Licence Appeal Tribunal File Number: 24-005027/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:
Sami Ali Mediouni
Applicant
and
Wawanesa Mutual Insurance Company
Respondent
DECISION
ADJUDICATOR:
Harouna Saley Sidibé
APPEARANCES:
For the Applicant:
Arvin Gupta, Counsel
For the Respondent:
Sophia Souffront, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Sami Ali Mediouni, the applicant, was involved in an automobile accident on March 3, 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, Wawanesa Mutual 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 the chiropractic services as outlined in the treatment plans/OCF-18 (“plans”), proposed by Aqua Wellness Centre, as follows:
$3,485.45 in a plan dated November 15, 2023;
$3,815.45 in a plan dated July 11, 2023;
$2,990.45 in a plan dated March 14, 2024;
$3,110.45 in a plan dated January 12, 2024; and
$3,695.45 in a plan dated August 22, 2023?
ii. Is the applicant entitled to $2,200.00 for an Occupational Therapy Assessment, proposed by Rehab Generations in a plan dated December 5, 2022?
iii. Is the applicant entitled to $500.00 for orthotics, submitted on a claim form (OCF-6) dated June 23, 2022?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3For the reasons below, I find that:
The applicant is not entitled to the disputed treatment plans.
The applicant is not entitled to interest.
PROCEDURAL ISSUES
Scope of Issues – Attendant Care Benefit
4A case conference was held on September 23, 2024. The Case Conference Report and Order (“CCRO”) identified the disputed issues as entitlement to chiropractic services claimed in various OCF-18s (including the July 11, 2023, plan) proposed by Aqua Wellness Centre; an Occupational Therapy Assessment; Orthotics; and interest on any overdue benefits. The CCRO does not include an Attendant Care Benefit (“ACB”) as an issue.
5In his written submissions dated May 20, 2025, the applicant identified two issues: (a) whether the OCF-18 dated July 11, 2023, is reasonable and necessary; and (b) whether the applicant is entitled to attendant care benefits.
6The applicant neither brought a motion to add the ACB issue, sought the respondent’s consent, nor filed a reply addressing this procedural step.
7The respondent objects to the addition of the ACB issue at this late stage, submitting that the applicant has improperly added the new issue unilaterally, without bringing a motion or seeking consent. The respondent argues that this causes prejudice because it has not had an opportunity to investigate or respond specifically to the attendant care benefits claim.
8I decline to add the ACB issue. The applicant did not raise this issue in the application, at the case conference, or prior to the hearing. It was reasonable for the respondent to proceed on the understanding that ACB was not in dispute. Notice of the case to meet is a fundamental element of procedural fairness. Given that this matter proceeded by written hearing, adding a new issue at this stage would be a breach of procedural fairness because the respondent had no opportunity to prepare its defence.
9Additionally, the applicant’s only submission regarding ACB is that, although objective findings may be limited at later assessment stages, the clinical presentation and functional impact justify continued treatment and attendant care benefits. This submission does not address the procedural deficiency or explain why the issue should be added at this stage.
10For these reasons, I find that the ACB issue was not properly raised and should not be added to this dispute.
11Accordingly, the scope of this decision remains limited to the issues identified in the CCRO.
ANALYSIS
Is the applicant entitled to the disputed treatment plans?
12I find that the applicant is not entitled to the disputed treatment plans.
13To 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.
14The disputed chiropractic treatment plans include:
i. November 15, 2023, in the amount of $3,485.45;
ii. March 14, 2024, in the amount of $2,990.45;
iii. January 12, 2024, in the amount of $3,110.45; and
iv. August 22, 2023, in the amount of $3,695.45.
15The applicant made no submissions regarding any of these plans.
16The respondent submits that the applicant appears to have abandoned these claims. Alternatively, the applicant has failed to address the merits of these plans or demonstrate how they meet the test for entitlement under the Schedule. The respondent argues that, without evidence or argument, the Tribunal cannot find these plans reasonable and necessary.
17Under the Schedule, the applicant bears the onus of proving, on a balance of probabilities, that the proposed treatment plans are reasonable and necessary as a result of the accident. Where no submissions or supporting evidence are provided, the Tribunal cannot assess whether the plans meet this standard.
18In this case, the applicant has not provided any explanation, clinical rationale, or supporting documentation for the plans dated November 15, 2023; March 14, 2024; January 12, 2024; and August 22, 2023. There is no evidence before me to establish that these plans would provide meaningful functional improvement or pain relief beyond that achieved through prior treatment.
19Accordingly, on a balance of probabilities, I find that the chiropractic treatment plans dated November 15, 2023; March 14, 2024; January 12, 2024; and August 22, 2023, are not reasonable or necessary.
The Plan Dated July 11, 2023
20I find that the applicant is not entitled to the chiropractic services plan dated July 11, 2023, in the amount of $3,815.45.
21The plan, signed by chiropractor Roy Priesnitz, sets forth goals of pain reduction, increased range of motion and strength, return to activities of daily living, and return to pre‑accident and modified work activities. It outlines extensive passive and manual care: 15 sessions of multiple‑site exercise, 30 sessions of multiple‑site hyperthermy, 15 sessions of back muscle stimulation, 15 sessions of multiple‑site manipulation, 15 sessions of multiple‑site mobilization, and 30 sessions of multiple‑site therapy.
22The applicant submits that the plan is reasonable and necessary. He relies on Aqua Wellness Centre clinical notes documenting ongoing neck pain, headaches, left wrist pain, and lower back pain affecting daily function. He points to April 2022 cervical and lumbar MRIs showing multilevel degenerative changes, mild cord compression at C3‑4, and foraminal narrowing as the objective context for persistent symptoms. He argues the insurer’s section 44 report by Dr. Pankaj Eric Bansal, a General Physician (September 29, 2023), overemphasizes the typical resolution of soft‑tissue injuries within three months and fails to account for chronic pain and degenerative conditions where symptoms may persist. He maintains that credible subjective complaints combined with functional limitations justify ongoing treatment notwithstanding limited late-stage objective findings.
23The respondent submits that the applicant must prove, on a balance of probabilities, that the goods and services in the July 11, 2023, plan are reasonable and necessary as a result of the accident. It relies on Dr. Bansal’s section 44 assessment, concluding the applicant’s injuries were soft‑tissue and self‑resolving, with no objective musculoskeletal or neurological impairment 18 months post‑accident to justify further chiropractic care. The respondent emphasizes a significant pre‑accident history of chronic pain, migraines, sleep disturbance, psychological issues, and prior pain clinic and medical marijuana use. It notes that the April 2022 MRIs reflect degenerative rather than traumatic pathology. It further argues that removal from the MIG on August 22, 2022, does not, by itself, justify continued treatment; the applicant must still establish the reasonableness and necessity of such treatment. Finally, it points to limited engagement with primary or specialist care between April 2022 and February 2024, and to a lack of evidence of escalation to multidisciplinary or active rehabilitation.
24Dr. An-Huy Nguyen, a physician at Med Path Clinic, noted in the clinical notes and records (“CNR”s) neck, mid‑ and low‑back, and wrist pain at the initial post‑accident visit on March 17, 2022, and continued low‑back and knee complaints in April 2022.
25April 2022 cervical and lumbar MRIs reveal multilevel degenerative changes, including mild cord compression at C3‑4 and degenerative changes at L4‑5 with mild foraminal narrowing. These findings are consistent with chronic degenerative disease rather than acute structural injury from the accident, although degenerative pathology can interact with soft‑tissue trauma to produce symptoms.
26Pre‑accident Med Path records establish longstanding chronic low‑back pain (8–9 years), prior accident‑related injuries dating to 2011, sleep disturbance, psychological issues, and previous disability accommodations.
27Aqua Wellness records reflect chiropractic and therapy attendance from December 28, 2022, to May 29, 2024, and document ongoing pain, stiffness, and limitations. While they support continued subjective complaints, they do not identify new pathology, deterioration, or a clear clinical rationale explaining how additional passive chiropractic modalities would yield measurable functional gains in the context of degenerative disease and chronic symptoms.
28Dr. Bansal’s September 29, 2023, section 44 report reviews the history, imaging, and examination findings, and concludes that—1.5 years post‑accident—there are no valid objective signs of ongoing musculoskeletal or neurological impairment related to the accident.
29I accept that the applicant continues to experience pain and that his reports to providers are genuine. The question under the Schedule is not simply whether he has pain, but whether the specific goods and services in this specific plan are reasonable and necessary as a result of the accident.
30Several factors weigh against the July 11, 2023, plan. The accident occurred in March 2022, and the plan was proposed more than 16 months later. The MRIs and pre‑accident records point to longstanding degenerative and chronic pain conditions. The plan comprises predominantly passive modalities (hyperthermia, stimulation, manipulation/mobilization) and does not set out patient‑specific, measurable goals or an evidence‑based rationale demonstrating incremental benefit beyond prior care. There is limited evidence of engagement in active rehabilitation, functional retraining, or multidisciplinary pain management, which would be more consistent with sustained functional gains at this stage.
31I place more weight on Dr. Bansal’s Section 44 opinion. It is temporally proximate to the disputed plan, as evidenced by a review of records and imaging. There is no contrary specialist or treating physician opinion directly engaging with Dr. Bansal’s findings and explaining why continued passive chiropractic care at 16+ months post‑accident would be reasonable and necessary.
32I am mindful that the absence of objective findings does not automatically preclude treatment where credible subjective complaints and functional impact exist. However, the applicant bears the burden of proof. On this record—chronic pre‑accident condition, degenerative imaging, the time elapsed since the accident, the passive nature of proposed modalities, and a comprehensive section 44 assessment—the applicant has not shown that this plan would produce measurable functional improvement or provide proportionate clinical benefit relative to cost.
33On the totality of the evidence, I find the plan dated July 11, 2023, in the amount of $3,815.45, is not reasonable or necessary.
34Accordingly, on a balance of probabilities, the applicant is not entitled to the disputed plan.
Occupational Therapy Assessment
35I find that the applicant is not entitled to the occupational therapy assessment treatment plan.
36The purpose of an assessment is to determine whether a condition exists that warrants further investigation or treatment. The applicant bears the onus of establishing, on a balance of probabilities, that there are grounds to believe such an assessment is reasonable and necessary as a result of the accident.
37The December 5, 2022, plan proposes documenting support activities and determining an Attendant Care Benefit.
38The applicant submits that, although objective findings may be limited at later stages, his clinical presentation and functional impact justify continued treatment and attendant care benefits.
39The respondent submits that the applicant appears to have abandoned this issue or, alternatively, has failed to address its merits or demonstrate entitlement. The plan was denied because it duplicated services already provided under a prior approved assessment and Form 1 dated September 18, 2022, with costs covered. The applicant has not provided evidence explaining why a second assessment is necessary.
40I agree with the respondent’s submissions. The applicant did not raise the Attendant Care Benefit issue at the case conference or file a motion to include it, and I have already declined to broaden the scope of issues. Further, the applicant has not provided evidence or submissions explaining why this assessment is required beyond the prior approved assessment and Form 1. There is no indication of new functional limitations or changes in condition that would justify duplication of services.
41Accordingly, on a balance of probabilities, I find that the Occupational Therapy Assessment plan dated December 5, 2022, in the amount of $2,200.00, is not reasonable or necessary.
Outstanding Expenses for Orthotics
42I find that the outstanding orthotics balance has been resolved.
43The plan dated June 16, 2022, signed by chiropractor Frederick Levenston, totals $1,271.19 and includes a full-body assessment, seven therapy sessions, and one orthotic device. The goals are pain reduction, increased range of motion, improved strength, and return to normal activities.
44The applicant made no submissions on this issue.
45The respondent submits that the applicant appears to have abandoned this claim. It notes that the plan was initially partially approved for $771.19 (covering chiropractic, massage therapy, and form completion) and denied $500.00 for orthotics. However, on August 23, 2022, the respondent reconsidered and fully approved the plan, with payment issued. Accordingly, the respondent argues that this issue is resolved and should be withdrawn.
46I accept the respondent’s submissions. The applicant has not disputed the respondent’s evidence that full payment was made, and there is no indication of any outstanding entitlement.
47Accordingly, on a balance of probabilities, I find that the orthotics issue has been resolved and does not require further determination.
Interest
48Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Interest is not payable because I have determined that no benefits are owed.
ORDER
49For the above reasons, it is ordered that:
i. The applicant is not entitled to the disputed treatment plans.
ii. The applicant is not entitled to interest.
iii. The application is dismissed.
Released: January 23, 2026
__________________________
Harouna Saley Sidibé
Adjudicator