobile accident on March 13, 2023, 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, TD 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:
- Is the applicant entitled to the treatment plans/OCF-18s proposed by Seksek Chiropractic Professional Corp., as follows:
i. $3,049.25 for physiotherapy services, in a plan submitted November 14, 2023; and
ii. $2,569.01 for chiropractic services, in a plan submitted November 1, 2024?
- Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant is not entitled to the treatment plans in dispute.
4No interest is payable.
5The application is dismissed.
ANALYSIS
Background
6The accident occurred in March 2023. The applicant sought and received treatment for both physical and psychological issues. The applicant received funding for nine sessions of physical therapy on November 1, 2023.
7The applicant sought further physiotherapy in an OCF-18 dated November 14, 2023, which was denied, based on the fact the applicant was in the Minor Injury Guideline (the “MIG”) with a $3,500 funding limit. This is issue 1(i) listed in the Issues in Dispute, above.
8On February 27, 2024, the applicant was removed from the MIG after an assessment with a s. 44 Psychologist, Dr. Peter Cobrin, on February 8, 2024. The applicant was diagnosed with Major Depressive Disorder and Specific Phobia, which was deemed to be “beyond a minor injury”.
9The applicant was also assessed by General Practitioner Dr. Pankaj Bansal, who opined that the applicant’s physical injuries were uncomplicated soft-tissue type injuries and that “there would be no reason as to why Ms. Na would have a physical impairment in relation to the MVA.”
10The applicant sought and received funding for physical therapies on two more occasions, in plans dated February 27, 2024 and July 19, 2024.
11The applicant was denied funding for chiropractic services on November 1, 2024. This is issue 1(ii) listed in the Issues in Dispute, above.
12On July 1, 2025, the applicant underwent a s.25 Psychological Assessment and was diagnosed with Somatic Symptom Disorder with Predominant Pain.
Is the applicant entitled to physiotherapy services?
13The applicant has not met her onus to demonstrate she is entitled to the proposed physiotherapy services.
14To 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.
15In dispute are 22 sessions of therapy, intended to reduce pain, increase strength and increase range of motion, with a stated goal of a return to the activities of normal living.
16The applicant submits that the treatment plan is reasonable and necessary because it was only denied due to the fact she was in the MIG, but she was later removed from the MIG. The applicant also argues that pain reduction is a reasonable and necessary goal and directly tied to her diagnosis of Chronic Pain Syndrome. To support that claim, the applicant relies on a s.25 Psychological Assessment conducted by Yaneth Romero, R.P. (Qualifying) and supervised by Psychological Associate Ms. Elena Baskakova, dated July 1, 2025, where the applicant is diagnosed with Somatic Symptom Disorder with Predominant Pain.
17The applicant further argues that she applied for and received funding for physical treatments after this OCF-18 was denied. The applicant received physical therapy in February 2024 and July 2024, and the applicant argues that this is evidence the respondent’s denial is illogical and without merit.
18The respondent argues that the denial was proper, and they have adjusted the file in good faith. It argues the applicant received funding for nine sessions of physical treatment proposed in a prior OCF-18 dated November 2, 2023, yet only went for physical treatment eight times in all of 2023.
19I find that being approved for physical therapy later while adjusting a file does not automatically render earlier denials for physiotherapy non-compliant. When determining whether a treatment plan is reasonable and necessary, the Tribunal must look at the OCF-18 in the context of information and medical evidence available to the parties at the time.
20I find the applicant has not provided persuasive evidence that she is entitled to the physiotherapy in question. I say this for several reasons:
21The applicant was provided with physical therapy two weeks prior to the submission of the OCF-18 dated November 14, 2023 for up to nine sessions. I have not been led to evidence that would indicate that the applicant had exhausted that treatment at the time the OCF-18 dated November 14, 2023 was submitted.
22The applicant has not directed me to caselaw which supports her claim that being removed from the MIG on psychological grounds and being funded for subsequent physiotherapy services renders prior OCF-18s payable. Rather, the key factor is whether medical evidence, contemporaneous with the submission of the treatment plans in dispute, establishes that ongoing physical treatment was reasonable and necessary.
23The applicant has not directed me to corroborative medical evidence that ongoing physical therapy had been recommended at the time of the dispute. For example, I have not been led to recommendations for further physical treatments from her family physician.
24When the respondent removed the applicant from the MIG on February 27, 2024, it also immediately approved 22 sessions of physical therapy treatments, in an OCF-18 dated the same day. I have not been provided with evidence to indicate why the applicant would require both of the February 2024 and November 2023 treatment plans approved, or why the treatment plans were not duplicative. In any event, the applicant sought - and received - physical treatments from the insurer, even though the primary reason for removal from the MIG was based on a psychological condition.
25I give little weight to the Psychological Report of Ms. Baskakova because it is dated July 1, 2025, which is 19 months after the OCF-18 in dispute. I find it is not contemporaneous to this plan in dispute. Further, the report of Ms. Baskakova was psychological in nature and does not provide a specific reference for physical therapies.
26In summary – the applicant was offered physical therapy two weeks prior to the OCF-18 in dispute, and I have not been led to indications that this approved physical therapy was exhausted at the time of the OCF-18 in dispute, or medical evidence that she was sustaining improvement with treatment.
27For these reasons, I find the applicant has not met her onus, on the balance of probabilities, to demonstrate she is entitled to the physical therapy in dispute.
Is the applicant entitled to physiotherapy services due to a procedural error?
28The applicant is not entitled to physiotherapy services due to s. 38(8) non-compliance by the respondent.
29Section 38(8) requires an insurer to inform an insured person, within 10 business days after it receives the treatment plan, of the medical and other reasons why it considered the goods and services not to be reasonable and necessary if it denies a plan. Pursuant to s. 38(11), if an insurer fails to comply with its obligations under section 38(8), it must pay for the goods and services that relate to the period starting on the 11th business day after the insurer received the application and ending on the day the insurer gives a notice described in s. 38(8) and it is prohibited from taking the position that the insured person has an impairment to which the MIG applies.
30The applicant argues that the denial letter dated November 27, 2023 for the physiotherapy treatment plan dated November 14, 2023 was boilerplate and did not provide a sufficiently detailed reason for the denial.
31I have read the letter in question and find it to be compliant with s. 38(8). The respondent wrote “your impairment has not been deemed to be outside of the Minor Injury, or to meet the criteria for catastrophic impairment.” I find that the reference to ‘minor injury’ is a medical reason, as it indicates that the applicant’s injuries are “minor,” which is a medical definition in the Schedule . The denial letter further clearly denies payment of the treatment plan, identifies the treatment provider, the OCF-18 in question, and as noted above, provides a medical reason for the denial.
32For these reasons, the applicant has not, on the balance of probabilities, met her onus to establish that she is entitled to the OCF-18 in dispute because of s. 38(8) non-compliance by the respondent.
Is the applicant entitled to chiropractic services?
33The applicant is not entitled to chiropractic services.
34In dispute are 20 sessions of chiropractic treatments, proposed by Chiropractor Dr. Tanya Gonzalez in a treatment plan submitted November 1, 2024, intended to reduce pain, increase strength and increase range of motion, with a stated goal of a return to the activities of normal living.
35The applicant has not provided specific submissions as to why the treatment plan for chiropractic services is reasonable and necessary. The applicant’s reference to this treatment plan is, “Maggie attended for and incurred the treatment proposed in the aforementioned denied Treatment Plan from Hands on Health.”
36The applicant later refers to the psychological assessment report from Ms. Baskakova, where the applicant is diagnosed with Somatic Symptoms Disorder with Predominant Pain. The applicant argues that the treatment plan is “reasonable and necessary in order to treat her chronic pain.”
37The respondent denies that chiropractic services are reasonable and necessary. To support their position, they refer to a s. 44 General Practitioner’s Assessment, conducted by Dr. Bansal, dated February 8, 2024, with a further paper review dated November 25, 2024. In his report, Dr. Bansal opines that the applicant has achieved maximal medical recovery for her physical ailments, and that further physical treatments are neither reasonable nor necessary.
38I give reduced weight to the report of Ms. Baskakova for the purposes of determining whether or not chiropractic services are reasonable and necessary. I say this for two reasons:
39Ms. Baskakova’s report is dated July 1, 2025, which as noted earlier, makes it non-contemporaneous to the issues in dispute. The denied OCF-18 in question is dated November 1, 2024, seven full months before Dr. Baskakova’s report was issued.
40Further, while Ms. Baskakova’s report specifically contains a number of explicit recommendations for treatment, such as further psychotherapy, a driving assessment and a neuropsychological assessment, she does not make any recommendation for further physical treatments or chiropractic treatments.
41The applicant did not direct me to recommendations from her family physician to indicate chiropractic treatment was being recommended. The onus rests with the applicant to provide sufficient medical evidence to support their claim, I have not been led to further corroborative medical evidence which would indicate that the chiropractic treatment in dispute is reasonable and necessary.
42For these reasons, I find the applicant has not, on the balance of probabilities, met her onus to demonstrate that the chiropractic services are reasonable and necessary.
Interest
43Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no benefits are overdue, no interest is payable.
ORDER
44The application is dismissed:
i. The applicant is not entitled to the treatment plans in dispute.
ii. No interest is payable.
Released: June 17, 2026
Jeff Chatterton
Adjudicator