[Applicant] v. Allstate Insurance Company of Canada, 2018 CanLII 8084

Date: 2018-01-26

Tribunal File Number: 17-001523/AABS

Case Name: 17-001523/AABS v Allstate Insurance Company of Canada

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:

[Applicant]

Applicant

and

Allstate Insurance Company of Canada

Respondent

DECISION

ADJUDICATOR: Billeh Hamud

APPEARANCES:

For the Applicant: Philip Kai Kwong Yeung, paralegal

For the Respondent: Richard Horst, counsel

Heard in writing: July 19, 2017

BACKGROUND:

1. The applicant was injured in an automobile accident on February 28, 2016 and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010¹ (the ''Schedule'').

2. The applicant claimed benefits for attendant care services and several treatment and assessment plans. The respondent partially approved most of the applicant’s benefits and denied others.

3. The applicant submitted an application for dispute resolution services to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”).

ISSUES TO BE DETERMINED:

4. The following are issues to be determined:

a. Is the applicant entitled to receive a medical benefit for services recommended by Perfect Physio & Rehab Centre for the following:

i. $772.00 for assistive devices, as detailed in a treatment plan dated March 29, 2016, denied by the respondent on April 25, 2016?

ii. $5,717.04 for chiropractic services, as detailed in a treatment plan dated May 11, 2016, denied by the respondent on June 6, 2016?

iii. $2,030.43 for assistive devices, as detailed in a treatment plan dated June 4, 2016, denied by the respondent on June 24, 2016?

iv. $3,817.72 for audiometric/speech language services, as detailed in a treatment plan dated July 13, 2016, denied by the respondent on August 4, 2016?

v. $3,239.08 for chiropractic services, as detailed in a treatment plan dated October 5, 2016, denied by the respondent on November 16, 2016?

b. Is the applicant entitled to attendant care benefits in the amount of $3,000.00 per month for the period March 9, 2016 to May 30, 2017, submitted on April 26, 2016, denied by the respondent on May 2, 2016?

c. Is the applicant entitled to receive a medical benefit for services recommended by Perfect Choice Psychological Services Inc. for the following:

i. $3,253.04 for psychological services, as detailed in a treatment plan dated December 27, 2016, denied by the respondent on February 10, 2017?

ii. $3,253.04 for psychological services, as detailed in a treatment plan dated August 29, 2016, denied by the respondent on October 17, 2016?

d. Is the applicant entitled to payment for prescriptions and parking in the amount of $113.12 submitted on March 15, 2016, denied by the respondent on April 18, 2016?

e. Is the applicant entitled to an allowance for expenses, in the amount of $418.08 for gas and parking, which were incurred by the applicant’s husband in visiting the applicant during her treatment or recovery submitted on April 8, 2016 and denied by the respondent on May 2, 2016?

f. Is the applicant entitled to interest for the overdue payment of benefits?

RESULT:

5. I find on all of the evidence that the applicant is entitled to outstanding attendant care benefits in the amount of $297.00 in total.

6. I find that the applicant is entitled to a medical benefit in the outstanding amount of $200.00 for a treatment and assessment plan dated March 29, 2016.

7. I find that the applicant is entitled to a medical benefit in the outstanding amount of $360.00 for a treatment and assessment plan dated August 29, 2016.

8. I find the applicant is entitled to interest on the outstanding amounts noted above in accordance with the Schedule.

ANALYSIS

1) Is the applicant entitled to receive Attendant Care benefits?

9. An applicant is entitled to reasonable and necessary expenses incurred as a result of the accident for services provided by an aide or attendant or by a long term care facility (s. 19(1))(a) of the Schedule). A prerequisite to entitlement is that the expense is “incurred”.

Background

10. On April 26, 2016, the applicant submitted an Attendant Care Assessment Form 1 completed by Raymond Wong, the applicant’s occupational therapist. The applicant submits that attendant care services were incurred by personal support workers employed through Perfect Physio. The applicant claimed that invoices were submitted to the respondent on a monthly basis. Mr. Wong assessed the applicant’s monthly attendant care benefit amount as $3,968.85.

11. The applicant also submits that the respondent did not respond within 10 days of receiving the Form 1 in accordance with s. 42(3) of the Schedule. The applicant claims the respondent responded on June 24, 2016 and also failed to specify which expenses “the insurer agrees to pay…refuses to pay” and failed to set out the “medical and any other reasons for the insurer’s decision”.

12. I disagree with the applicant that the respondent failed to comply with s. 42(3) of the Schedule. I find that the respondent responded to the applicant in the form of an explanation of benefits (“EOB”) on May 2, 2016 and within the 10 day time period noted in s.42(3) of the Schedule. Furthermore, the respondents’ EOB clearly explained that the maximum amount of attendant care benefits payable for non-catastrophic injuries is $3000.00 per month. The respondent further stated that it disagreed with the level of care reported on the Form 1 because Mr. Wong claimed that the applicant sustained a fractured lower jaw but the operative report from Scarborough Grace Hospital noted that the applicant did not sustain any facial fractures. The respondent also stated that there was no medical evidence to support Mr. Wong’s assessment that the applicant does not have the ability to respond in an emergency and that the applicant requires custodial care due to changes in their behaviour. The respondent also outlined s. 3(2)(7)(e) of the Schedule and requested proof that the attendant care services were incurred. Lastly, the respondent advised the applicant that it would require an insurer examination to determine if the level of care as reported was as a result of the accident.

13. I find the respondent’s reasons to be in accordance with s.42(3) of the Schedule since the insurer provided reasons, including medical reasons, why it disputed the Form 1 and also provided notice to the applicant in accordance with s. 42(4) of the Schedule that it would require the applicant to undergo a s.44 examination.

14. On October 3, 2016, the respondent sent an EOB to the applicant enclosing a report by Jenna Abraham, the respondent’s occupational therapist. Ms. Abraham found that the level of care claimed was excessive given the nature of the applicant’s injuries. However, she still determined that attendant care services were needed, albeit at a rate of $951.66 per month. The respondent stated that this rate would take effect as of October 10, 2016. The applicant did not contest this revised rate.

15. On April 3, 2017, Ms. Abraham performed an in-home assessment of the applicant. In her report, Ms. Abraham completed a Form 1 and opined that no further attendant care services were required. The report and EOB were sent to the applicant on June 21, 2017, advising that no attendant care payments would be made beyond June 27, 2017. The applicant does not dispute any attendant care benefits beyond June 27, 2017 and there are no invoices to support any care beyond June 27, 2017.

16. The respondent claims that the applicant failed to prove that PSWs were qualified to work and were working at the time of the accident. The respondent subsequently paid attendant care benefits once the applicant provided the required information, but denied payment for some PSWs that were not, according to the respondent, qualified to work as PSWs and working at the time of the accident.

17. The applicant submits that the respondent’s continued requests for information to show that the PSWs were employed at the time of the accident were unreasonable and thus had the effect of delaying payment of benefits to the applicant.

18. I note that the respondent paid the applicant $20,002.20 in outstanding attendant care benefits from March 9, 2016 to May 30, 2017. The parties do not dispute the amount of attendant care benefits paid to date with the exception of some denied payments in October 2016, April 2017 and May 2017 relating to the qualifications of PSWs. Specifically, the parties disagree on whether certain PSWs were qualified to provide attendant care services in accordance with the Schedule.

19. The issue I must determine is whether the PSWs in dispute are entitled to payment.

Qualifications of PSWs

20. I have determined that only one of the applicant’s PSWs were acting within the course of their employment, occupation or profession in which they would ordinarily have been engaged for remuneration but for the accident, when they provided attendant care services to the applicant. This was in accordance with s.19(3), (4) and s. 3(7)(e)(iii) of the Schedule.

21. I have reviewed the invoices submitted by Perfect Physio and Rehab Centre and it appears that invoices were submitted by the applicant from March 2016 to April 2017. I have also reviewed the qualifications of the PSWs who were referenced in the invoices and the respondent’s EOBs.

22. In their submissions, the respondent states that the information required to determine whether the PSWs were qualified to work and were working at the time of the accident in accordance with s.3(7)(e)(iii) of the Schedule was not provided until June 15, 2017. In reply, the applicant submits that s.3(7)(e) of the Schedule does not require a PSW to be employed as long as they are all certified and engaged in the industry prior to providing services to the applicant.

23. I agree with the applicant that s.3(7)(e) of the Schedule does not require a service provider to be employed at the time of the accident as long as they are normally engaged in the profession through occupation, training and/or professional certification.

24. Section 3(7)(e)(iii)(A) of the Schedule states:

“For the purposes of this Regulation, subject to subsection (8), an expense in respect of goods or services referred to in this Regulation is not incurred by an insured person unless,

(iii) the person who provided the goods or services,

(A) did so in the course of the employment, occupation or profession in which he or she would ordinarily have been engaged, but for the accident”

25. In its most recent EOB dated June 29, 2017, the respondent denied some benefits because it did not receive evidence that the following PSWs were employed as PSWs at the time of the accident: Run Lian Huang, Lu Zheng, Li Mei Yang and Liang Jin Liu.

26. I have reviewed the applicant’s evidence and I find that Run Lian Huang received a Personal Support Worker Certificate from the National Association of Career Colleges on November 30, 2015. I note that the applicant was injured in the accident on February 26, 2016. Therefore, I find Ms. Huang was a qualified PSW at the time of the accident.

27. Several decisions from this Tribunal have interpreted s. 3(7)(e)(iii) of the Schedule as not requiring a service provider to be employed at the time of the accident as long as they are normally engaged in the profession through occupation, training and/or professional certification.²

28. In 17-000848 v Echelon General Insurance Company, Adjudicator Go outlined the test as follows:

I accept the applicant’s submission that the fact that Ms. Salazar has also worked in non-PSW positions does not mean she was not providing care to the applicant in a capacity as a PSW. The Schedule does not provide that the care provider must be exclusively employed as a health professional for an insured person to obtain the maximum amount of benefits. Nor is the provision limited to a health professional who is engaged in the profession though employment alone. As pointed out by Adjudicator Truong in A.P., the phrase “ordinarily engaged in” is not restricted to employment, but also includes profession and occupation, which can be demonstrated through training and professional certification. Ms. Salazar has the qualifications of a PSW. The fact that she had not been working as a PSW immediately prior to the time in question should not disqualify her from providing such services to the applicant. (emphasis in original)

29. By contrast, I was provided with no evidence from the applicant to support the position that Lu Zheng, Li Mei Yang or Liang Jin Liu were PSWs or otherwise engaged in the profession through occupation, training and/or professional certification. Therefore, I uphold the respondent’s denial with respect to payment for these individuals for October 2016, April 2017 and May 2017, as noted in the respondent’s EOB dated June 29, 2017.

30. Therefore, I find the applicant is entitled to $297.00 for the denied payment for the services of Run Lian Huang.

2) Treatment Plans from Perfect Physiotherapy and Rehab Centre

(i) Treatment Plan dated March 29, 2016

31. The applicant submitted a treatment plan on March 29, 2016 from Raymond Wong, Occupational Therapist, at Perfect Physio and Rehab Centre. Mr. Wong recommended certain assistive devices on the OCF-18 form for a total amount of $772.00.

32. The respondent partially approved these assistive devices in the amount of $255.00. In addition, the respondent submits that the costs charged by Perfect Physio and Rehab Centre are excessive. Specifically, the respondent found another provider: AgTA Home Health Care, charging $65.00 per month for a wheelchair rental and $35.00 for a delivery fee. The respondent also agreed to pay $70.00 for the completion of the OCF-18 instead of $200.00 because an assessment was already completed.

33. In their submissions, the applicant did not dispute the lower amounts from AgTa Home Health Care but contests the respondent’s partial approval of $70.00 for the completion of the OCF-18. The applicant relies on the FSCO Professional Services Guideline Superintendent Guideline No. 03/14 (“the Guideline”) which states that:

“The $200 maximum fee referred to in this Guideline and in Superintendent’s Guideline No. 06/10 (July 2010 Professional Services Guideline) for a Treatment and Assessment Plan (OCF-18) applies only to the services of a health practitioner as referred to in subsection 25 (1) 3 of the SABS, namely reviewing and approving an OCF-18 under subsection 38 (3) (c), including any assessment or examination necessary for the purpose of that review and approval by the heath practitioner. The $200 maximum fee does not apply to assessments or examinations that are proposed in an OCF-18 and that an insurer agrees to pay for under subsection 38 (8) of the SABS.

As stipulated in section 25 (1) 3 of the SABS, the fee for the OCF-18 is payable only if any one or more of the goods, services, assessments or examinations described in the OCF-18 have been:

i. approved by the insurer;

ii. deemed by the SABS to be payable by the insurer; or

iii. determined to be payable by the insurer on the resolution of a dispute in accordance with sections 279 to 283 of the Insurance Act.”

34. The Superintendent of Financial Services has issued guidelines regarding the interpretation of the Schedule. According to s.268.3(2) of the Insurance Act,³ “a guideline shall be considered in any determination involving the interpretation of the Statutory Accident Benefits Schedule”.

35. I find the $200.00 amount claimed by the applicant to be reasonable and within the maximum amount allowed by the Guideline. I find the respondent’s argument that a lower amount should be allowed because “an assessment had already been done” to be unpersuasive. As noted by the applicant, there is nothing in the Guideline which bars payment for the completion of an OCF-18 as long as the health care practitioner is 1) reviewing and approving the OCF-18 and 2) the insurer approved one or more of the goods, services, assessments or examinations noted in the OCF-18. In this case, the applicant has satisfied both conditions since Mr. Wong reviewed and approved the OCF-18 in dispute and the respondent approved the assistive devices noted in the OCF-18, albeit for a lesser amount.

36. As a result, the applicant is entitled to the $200.00 for the completion of the OCF-18.

(ii) Treatment Plan dated May 11, 2016

37. In their initial submissions, the applicant did not provide any arguments with respect to this treatment plan. Nevertheless, the applicant sent a treatment plan dated May 11, 2016 to the respondent claiming various treatments and items in the amount of $5,717.04.

38. The respondent partially approved the treatment plan in the amount of $4,204.88. The respondent denied $56.41 for travel time because the treatment claimed was received at the clinic. The respondent also denied $576.80 for transportation since the applicant did not comply with s. 3(1) of the Schedule which requires a roundtrip to the clinic to be greater than 50 kilometres to be compensable. The respondent maintains that the actual distance is less than 15 kilometres. The respondent also denied $300.00 for eyeglasses since there was no explanation given why they were required. A cervical collar was denied because it was allegedly already provided to the applicant. A hand massager was approved at $99.13 instead of $250.00 since a lower amount was available at AgTa Home Health Care.

39. The applicant’s reply, for the first time, addresses his entitlement to the benefits listed in the OCF-18 and claims that the respondent failed to comply with s. 38(8) of the Schedule because a response was not provided within the 10 day period. This is troublesome since the respondent did not have an opportunity to directly respond to the applicant’s initial submissions because the applicant failed to address this issue in their initial submissions. A party cannot split its case. As a result, I have disregarded this argument since the applicant failed to address it in their initial submissions and I find the respondent is prejudiced because they were denied the right to respond to this argument.

40. Accordingly, I find the applicant has failed to establish entitlement to any of the denied benefits, since no argument was provided in their initial submissions. It is the applicant’s onus to establish entitlement to a benefit in accordance with the Schedule and I find the applicant has failed to do so.

(iii) Treatment Plan dated June 4, 2016

41. The applicant submitted a treatment plan in the amount of $2,030.43 for assistive devices. This expense was partially approved by the respondent in the amount of $549.39. The only exclusion was the cost for an orthopedic mattress. The remaining amount in dispute is $1,481.04 for an orthopedic mattress.

42. The applicant submits that an orthopedic mattress is required because the applicant suffers from insomnia-related fatigue since the accident. Mr. Wong’s assessment report dated March 10, 2016 states that the applicant’s “sleep quality and quantity has been poor since the accident due to her constant headache, constant neck pain….she wakes up intermittently throughout the evening to change positions due to her pain and discomfort and/or as a result of worrying thoughts”. At paragraph 14 of the applicant’s affidavit, the applicant states that an orthopedic mattress would benefit her sleep.

43. The respondent submits that there was no explanation why the orthopedic mattress was required by the applicant.

44. While the applicant submits that Mr. Wong’s assessment report recommends an orthopedic mattress, the report does not link the applicant’s symptoms regarding sleep disturbance with the need for an orthopedic mattress. Specifically, insomnia related fatigue is not referred to in Mr. Wong’s report as a justification for recommending an orthopedic mattress. I also have concerns that other factors may be contributing to the applicant’s poor sleep quality, including Mr. Wong’s report which states the applicant complained of “worrying thoughts” and a “constant headache”. It’s unclear from Mr. Wong’s report how an orthopedic mattress will resolve these complaints. Also, I have put no weight on the applicant’s affidavit regarding this issue. At paragraph 14 of the affidavit, the applicant is essentially providing a medical opinion and I find the applicant is not qualified to do so. As a result, I find the applicant failed to establish on a balance of probabilities that the orthopedic mattress is reasonable and necessary.

(iv) Treatment Plan dated July 13, 2016

45. In their submissions, the applicant did not provide any arguments with respect to this treatment plan. Nevertheless, the applicant sent a treatment plan dated July 13, 2016 claiming various treatments and items in the amount of $3,817.72.

46. The respondent partially approved this treatment plan in the amount of $2,794.00. Specifically, in its EOB dated August 4, 2016, the amount for the completion of the assessment and OCF-18 was reduced from $400.00 to $200.00, as, according to the respondent, this is the maximum payable pursuant to the Guideline. The respondent also reduced the transportation cost from $1,346.64 to $673.32 even though the applicant was not eligible for transportation expenses since the round trip from the applicant’s home was less than 50 kilometres. The respondent relied on MapQuest’s calculation of the distance from Perfect Physio and Rehab Centre to the applicant’s address as 6.7km. The respondent also denied a $150.00 brokerage fee since it determined that such an expense was “an expense related to professional services” and all such expenses are already included in the hourly amount a professional can charge pursuant to the Schedule and the Guideline. As a result, the respondent found it was therefore not payable.

47. The applicant bears the onus to prove their entitlement to benefits in dispute. Since I have been provided with no arguments regarding this treatment plan, I find the applicant has failed to prove entitlement to any amount beyond the $2,794.00 already approved by the respondent.

(v) Treatment Plan dated October 5, 2016

48. Again, in their submissions, the applicant did not provide any arguments with respect to this treatment plan. Nevertheless, the applicant sent a treatment plan dated October 5, 2016 claiming various treatments and items in the amount of $3,239.08.

49. The respondent partially approved this treatment plan in the amount of $2,833.04 for further chiropractic treatment. The only amount that was denied was for transportation in the amount of $420.00. The respondent denied this amount because the applicant failed to establish that the clinic was more than a 50 kilometre round trip from the applicant’s home in accordance with s.3(1) of the Schedule.

50. I find that it is the applicant’s onus to establish compliance with s. 3(1) of the Schedule in order to claim an “authorized transportation expense” and it has failed to do so. As a result, the applicant is not entitled to transportation expenses in the amount of $420.00.

3) Treatment Plans from Perfect Choice Psychological Services Inc.

(i) Treatment plan dated December 27, 2016

51. The applicant submitted a treatment plan in the amount of $3,253.04 for further psychological treatment.

52. The respondent denied this treatment plan on the basis that the applicant was already approved for 26 counselling sessions, the proposed treatment plan did not differ from those sessions and there was no reduction in treatment sessions. The plan was denied pending the report of a s.44 psychological assessment. The respondent relies on Dr. Terra Seon’s report in denying the treatment plan. Dr. Seon is a psychologist.

53. In their reply, the applicant submits that both therapist Xiao Lang and Dr. Ming Che Yeh, psychologist, have identified improvement with psychological counselling. The applicant submits that on multiple occasions she also indicated the helpfulness of her counselling sessions. The applicant submits the treatments have benefited her through “reducing emotional distress and building essential adaptive skills necessary to adjust with the substantial changes to her life as a result of the accident.”

54. After reviewing the evidence, I conclude that this treatment plan dated December 27, 2016 is not reasonable or necessary.

55. I find that many of the applicant’s main concerns remained the same as the progress report dated August 27, 2016. I note that Mr. Yang’s recommendations are the same as the August 2016 progress report and there is no evidence that further psychological counselling sessions are benefiting the applicant. In fact, it appears that further psychological treatment has worsened the applicant’s condition. For example, the applicant reported being depressed at a severe level in December 2016, in contrast to the moderate level reported in August 2016.

56. I agree with the respondent’s psychologist report by Dr. Seon dated April 24, 2017, in which Dr. Seon notes that the applicant’s subjective psychological difficulties were not supported by objective psychometric test findings. Specifically, the applicant’s test scores were significantly above the recommended cut-off score in the Structured Inventory of Malingered Symptomology test (SIMS), a self-report measure designed to detect feigning of symptoms. Also, the applicant’s cut-off scores were above the recommended cut-off score on four out of the five domains, including amnesia, neurological impairment, affective disorder and low intelligence and a high likelihood of potential symptom magnification was identified. I agree with Dr. Seon’s view that there appears to be no improvement in the applicant’s symptoms after receiving 26 sessions of individual psychotherapy and I assign it greater weight. In fact, as I already noted, Dr. Seon acknowledged that the applicant’s depressive symptomology increased from being viewed as moderate in August 2016 to severe in December 2016.

57. Based on the above, I find the treatment plan dated December 27, 2016 is not reasonable and necessary.

(ii) Treatment Plan dated August 29, 2016

58. The applicant submitted a treatment and assessment plan for psychological services on August 29, 2016 in the amount of $3,253.04. The respondent partially approved the treatment and assessment plan in the amount of $2,893.04. The only item which was not approved was a progress report in the amount of $360.00. The respondent claims that since a progress report was not requested it was not approved. I disagree with the respondent’s position.

59. I agree with the applicant’s position on this issue. I find that the progress report would have been relied upon by the respondent in determining whether or not the treatment plan was reasonable and necessary. This is supported by the applicant’s reliance on Cowans and Motors Insurance Company, FSCO A09-003237. I find the following paragraph at p.15 of Cowans to be particularly relevant:

“Likewise, an insurer in making a determination cannot ignore credible evidence that is available to it. An insurer has an obligation to assess and critically examine these opinions, and not simply pretend that they do not exist. To repeat, as O’Connor J. noted in 702535 Ontario Inc. v. Non-Marine Underwriters, Lloyd’s of London: “In making a decision whether to refuse payment of a claim from its insured, an insurer must assess the merits of the claim in a balanced and reasonable manner.” I do not accept that it is reasonable to ignore or discount credible information that merely disagrees with preconceptions or conclusions already made.”

60. The progress report in question was also essential in determining the progress of the applicant’s psychological treatments thus far. I find it was unreasonable for the respondent to deny payment for the progress report. The fact that the respondent ultimately approved treatment is also telling.

61. Therefore, I find the applicant is entitled to the remaining $360.00 for a progress report.

Expense Claim form dated March 15, 2016

62. The applicant submitted an expense claim form (OCF-8) dated March 15, 2016 in the amount of $113.12. Specifically, the applicant submits that she should be reimbursed for various prescription costs in the amount of $81.12 and parking in the amount of $32.00.

63. The respondent partially approved payment in the amount of $64.59 in its EOB dated April 18, 2016. The respondent fully approved the parking expense of $32.00 and partially approved payment in the amount of $32.59 for the prescription expense. The respondent also noted that the applicant’s calculation of the prescription expenses is incorrect.

64. I have reviewed the applicant’s claimed prescription and parking expenses, and I agree with the respondent that the applicant’s calculation of prescription expenses is incorrect, since there are no additional prescription receipts which total $81.12. I find that the following prescription expenses have been established with receipts:

Lenoltec (Feb 29/16) $9.78

Novo-Clindamycin (Feb 29/16) $10.75

Novo-Clindamycin (Mar 2/16) $12.06

Total: $32.59

65. Therefore, I agree with the respondent’s calculation of the prescription expenses in the amount of $32.59, since the applicant has failed to prove the correct calculation for the claimed expense with supporting documentation.

Expense Claim Form dated April 8, 2016

66. The applicant submitted an expense claim form (OCF-8) dated April 8, 2016 in the amount of $418.08. In their submissions, the applicant is only contesting the $46.70 for gas and parking incurred by the applicant’s husband when accompanying the applicant for an appointment with her eye doctor, Dr. Jordan Cheskes on March 8, 2016. The applicant relies on s. 22 of the Schedule.

67. The respondent failed to address this expense in their submissions, however, I have reviewed the EOB dated May 2, 2016 which stated that there was no coverage for gas receipts. The respondent claimed it only pays mileage and requested additional details on the name of the visitor, the address where they resided and where they visited the applicant.

68. Furthermore, the Transportation Expense Guideline only provides reimbursement for mileage and not the cost of gas. As noted, the Transportation Expense Guideline, in part, states:

“The insurer is liable to pay a mileage expense for transportation of the insured person and his/her aide or attendant, to and from treatment sessions, counselling sessions, training sessions, assessments and examinations, using the insured person’s automobile, excluding the first 50 kilometers of each round-trip.” (emphasis added)

69. I have also been provided with no information regarding the address of the eye doctor.

70. As a result, I find the applicant has failed to provide sufficient evidence for reimbursement of mileage expenses since there is no information regarding the distance from the claimant’s home to the eye doctor’s office.

Interest

71. I find the applicant is entitled to interest on any overdue amounts in accordance with the Schedule.

ORDER:

72. For the reasons outlined above, I order that the applicant is entitled to payment for the following:

i) $297.00 for outstanding attendant care benefits

ii) $200.00 for treatment and assessment plan dated March 29, 2016

iii) $360.00 for treatment and assessment plan dated August 29, 2016

iv) Interest on any overdue amounts in accordance with the Schedule

Released: January 26, 2018

___________________________

Billeh Hamud, Adjudicator

Footnotes

1. 1O. Reg. 34/10.
2. 2See: 17-000848 v Echelon General Insurance Company, 2017 CanLII 85731 (ON LAT), and 16-004363 v Coseco Insurance Company, 2017 CanLII 76917 (ON LAT).
3. 3RSO 1990.