An Ontario tribunal dismissed a catastrophically impaired claimant's bid for further physiotherapy and psychological treatment, citing outdated medical evidence.
The Licence Appeal Tribunal ruled on July 22, 2026, that a pedestrian injured in a 2019 crosswalk collision failed to prove that two proposed treatment plans - totaling $5,925.76 - were reasonable and necessary under Ontario's Statutory Accident Benefits Schedule.
The claimant sustained a compound fracture of the left distal tibia and fibula, among other injuries, when struck by a vehicle on May 17, 2019. Wawanesa Mutual Insurance Company determined the claimant had sustained a catastrophic impairment on November 2, 2021.
Despite that determination, Wawanesa denied an August 2, 2024, treatment plan requesting $3,532.88 for physiotherapy services and another dated August 20, 2024, seeking $2,392.88 for psychological services. The claimant applied to the Tribunal for resolution.
On the physiotherapy claim, the Tribunal found the claimant relied primarily on an orthopaedic surgeon's January 24, 2020, report and a physiatrist's May 19, 2022, report to support a treatment plan submitted more than four and two years later, respectively. The adjudicator found the orthopaedic report was "of limited value" in assessing whether the treatment proposed in August 2024 was reasonable and necessary.
Wawanesa had already approved 457 sessions of physiotherapy. The claimant had been attending treatment at two facilities two to three times a week. Treatment records showed varied levels of pain relief, with entries from June to August 2024 reporting ongoing chronic pain without reference to improvement. In a September 18, 2024, note, the claimant reported being "very tired of being in pain."
The insurer's section 44 orthopaedic assessment, dated January 20, 2023, found the claimant had reached maximum medical recovery and that further facility-based treatment was not reasonable and necessary.
On the psychological services claim, the Tribunal similarly found the claimant had not met the evidentiary burden. Although diagnosed with somatic symptom disorder with predominant pain and major depressive disorder in 2020 and 2021, the treatment plan was not submitted until August 2024. Wawanesa had already approved 52 counselling sessions from April 2022 to April 2024, but treatment records did not demonstrate improvement in psychological functioning. Therapy notes repeatedly referenced the same concerns - "Pain, mood, memory and lack of sleep" - without discussion of whether progress had been made.
The adjudicator noted that the treatment plan's response to the question of what improvement the claimant had shown was "Not applicable" - despite the claimant having attended counselling for over two years.
The Tribunal dismissed the application. The decision turned on the evidentiary standard under sections 15 and 16 of the Schedule, which places the onus on claimants to demonstrate not only their impairments but also that treatment goals are being met to a reasonable degree and that the overall costs are reasonable.
