An Ontario auto insurer beat a $5,108 physiotherapy claim after a tribunal found the claimant's recovery had already plateaued despite extensive prior treatment.
The applicant was injured in an automobile accident on October 13, 2022, and sought statutory accident benefits from Onlia Insurance Company. After the insurer denied a treatment plan, the applicant took the dispute to Ontario's Licence Appeal Tribunal, which dismissed the case in a decision released July 31, 2026, finding the disputed treatment had not been shown to be reasonable and necessary.
At issue was an OCF-18 treatment plan dated March 16, 2023, seeking $5,108 for physiotherapy services, including sessions of physical rehabilitation, multiple-body-site therapy, and a percussion massager, aimed at reducing pain, improving range of motion and strength, and returning the claimant to daily activities and pre-accident work. Onlia denied the plan on March 30, 2023.
Onlia argued the treatment was neither reasonable nor necessary, pointing out that the claimant had already undergone approximately 41 physiotherapy sessions before the disputed plan was submitted without demonstrating measurable progress. Clinical records showed little change in symptoms after February 2023, and the claimant's family doctor's notes recorded ongoing pain despite treatment, recommending conservative management instead.
An insurer-appointed physician who examined the claimant in November 2024 found he had reached maximum medical recovery and was "unlikely to achieve meaningful improvement with additional facility-based treatment." That opinion carried weight with the Tribunal because it directly addressed the claimant's treatment history and lined up with the contemporaneous clinical records.
The claimant also raised hip pain as grounds for further treatment, but the Tribunal was not satisfied this was related to the accident. The symptoms did not surface until more than a year later, during a work-related activity, and the specialist reports recommending physiotherapy for the hip were written many months after the disputed plan was submitted, without addressing whether that plan was reasonable at the time.
Weight also went to the family doctor's January 19, 2023 note that the claimant's physiotherapy and chiropractic care had not produced meaningful gains. Nothing in the treatment records or later medical reports showed progress toward the plan's stated goals, or gave reason to expect a further course of similar treatment would succeed where extensive prior therapy had not. Pre-existing conditions and chronic pain, the Tribunal added, do not on their own entitle a claimant to more treatment.
The application was dismissed in full. With no benefits found payable, no interest was owed either.
The decision turns on a narrow but recurring question for claims files: once substantial treatment has already been funded, what evidence is needed to justify more? Here, the Tribunal found none - no measurable gains, and no clinical explanation for why further sessions would produce a different result.
