Stringer v. Co-operators General Insurance Company, 2026 CanLII 6228

Citation: Stringer v. Co-operators General Insurance Company, 2026 ONLAT 24-004415/AABS

Licence Appeal Tribunal File Number: 24-004415/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:

Freeman Stringer

Applicant

and

Co-operators General Insurance Company

Respondent

DECISION

ADJUDICATOR:

Harouna Saley Sidibé

APPEARANCES:

For the Applicant:

Sundeep Singh, Counsel

For the Respondent:

Amanda Lennox, Counsel

HEARD:

By way of written submissions

OVERVIEW

1Freeman Stringer, the applicant, was involved in an automobile accident on July 12, 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, Insurer, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

2A case conference was held on August 12, 2024, and the Case Conference Report and Order (“CCRO”) dated August 19, 2024, outlined the issues to be decided. On April 14, 2025, the respondent filed a Notice of Motion, with the applicant’s consent, to amend the issues in dispute. The Motion Order dated April 23, 2025, sets out the final list of issues; the parties structured their written submissions accordingly.

ISSUES

3The issues in dispute are:

i. Is the applicant entitled to attendant care benefits in the amount of $1,372.21 per month from November 16, 2023, to ongoing?

ii. Is the applicant entitled to $169.99 for Other Assistive Devices, proposed by Mackenzie Medical Rehabilitation Centre in a treatment plan/OCF‑18 (“plan”) dated December 20, 2023?

iii. Is the applicant entitled to $946.90 for Physiotherapy treatment, proposed by Mackenzie Medical Rehabilitation Centre in a plan dated January 17, 2024?

iv. Is the applicant entitled to $2,029.74 for Physiotherapy treatment, proposed by Mackenzie Medical Rehabilitation Centre in a plan dated March 13, 2024?

v. Is the applicant entitled to $1,785.84 for Physiotherapy treatment, proposed by Mackenzie Medical Rehabilitation Centre in a plan dated November 30, 2023 (OCF‑18 total $3,635.54, partially approved $1,849.70)?

vi. Is the applicant entitled to $1,530.72 for Physiotherapy treatment, proposed by Mackenzie Medical Rehabilitation Centre in a plan dated May 22, 2024?

vii. Is the applicant entitled to $2,443.86 for Psychological treatment, proposed by Princeton Hills Medical in a plan dated January 19, 2024?

viii. Is the applicant entitled to $5,841.28 for Chiropractic treatment, proposed by Complete Balance in a plan dated December 6, 2023?

ix. Is the applicant entitled to $2,486.00 for a Chronic Pain Assessment, proposed by Downsview Health in a plan dated April 23, 2024?

x. Is the applicant entitled to $2,486.00 for an Orthopaedic Assessment, proposed by Performance Assessment and Rehab in a plan dated December 19, 2023?

xi. Is the applicant entitled to $2,195.00 for an Attendant Care Assessment, proposed by Scarborough Physiotherapy and Rehabilitation Centre in a plan dated April 3, 2024?

xii. Is the applicant entitled to $2,200.00 for a Vocational Assessment, proposed by Scarborough Physiotherapy and Rehabilitation Centre in a plan dated June 25, 2024?

xiii. Is the applicant entitled to $2,486.00 for a Concussion Assessment, proposed by Complete Balance Health Centre in a plan dated April 23, 2023?

xiv. Is the applicant entitled to $624.92 for Physiotherapy treatment, proposed by Mackenzie Medical Rehabilitation Centre in an OCF‑21 dated November 30, 2023?

xv. Is the applicant entitled to $283.28 for Physiotherapy treatment, proposed by Mackenzie Medical Rehabilitation Centre in an OCF‑21 dated February 2, 2024?

xvi. Is the applicant entitled to $283.28 for Physiotherapy treatment, proposed by Mackenzie Medical Rehabilitation Centre in an OCF‑21 dated April 1, 2024?

xvii. Is the applicant entitled to $283.28 for Physiotherapy treatment, proposed by Mackenzie Medical Rehabilitation Centre in an OCF‑21 dated July 7, 2024?

xviii. Is the applicant entitled to $710.00 for Physiotherapy treatment, proposed by Mackenzie Medical Rehabilitation Centre in an OCF‑21 dated November 16, 2023?

xix. Is the applicant entitled to $424.92 for Physiotherapy treatment, proposed by Mackenzie Medical Rehabilitation Centre in an OCF‑21 dated January 2, 2024?

xx. Is the applicant entitled to $314.02 for Physiotherapy treatment, proposed by Mackenzie Medical Rehabilitation Centre in an OCF‑21 dated April 1, 2024?

xxi. Is the applicant entitled to $1,068.28 for Physiotherapy treatment, proposed by Mackenzie Medical Rehabilitation Centre in an OCF‑21 dated March 1, 2024?

xxii. Is the applicant entitled to $291.43 for Psychological treatment, proposed by Princeton Hills Medical in an OCF‑21 dated April 4, 2024?

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

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

RESULT

4For the reasons below, I find that:

1. The applicant is entitled to an attendant care benefit of $1,372.21 per month from November 16, 2023, to November 7, 2024, and $1,297.46 per month from November 8, 2024, on an ongoing basis.

2. The applicant is entitled to the concussion assessment plan for $2,486.00 and the chronic pain assessment for $2,486.00.

3. The applicant is entitled to the OCF-21s only to the extent they represent a balance owing after Manulife or other collateral benefits have responded.

4. The applicant is entitled to interest on any overdue payment of benefits.

5. The applicant is not entitled to the outstanding amounts or to the remaining physiotherapy plans.

6. The applicant is not entitled to the plan for chiropractic services in the amount of $5,841.28, the outstanding balance for psychological services of $2,443.68, the plan for other assistive devices of $169.99, the orthopaedic assessment of $2,486.00, and the attendant care assessment of $2,195.00.

7. The applicant is not entitled to an award.

5In its submissions, the respondent stated that the vocational assessment plan was approved on July 17, 2024. Therefore, the plan is no longer in dispute.

ANALYSIS

Is the applicant entitled to the disputed treatment plans?

6To 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.

7The purpose of assessments is to determine whether a condition exists. For an insured, they bear the onus of demonstrating that there are grounds on which to believe that a condition exists that would warrant further investigation by way of an assessment.

8Under Section 47(2) of the Schedule, where a medical or rehabilitation benefit is reasonably available to the insured under another plan of insurance, the accident benefits insurer is liable only for the difference between what is reasonably available under the other plan and the total reasonable and necessary expense.

The Treatment Plans (OCF-18s)

Concussion and Chronic Pain Assessments

9I find that both the concussion assessment plan and the chronic pain assessment plan, each in the amount of $2,486.00, are reasonable and necessary.

10The chronic pain assessment plan, dated April 23, 2024, and signed by Dr. Dimitri Louvish (physician) and Domenic Minnella (chiropractor), seeks to evaluate the extent of the applicant’s chronic injuries and psychological complaints. Its purpose is to provide a prognosis and treatment recommendations. The plan includes a comprehensive physical examination and documentation of functional activities.

11The concussion assessment plan, dated April 23, 2023, and signed by Dr. Joseph Kwok (physician), is intended to evaluate the applicant’s current condition. It similarly includes a full-body examination and documentation of functional activities.

12The applicant reports ongoing post-concussive symptoms—such as headaches, dizziness, imbalance, and cognitive difficulties—alongside persistent musculoskeletal pain affecting the right shoulder, back, hip, and knee. He relies on Dr. James Fung, a chiropractor, for his concussion evaluation and orthopedic reports from Drs. Kwok and Raaj Vora (Orthopedic Surgeon), who document significant pain, reduced range of motion, and functional limitations, with interventions including injections. The applicant submits that both assessments are necessary to clarify diagnoses, guide treatment planning, and address impairments that have not resolved with conservative care.

13The respondent disputes the medical basis for both assessments. Regarding concussion, it argues there is no reliable evidence of mild traumatic brain injury (MTBI): contemporaneous EMS and hospital records do not note head trauma, loss of consciousness, amnesia, disorientation, or acute concussion symptoms; the applicant was discharged without neuroimaging and traveled the next day; and the first mention of concussion appeared months later. The respondent relies on the section 44 neurological examination by Dr. Rehan Dost, a neurologist (January 31, 2024), who concluded the applicant did not sustain a concussion and attributed headaches to whiplash and balance issues to mechanical pain. Regarding chronic pain, the respondent contends that chronic pain syndrome has not been diagnosed by treating physicians, that the pain can be managed through primary care and conservative rehabilitation, and that the plans lack details on frequency, duration, and measurable goals. It also raises concerns about duplication of services available through physiotherapy or psychotherapy and questions the appropriateness of virtual concussion therapy delivered by a chiropractor.

14The hospital records do not document acute neurological signs. Dr. Dost’s report sets forth the accepted diagnostic criteria for MTBI (CDC/WHO/DSM-5), notes the absence of the required acute features, and offers alternative explanations for the symptoms, including undertreated whiplash and mechanical pain. In contrast, Dr. Fung’s report reflects a structured concussion assessment by a clinician with specialized training, with later-emerging symptoms consistent with the applicant’s complaints.

15Orthopedic reports (Dr. Kwok, February 8, 2024; Dr. Vora, September 12, 2024) document persistent, function-limiting pain in multiple regions, reduced range of motion, degenerative changes—including advanced right shoulder arthropathy—superimposed on accident-related aggravation, and interventions, including injections. The evidence shows pain persisting beyond six months despite conservative measures, with impacts on sleep and mobility.

16Regarding concussion, the evidence is mixed. The absence of acute neurological findings weighs against a definitive MTBI diagnosis. However, the Schedule does not require proof of a specific diagnosis for an assessment to be reasonable and necessary. The purpose of an assessment is to determine whether a condition exists. Given the applicant’s persistent symptoms (headaches, dizziness, cognitive complaints, imbalance), a targeted concussion assessment may reasonably assist in clarifying etiology and guiding management for headaches and balance difficulties. The plan’s cost is modest relative to its potential clinical benefit.

17Regarding chronic pain, I accept that the applicant’s pain is longstanding, multi-site, and functionally limiting despite conservative care. Considering the documented complexity, including right shoulder adhesive capsulitis and osteoarthritis with significant restriction, hip and knee complaints, sleep disturbance, and psychological overlay, a comprehensive chronic pain assessment is reasonable and necessary.

18On a balance of probabilities, I find that:

(a) the concussion assessment plan in the amount of $2,486.00 is reasonable and necessary; and

(b) the chronic pain assessment plan in the amount of $2,486.00 is reasonable and necessary.

Physiotherapy Treatment Plans

19I find that the applicant is not entitled to the outstanding or remaining amounts under the physiotherapy plans.

20The applicant seeks payment for several physiotherapy plans, including:

i. January 17, 2024 – $946.90 (after partial approval), signed by Anjali Patil, physiotherapist, and Vadim Chachashvili. This plan includes 22 sessions across multiple body sites, an assessment, and 11 pairs of protective and therapeutic gloves.

ii. March 13, 2024 – $2,029.74;

iii. November 30, 2023 – $1,785.84 (after partial approval); and

iv. May 22, 2024 – $1,530.72.

21These plans generally propose multiple sessions targeting several body sites, assessments, and, in some cases, therapeutic equipment such as protective gloves. The stated goals include pain reduction, improved mobility, and return to normal daily activities and modified work.

22The applicant submits that ongoing physiotherapy is reasonable and necessary in light of his persistent musculoskeletal impairments. He relies on recommendations from his family physician, concussion specialist, orthopaedic surgeon, and physiotherapy providers, all of whom support structured physiotherapy to address deficits. He argues that pain relief and functional improvement are legitimate goals.

23The respondent acknowledges that some physiotherapy was appropriate but relies on the physiatry IE by Dr. Alfonse Marchie, physiatrist, who approved limited physiotherapy to a specified monetary cap and did not support repeated or extensive courses. The respondent submits that any amounts exceeding those limits are not reasonable or necessary.

24The evidence establishes that the applicant has already undergone significant physiotherapy (see CNRs from Dr. Myrna Monte, family doctor, dated August 27, 2024, and October 1, 2024). There is general agreement that some physiotherapy was warranted; the dispute concerns the volume and duration of treatment.

25Dr. Marchie’s IE dated January 31, 2024, partially approved specific plans and set monetary limits while declining others. He reached similar conclusions in his physiatry paper reviews. His opinion was that extended passive treatment beyond those limits was unlikely to yield meaningful functional gains.

26While the applicant’s treating practitioners recommend further physiotherapy, their reports do not persuasively explain why extended courses beyond the approved limits would produce sustained improvement rather than short-term symptomatic relief.

27Pain relief is a legitimate treatment goal; however, it must be balanced against cost and the likelihood of benefit.

28The applicant has demonstrated a need for physiotherapy, but the evidence does not support extended or repeated courses beyond those already approved. The treating reports lack objective measures of functional progress or justification for prolonged treatment. Accordingly, the respondent’s position aligns with the principle that treatment must be reasonable and necessary.

29On the evidence before me, I find that physiotherapy treatment is reasonable and necessary only to the extent approved by Dr. Marchie’s recommendations. Any amounts in excess of those approved limits are not reasonable or necessary and are not payable.

30On a balance of probabilities, I find that the physiotherapy treatment plans are payable only to the extent approved by Dr. Marchie. All amounts beyond those limits are not reasonable or necessary. Accordingly, the applicant is not entitled to the outstanding or remaining amounts under the physiotherapy plans.

Chiropractic Services

31I find that the applicant is not entitled to funding for the proposed chiropractic treatment plan.

32The issue is whether the chiropractic treatment plan dated December 6, 2023, in the amount of $5,841.28, is reasonable and necessary.

33The plan, signed by Dr. James Fung (chiropractor), is intended to improve balance, reduce concussion-related symptoms, such as headaches and dizziness, and enhance daily functioning. It proposes 24 sessions, including motor and living skills therapy, cognitive training, educational materials, and a full-body assessment.

34The applicant submits that the plan is reasonable and necessary to address persistent post-concussive symptoms documented in Dr. Fung’s concussion evaluation dated October 20, 2023. He argues that poor balance and ongoing headaches have significantly impaired his ability to perform daily activities since the accident.

35The respondent disputes the plan’s reasonableness, asserting that there is no reliable evidence that the applicant sustained a concussion. It relies on contemporaneous records showing the applicant denied head trauma, loss of consciousness, or dizziness at the accident’s scene and in the hospital. He was discharged without concussion testing and drove to Newfoundland the next day. The first mention of concussion occurred two months later, and his family physician did not diagnose it. The respondent also relies on the section 44 neurological examination by Dr. Rehan Dost (January 31, 2024), which concluded the applicant did not sustain a concussion and attributed headaches and balance complaints to whiplash and mechanical pain. Accordingly, the respondent submits that the plan would provide no benefit.

36Dr. Fung diagnosed persistent post-concussion syndrome (PCS) based on the applicant’s reported symptoms and clinical findings, referencing ICD-10 criteria requiring at least three symptoms (e.g., headache, dizziness, fatigue, irritability, sleep disturbance, concentration or memory problems) persisting for four weeks post-injury.

37Dr. Dost’s report explains that accepted diagnostic criteria for mild traumatic brain injury/concussion (CDC, WHO, DSM-5) require: (a) concussive force to the brain; (b) one of loss of consciousness, amnesia, disorientation, or confusional state at the time of trauma; and (c) exclusion of non-brain injury factors. Post-concussive symptoms alone are not diagnostic. He found no evidence of acute neurological signs in EMS or ER records and considered the applicant’s later self-report inconsistent with early documentation and influenced by psychological distress and pain. On that basis, Dr. Dost concluded that the applicant did not sustain a concussion. He attributed headaches to undertreated whiplash and recommended pharmacologic and interventional pain management. He also noted that dizziness was nonspecific and likely related to mechanical pain rather than neurological dysfunction.

38The evidence on concussion is conflicting. While Dr. Fung diagnosed PCS, his opinion is based primarily on subjective reporting and lacks corroboration from contemporaneous records. Dr. Dost’s opinion is detailed, applies recognized diagnostic criteria, and is supported by objective findings. I accept his conclusion that the applicant did not sustain a concussion. In these circumstances, a treatment plan directed at concussion-related symptoms is unlikely to provide meaningful benefit. Further, the plan lacks clear functional goals, measurable outcomes, and justification for the proposed modalities, many of which appear duplicative of physiotherapy and psychotherapy.

39Accordingly, on a balance of probabilities, I find that the chiropractic treatment plan dated December 6, 2023, in the amount of $5,841.28, is not reasonable and necessary.

Outstanding Balance of the Plan for Psychological Services

40I find that the applicant is not entitled to the outstanding balance of the psychological services plan.

41The plan, dated January 19, 2024, signed by Nina Belyakova (psychologist), seeks $4,015.13 for 12 sessions of individual psychotherapy, testing and scoring, treatment planning, a progress report, and fees for completing the OCF-18. Its stated goals include pain reduction, return to pre-accident psychological functioning, and resumption of normal living and work activities. The disputed balance is $2,443.68 following partial approval.

42The applicant submits that psychological treatment is reasonable and necessary based on an assessment dated January 26, 2024, which diagnosed depression, anxiety, and PTSD, with symptoms such as hopelessness, driving anxiety, and difficulty concentrating. A progress report dated November 23, 2024, indicates worsening depression (now severe) and persistent moderate anxiety, with ongoing symptoms including guilt, worthlessness, low mood, and inability to relax. The applicant argues that additional psychological treatment is essential for recovery.

43The respondent clarifies that it partially approved the plan on February 13, 2024, authorizing 12 one-hour sessions and a progress report for $1,571.45, leaving a balance of $2,443.68. The respondent submits that 1.5-hour sessions are not justified, as one-hour sessions are the standard, and that additional testing and planning were unnecessary because they had already been completed during the January 26, 2024, psychological assessment. The respondent also notes that it paid $91.43 per hour for psychotherapy, consistent with LAT-accepted rates, and argues that the applicant has not provided evidence to justify a higher hourly rate or to equate a psychotherapist’s qualifications with those of a psychologist.

44The dispute, therefore, concerns the reasonableness of extended session lengths, additional testing and planning, and the requested hourly rate.

45I accept that psychological treatment is reasonable and necessary given the applicant’s documented psychological impairments and worsening symptoms. However, the evidence does not justify 1.5-hour sessions or additional testing and planning beyond what was completed in the initial assessment. The respondent’s approval of 12 one-hour sessions and a progress report aligns with standard practice. The applicant has not provided persuasive evidence to support a higher hourly rate or extended session duration, as the treatment goals can be adequately addressed within standard one-hour sessions, and no clinical rationale or supporting documentation was offered to demonstrate that longer sessions or additional testing would improve outcomes. Accordingly, the outstanding balance of $2,443.68 is not reasonable and necessary.

46Accordingly, on a balance of probabilities, I find that the remaining balance of the psychological treatment plan is not reasonable and necessary.

Other Assistive Devices

47I find that the applicant is not entitled to funding for the proposed assistive device plan.

48The issue is whether the assistive device plan dated December 20, 2023, in the amount of $169.99, is reasonable and necessary.

49The plan was submitted by Mackenzie Medical Rehabilitation Centre and denied on January 9, 2024. It proposes the purchase of a specialized pillow intended to reduce pain, improve strength and range of motion, and facilitate a return to modified work and normal activities.

50The applicant submits that the pillow is reasonable and necessary given his persistent neck pain, as documented in clinical notes and Dr. Joseph Kwok’s orthopaedic assessment dated February 8, 2024. He argues that the device would help alleviate symptoms and improve comfort during recovery.

51The respondent argues that the plan lacks sufficient justification for the proposed pillow's necessity and cost. It notes that similar products, such as the Mediflow water pillow, are available online for under $100. The respondent relies on the s. 44 physiatry paper review by Dr. Marchie (January 31, 2024), which concluded the pillow would not provide prolonged symptom relief for musculoskeletal issues and therefore is not reasonable or necessary. The respondent emphasizes that the applicant bears the onus of establishing reasonableness and necessity, which has not been met.

52While I accept that the applicant experiences ongoing neck pain, the evidence does not demonstrate that the proposed pillow would provide meaningful or sustained functional improvement beyond what could be achieved with standard, less costly alternatives. The plan does not include a clinical rationale explaining why this specific device is required or superior to commonly available pillows. Dr. Marchie’s opinion that the device would not materially impact recovery is persuasive. The applicant has not discharged the burden of proof under the Schedule.

53Accordingly, on a balance of probabilities, I find that the assistive device plan dated December 20, 2023, in the amount of $169.99, is not reasonable and necessary.

Orthopaedic Assessment

54I find that the applicant is not entitled to the plan for orthopaedic assessment.

55The issue is whether the orthopaedic assessment plan dated December 19, 2023, in the amount of $2,486.00, is reasonable and necessary.

56The plan, signed by Dr. Joseph Kwok, proposes an assessment to evaluate the applicant’s current condition and includes a comprehensive physical examination and documentation of findings.

57The applicant submits that the assessment is reasonable and necessary given his numerous ongoing complaints, including headaches, dizziness, TMJ pain, neck and back pain, sleep disturbance, right-sided upper and lower limb pain, numbness in the right hand and foot, poor balance, and psychological symptoms such as depression and anxiety. He argues that an orthopaedic assessment would assist in clarifying the nature and extent of these impairments.

58The respondent relies on section 47 of the Schedule and submits that the applicant’s impairments are orthopaedic in nature and that he has already been referred to orthopaedic surgeons through OHIP for surgical intervention. It points to evidence that Dr. Cheng assessed the applicant in November 2023 and recommended a total shoulder replacement for longstanding arthritis. The respondent argues that the disputed OCF-18 duplicates services reasonably available through OHIP and is therefore not payable under section 47. Dr. Marchie’s report dated January 31, 2024, also notes that the applicant confirmed he was scheduled to see Dr. Cheng, making the proposed assessment redundant.

59I accept that the applicant has significant orthopaedic issues; however, section 47 applies once the insurer establishes that the benefit at issue was reasonably available under another plan. The respondent has met that initial onus by showing that the applicant was assessed by Dr. Cheng and scheduled for further consultation through OHIP. The burden, therefore, shifts to the applicant to prove that the proposed assessment was not reasonably available or offered additional value beyond what OHIP provides. The applicant has not discharged this burden. He has not explained why Dr. Kwok’s assessment would provide materially different or necessary information beyond the OHIP referral and surgical planning already in place. On this basis, the plan is duplicative and not reasonable or necessary.

60Accordingly, on a balance of probabilities, I find that the orthopaedic assessment plan dated December 19, 2023, in the amount of $2,486.00, is not reasonable and necessary.

Attendant Care Assessment

61I find that the applicant is not entitled to the attendant care assessment plan.

62The issue is whether the attendant care assessment plan dated April 3, 2024, in the amount of $2,195.00, is reasonable and necessary.

63The plan, signed by occupational therapist Jain Ashok, proposes an assessment of attendant care needs, completion of a new Form 1, and evaluation for assistive devices. It includes multiple assessments, documentation, preparation services, provider travel time, and an attendant care benefit determination.

64The applicant submits that the assessment is reasonable and necessary to update the previous Form 1 completed on November 16, 2023, to reflect his current needs.

65The respondent argues that the proposed assessment is unnecessary and duplicative, noting that an attendant care assessment was completed only four months earlier, in November 2023. It submits that the applicant has not provided evidence of any material change in condition or clinical justification to warrant a new assessment within such a short timeframe.

66I accept that attendant care assessments may be appropriate where there is evidence of a significant change in functional status. However, the applicant has not demonstrated any such change since the prior assessment conducted only four months earlier, in November 2023. This relatively short interval indicates that the proposed plan largely duplicates existing services and lacks clinical justification for reassessment at this time.

67Accordingly, on a balance of probabilities, I find that the attendant care assessment plan dated April 3, 2024, in the amount of $2,195.00, is not reasonable and necessary.

Vocational Assessment

68I find that the vocational assessment plan is no longer in dispute.

69The issue is whether the vocational assessment plan dated June 25, 2024, in the amount of $2,200.00 is disputed.

70The plan, signed by Shireen Sundrani, physiotherapist, proposes an assessment to address pain reduction, increased range of motion, and return to activities of normal living, with documentation and a full-body examination.

71The applicant submits that the plan is reasonable and necessary to improve his condition and explore alternative vocational options, noting he has not worked since the accident and spends most of his time resting at home.

72The respondent states that the vocational assessment plan dated June 25, 2024, was approved on July 17, 2024, and therefore is not a matter in dispute.

73As the respondent has confirmed approval of the vocational assessment plan, I find there is no dispute for determination.

74Accordingly, on a balance of probabilities, I find that the vocational assessment plan dated June 25, 2024, in the amount of $2,200.00, has already been approved and is not in issue.

Invoices (OCF-21s)

75I find that the invoices are payable only to the extent they represent a balance owing after Manulife or other collateral benefits have responded.

76The issue is whether the disputed invoices for physiotherapy and psychological services are payable, given section 47(2) of the Schedule.

Physiotherapy Services

77I find that the applicant has not met the burden of proving that the disputed physiotherapy invoices were not reasonably available under his Manulife plan

78The applicant seeks payment for multiple OCF-21s for physiotherapy services, including invoices dated November 16, 2023 ($710.00), November 30, 2023 ($624.92), January 2, 2024 ($424.92), March 1, 2024 ($1,068.28), April 1, 2024 ($283.28 and $314.02), and July 7, 2024 ($283.28).

79The applicant submits that these invoices represent reasonable and necessary treatment for ongoing pain and functional deficits, as supported by his treating providers. He argues that the respondent should pay these invoices, subject only to reductions for amounts already paid by Manulife.

80The respondent relies on s. 47(2) of the Schedule and submits that the applicant has extended health coverage with Manulife for physiotherapy, chiropractic, and massage therapy. It points to evidence that at least one invoice (January 2, 2024) was partially paid by Manulife, with the balance paid by the respondent, and argues that the applicant has not shown that the remaining invoices were submitted to Manulife or denied.

81I accept that s. 47(2) applies in these circumstances. Once the insurer puts s. 47(2) “in play” by advancing evidence or submissions that, on balance, establish the collateral benefit was reasonably available, the burden shifts to the insured to prove that the benefit at issue was not, in fact, reasonably available from the collateral provider.

82The respondent has met its initial onus under s. 47(2) by showing the existence of Manulife coverage for physiotherapy and pointing to a prior payment by Manulife on the January 2, 2024, invoice. That evidence is sufficient to establish, on balance, that physiotherapy benefits were reasonably available under the Manulife plan.

83The burden therefore shifts to the applicant to prove that the disputed invoices were not reasonably available under Manulife (e.g., by filing the Manulife benefits booklet, confirmation of coverage limits/exclusions, proof of submission and denial, or exhaustion of benefits). The applicant has not provided such evidence regarding the disputed invoices.

84In the absence of evidence that the collateral benefits were not reasonably available, I find that, while the underlying physiotherapy may be reasonable and necessary to the extent found earlier in this decision, s. 47(2) requires Manulife to respond first. The respondent is liable only for any remaining balances after Manulife (or other collateral benefits) and only within the monetary limits set forth above.

85Accordingly, on a balance of probabilities, I find that the applicant has not met the burden of proving that the disputed physiotherapy invoices were not reasonably available under his Manulife plan. As a result, the respondent is only responsible for any remaining balances after Manulife or other collateral benefits have responded, and only within the approved monetary limits.

Psychological Services

86I find that the applicant has not proven that the April 4, 2024, psychological invoice was not reasonably available under his Manulife plan.

87The applicant seeks payment of $291.43 for an OCF‑21 dated April 4, 2024, for psychological services recommended following an assessment on January 26, 2024. The assessment diagnosed depression, anxiety, and PTSD, and recommended treatment.

88The respondent submits that the applicant has not provided his Manulife benefits booklet; however, the benefits statement on file confirms coverage for chiropractic, massage therapy, and physiotherapy and indicates that psychological treatment may also be covered. The respondent argues that collateral benefits through Manulife are reasonably available and that, under section 47(2), the applicant must establish that the disputed invoice is not payable under Manulife before the respondent is required to pay. The applicant has not discharged this burden.

89I accept that psychological treatment is reasonable and necessary in light of the applicant’s documented impairments. However, section 47(2) applies equally to psychological services. The applicant has not provided evidence that the disputed invoice was submitted to Manulife or that it was denied. Without such evidence, I cannot find that the expense is not otherwise payable under the other plan.

90Accordingly, on a balance of probabilities, I find that the applicant has not proven that the April 4, 2024, psychological invoice was not reasonably available under his Manulife plan. The respondent is therefore liable only for any remaining balance after Manulife or other collateral benefits have responded, and only within the approved monetary limits.

Is the applicant entitled to an Attendant Care Benefit?

91I find that the applicant is entitled to attendant care benefits in the amount of $1,372.21 per month from November 16, 2023, to November 7, 2024, and $1,297.46 per month from November 8, 2024, on an ongoing basis.

92Section 19 of the Schedule states that an insurer shall pay for all reasonable and necessary expenses incurred by or on behalf of an insured person as a result of an accident for attendant care services (ACBs) provided by an aide or attendant. Section 42(1) of the Schedule provides that an application for ACBs must be in the form of, and contain the information required to be provided in, the version of the document entitled Assessment of Attendant Care Needs (“Form-1”).

93The applicant relies on two in-home occupational therapy assessments by Mr. Ashok Jain, dated November 16, 2023, and November 8, 2024. The first assessment calculates attendant care needs at $1,372.21 per month. The second assessment calculates attendant care needs at $1,297.46 per month. The applicant submits that Mr. Jain is highly experienced and that his most recent assessment best reflects the applicant’s fluctuating needs.

94The applicant argues that he continues to experience significant limitations in self-care, household management, and community access due to pain, balance difficulties, dizziness, and psychological symptoms. He submits that a higher level of attendant care is required to assist with bathing, dressing, meal preparation, housekeeping, transportation, and supervision.

95The respondent relies on the occupational therapy insurer examination (IE) by Emily O’Callaghan, referenced in its March 12, 2024, letter, which determined that the applicant required attendant care at a rate of $260.74 per month. It submits that this level of care reflects the applicant’s needs, which are limited to heavier housekeeping and some supervision, rather than personal care at Levels 2 or 3 under the Form 1.

96The respondent emphasizes that hospital records show no acute neurological injury, that the applicant had significant pre-existing right shoulder degenerative disease, and that he was able to undertake a lengthy road trip the day after the accident. It argues that the applicant remains independent mainly in self-care and that the higher recommendations are inconsistent with his demonstrated functioning.

97The evidence indicates that the dispute concerns not entitlement to attendant care benefits, but instead whether the claimed amounts are reasonable and necessary. The insurer acknowledges entitlement at $260.74 per month based on its IE. The issue is whether the applicant has established that his needs justify the substantially higher amounts recommended by Mr. Jain.

98I accept that attendant care needs can fluctuate over time.

99However, I must weigh the recommendations against the broader medical record, including hospital notes, family physician records, and physiatry IE reports. The hospital records show no acute neurological injury. Imaging demonstrates severe pre-existing osteoarthritis in the right shoulder, which reasonably accounts for some limitations in overhead activities and heavy lifting, irrespective of the accident.

100Surveillance and clinical records relied upon by the respondent indicate that the applicant remains independent mainly in basic activities of daily living, albeit at a slower pace and with increased pain. He continues to mobilize in the community, drive, and attend medical appointments.

101The applicant submitted two Form 1 assessments: one for $1,372.21 (November 16, 2023) and the other for $1,297.46 (November 8, 2024).

102The November 16, 2023, Form 1 indicated Level 1 (dressing, grooming, feeding) for 845 minutes per week; Level 2 (hygiene and coordination of attendant care) for 310 minutes per week; and Level 3 (bathing) for 105 minutes per week.

103The November 8, 2024, Form 1 indicated Level 1 for 775 minutes per week, Level 2 for 310 minutes per week, and Level 3 for 105 minutes per week.

104The respondent’s OT recommended Level 1 (dressing and grooming) for 145 minutes per week and Level 3 (bathing) for 70 minutes per week. She did not recommend Level 2, noting that the applicant demonstrates the functional ability to perform light cleaning tasks and can seek assistance from his wife as needed.

105The physiatry assessment by Dr. Marchie, dated January 31, 2024, noted that the applicant used a cane in his right hand and demonstrated an antalgic gait secondary to right-leg pain. Neck and lumbar movements increased discomfort, and he was unable to flex his right knee due to pain. There was pain in his right hip with any flexion movements.

106I prefer Mr. Jain’s assessments because they include two in-home evaluations over a year and align more closely with the medical evidence, including Dr. Marchie’s findings of gait disturbance, pain, and mobility limitations. These support ongoing needs for assistance with daily activities. Jain’s analysis accounts for fluctuating function, consistent with records of persistent pain and mobility issues. Conversely, the insurer’s IE by Ms. O’Callaghan minimizes care needs, overlooking gait, cane use, and pain’s impact on daily tasks. It also fails to justify excluding Level 2 needs given documented assistance and overstresses isolated independence observations, neglecting safety, speed, and endurance issues. Therefore, Jain’s comprehensive, long-term assessments are more reliable for determining the applicant’s care needs.

107Accordingly, I find that attendant care benefits are payable at $1,372.21 per month from November 16, 2023, to November 7, 2024, and $1,297.46 per month from November 8, 2024, on an ongoing basis.

Interest

108Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. I find that interest is payable on any overdue payment.

Award

109The applicant seeks an award under section 10 of Regulation 664. Under section 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. The Tribunal has determined that an award is justified where the delay or withholding of benefits by the insurer is unreasonable conduct, meaning “behaviour which is excessive, imprudent, stubborn, inflexible, unyielding or immoderate.” [ See, for e.g., 17-006757 v. Aviva Insurance Canada, 2018 CanLII 81949 (ON LAT); and S.M. v. Unica Insurance Inc., 2020 CanLII 61460 (ON LAT Reconsideration]. The onus is on the applicant to prove, on a balance of probabilities, that the respondent’s conduct meets this threshold.

110The applicant submits that the respondent unreasonably withheld or delayed payment of benefits, particularly in relation to attendant care, concussion treatment, chronic pain assessment, and physiotherapy. He relies on the volume of medical evidence supporting his ongoing impairments and argues that the insurer’s reliance on independent examinations (IEs) and collateral benefits is unduly restrictive. In reply, he cites Personal Insurance Company v. Hoang, 2014 ONSC 81 and submits that the impact of the insurer’s conduct on his life and recovery should be considered.

111The respondent submits that an award is only warranted where an insurer has acted unreasonably in withholding or delaying payment. It relies on LAT decisions such as 17-006927 v. Co-Operators General Insurance Company, 2018 CanLII 83537 (ONLAT) and 16-002346 v. Unifund Assurance Company, 2017 CanLII 81583 (ONLAT), which hold that a mere difference of opinion among qualified assessors does not justify a special award.

112The respondent argues that it adjusted the claim fairly and in a timely manner, relying on multiple IEs, approving some benefits, partially approving others, and paying certain OCF-21s after Manulife’s contribution. It acknowledges that any errors—such as a delay in approving the OT attendant care assessment after the applicant was removed from the MIG—were corrected.

113In this case, although I have found that some additional benefits are payable, the insurer obtained multiple IEs, partially approved treatment and attendant care, and paid portions of physiotherapy invoices in conjunction with Manulife. The evidence does not support a finding that the insurer acted in bad faith, in a high-handed or oppressive manner, or that it ignored compelling evidence of entitlement. Instead, this is a case of genuine disagreement among qualified assessors about diagnosis, causation, and the appropriate extent of treatment and attendant care.

114While I accept that the applicant has experienced hardship and disagrees with the insurer’s position, I am not persuaded that the respondent’s conduct rises to the level of being unreasonable within the meaning of section 10. An award is therefore not warranted.

ORDER

115For the above reasons, it is ordered that:

i. The applicant is entitled to an attendant care benefit of $1,372.21 per month from November 16, 2023, to November 7, 2024, and $1,297.46 per month from November 8, 2024, on an ongoing basis.

ii. The applicant is entitled to the concussion assessment plan for $2,486.00 and the chronic pain assessment for $2,486.00.

iii. The applicant is entitled to the OCF-21s only to the extent they represent a balance owing after Manulife or other collateral benefits have responded.

iv. The applicant is entitled to interest on any overdue payment of benefits.

v. The applicant is not entitled to the outstanding amounts or to the remaining physiotherapy plans.

vi. The applicant is not entitled to the plan for chiropractic services in the amount of $5,841.28, the outstanding balance for psychological services of $2,443.68, the plan for other assistive devices of $169.99, the orthopaedic assessment of $2,486.00, and the attendant care assessment of $2,195.00.

vii. The applicant is not entitled to an award.

Released: January 26, 2026

Harouna Saley Sidibé

Adjudicator