Citation: Lynes v. Wawanesa Mutual Insurance Company 2026 ONLAT 24-006934/AABS

Licence Appeal Tribunal File Number: 24-006934/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:

Clint Lynes

Applicant

and

Wawanesa Mutual Insurance Company

Respondent

DECISION

ADJUDICATOR: Amanda Marshall

APPEARANCES:

For the Applicant: Ognjen Miketic, Counsel

For the Respondent: Louise A. Kanary, Counsel

HEARD: By way of written submissions

OVERVIEW

1Clint Lynes, the applicant, was involved in an automobile accident on October 19, 2021, 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.

2A reconsideration decision dated January 5, 2026, ordered that the decision of October 14, 2025, be canceled and the application reheard by a different adjudicator.

ISSUES

3The issues in dispute are:

i. Is the applicant entitled to $2,460.00 for a neurological assessment, proposed by Total Wellness Clinic in a treatment plan dated January 28, 2023?

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

4The applicant is not entitled to the neurological assessment, interest or an award.

PROCEDURAL ISSUE

5I find the applicant is permitted to rely on the clinical notes and records (“CNRs”) from Total Wellness Clinic.

6In its submissions, the respondent contends that the applicant should not be allowed to rely on the CNRs from Total Wellness Clinic as the file records were to be delivered within 30 days of the case conference. The respondent submits it was not provided with the CNRs until June 11, 2025, along with the document brief.

7The applicant was provided an opportunity to reply to the respondent’s submissions but did not provide a response.

8Although the applicant did not comply with the document production deadlines, I am satisfied that the respondent received the CNRs and had sufficient time to review them before making its submissions. Accordingly, the applicant is permitted to rely on the CNRs from the Total Wellness Clinic.

ANALYSIS

Is the applicant entitled to the neurological assessment?

9I find the applicant is not entitled to the neurological assessment.

10To 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.

11The purpose of an assessment is to determine whether a condition exists. An insured bears the onus of demonstrating that there are reasonable grounds to believe a condition exists that warrants further investigation.

12The treatment plan proposing the neurological assessment was prepared by Dr. Roya Salehoun, chiropractor. The goals of the plan are to determine if there is an accident-related neurological impairment and to provide recommendations for recovery, if applicable.

13The applicant submits that the neurological assessment was submitted by a regulated health professional as part of the applicant’s ongoing treatment and is necessary in order to understand the extent of his injuries. He relies on the Disability Certificate (“OCF-3”), the clinical notes and records (“CNRs”) from Total Wellness Clinic, as well as the treatment plan itself.

14The respondent argues that neither the applicant’s injuries listed in the treatment plan nor the stated goals for the assessment support a neurological assessment. The respondent relies on the CNRs of the applicant’s family doctor, and the s. 25 independent assessment of Dr. Joseph Kwok, orthopaedic surgeon.

15The evidence shows that the applicant had a telephone appointment with his family doctor, Dr. Kelsi Cole, on October 27, 2021, during which he reported being in an accident. He stated he has pain in his neck, shoulders, low back and arms. The wellness clinic he is attending advised he get x-rays done. He denied any numbness or tingling in his arms.

16At a follow-up appointment on November 2, 2021, Dr. Cole advised that the results of the x-rays show that the applicant has multilevel degenerative disc disease which are in keeping with previous x-ray results he had prior to the accident. There are no other appointments with his family doctor pertaining to the accident.

17It appears that Total Wellness Clinic arranged for the applicant to undergo an MRI in August 2022. The findings are consistent with the October 2021 x-rays, which identified degenerative changes. While the MRI provided greater details, the results remain degenerative in nature.

18An independent section 25 orthopedic assessment by Dr. Kwok, an orthopedic surgeon, was completed on November 16, 2022. The report indicates that the applicant did not report symptoms of numbness, tingling, or radicular pain. Dr. Kwok recommended a neurological assessment to investigate occasional headaches; however, this was the first documented mention of headaches. Headaches were not listed as an accident-related injury on the OCF-3, nor were they reported to the applicant’s family physician.

19In summary, I find that the applicant has not met his burden of proving, on a balance of probabilities, that a neurological assessment is warranted. Dr. Kwok suggested the assessment to investigate occasional headaches; however, this was the first documented mention of headaches. Headaches were neither reported to the family physician nor listed as an accident-related injury on the OCF-3. The applicant also did not report numbness or tingling to his doctor, Total Wellness Clinic, or Dr. Kwok. Diagnostic imaging results indicate degenerative changes that are not related to the accident.

Interest

20Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since I have determined that no benefits are overdue, the applicant is not entitled to interest.

Award

21The 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. Since the neurological assessment was not found to be payable, I find that the insurer did not unreasonably delay or withhold payment, therefore, the applicant is not entitled to an award.

ORDER

22For the reasons above, I find that:

i. The applicant is not entitled to the neurological assessment, interest or an award.