An Ontario driver's chronic pain claim collapsed after she never touched treatment her own insurer had already approved.
Ontario's Licence Appeal Tribunal has dismissed an application against Primmum Insurance Company over three disputed treatment plans stemming from a January 24, 2024 car accident, finding the applicant failed to prove the treatments were reasonable and necessary.
The applicant sought statutory accident benefits after the crash, reporting persistent neck, back and right lower-extremity pain that she said had developed into a chronic condition, along with a psychological impairment. Primmum removed her from Ontario's Minor Injury Guideline by a letter dated July 28, 2025, based on the psychological impairment, and approved previously denied plans for a psychological assessment and psychological services. It maintained, however, that her physical injuries remained minor, and disputed a chiropractic plan from Downsview Healthcare Inc. dated April 29, 2024, a physiotherapy plan from Ajax Rehabilitation Centre worth $1,737.25 after a partial approval of $1,201.15 on a $2,938.40 plan dated April 15, 2024, and a $2,540.00 chronic pain assessment from Oshawa Physiotherapy and Rehabilitation Centre dated February 4, 2025.
The tribunal sided with the insurer on all three. Adjudicator Melanie Malach found the applicant's submissions were too general, failing to address how each specific treatment would aid her recovery. She also flagged gaps in the medical record: the family doctor notes the applicant relied on predated the accident, and an emergency department record from the day after the crash noted only right shin pain, with no documented neck or back pain.
Primmum also raised the applicant's own treatment record. Its benefit statements showed no charges submitted for the OCF-23 treatment it had approved or for the partially approved physiotherapy plan, and Malach found no evidence a further physiotherapy and massage therapy plan, approved in November 2025, had been used either. Primmum pointed out that between April 5, 2024 and April 9, 2025, the applicant attended only 21 treatment sessions, with what it called substantial gaps between visits.
Malach agreed with the insurer, citing the tribunal's earlier decision in Baheeran v. Security National Insurance Company, and found the pattern amounted to "compelling evidence that treatment is not medically needed."
The tribunal also weighed competing medical opinions. It found the applicant's treating orthopaedic surgeon relied heavily on her self-reported symptoms without objective testing, while the insurer's examining orthopaedic surgeon conducted a more rigorous and comprehensive assessment, concluding the applicant had reached maximum medical recovery with no residual impairment tied to the accident. Malach gave more weight to the insurer's report.
The application was dismissed in full. The decision was released August 5, 2026.
