An Ontario tribunal handed Aviva a partial win, denying disputed chiropractic and psychological benefits while ordering the insurer to fund a chronic pain assessment.
The dispute stemmed from an April 28, 2023 automobile accident, after which the claimant sought statutory accident benefits and was denied by his insurer. He brought the matter to Ontario's Licence Appeal Tribunal, challenging denials tied to chiropractic treatment, a psychological treatment plan and a chronic pain assessment.
At the centre of the ruling were three chiropractic treatment plans - calling for a combined 30 sessions - submitted between March and July 2024, worth $3,450.45, $2,993.11 and $2,599.21. The claimant argued the treatments were reasonable and necessary because they provided pain relief, relying on his family physician's clinical notes and records from the treating rehabilitation facility.
The adjudicator was not persuaded. He found no contemporaneous, corroborating medical evidence that the claimant was receiving any benefit - even temporary pain relief - from the facility-based treatments in dispute. The family physician's post-accident recommendation had been for physiotherapy and massage, not chiropractic care. A later note referencing chiropractic services, written roughly 18 months after the accident, drew little weight because it came four months after the last treatment plan was submitted.
The insurer relied on a general practitioner assessment concluding the claimant had reached maximal medical recovery, with no objective evidence of ongoing musculoskeletal impairment warranting further intervention. Given the time elapsed since the accident, the adjudicator found that opinion persuasive and ruled the chiropractic plans were not reasonable and necessary.
The claimant also fell short on the psychological treatment plan. The insurer had approved all requested treatments, leaving only administrative reports, planning and documentation items in dispute. Because the claimant's submissions did not address a progress report or documentation fees, the adjudicator found he had not met his onus on the remaining balance.
The insurer did not win outright. The adjudicator ordered it to fund a $2,291.08 chronic pain assessment, applying a lower evidentiary threshold than the one for treatment. For an assessment, an insured need only show grounds to believe a condition exists that warrants further investigation. Here, the claimant's family physician and a psychologist had both recorded recurring back pain and headaches.
Notably, the same general practitioner assessment that helped defeat the chiropractic claims carried little weight on the assessment question. The adjudicator found the assessor silent on why the claimant was still reporting pain, merely observing that it "should have resolved."
The decision is a reminder for claims professionals of how the evidentiary bar shifts between treatment plans and assessments. Interest was ordered on the chronic pain assessment under the Schedule. The application was granted in part, in a decision released July 14, 2026.
