Released Date: 01/18/2021
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:
Faisal Rohile
Applicant
and
Intact Insurance Company
Respondent
DECISION
ADJUDICATOR:
Robert Watt
APPEARANCES:
For the Applicant:
Kathryn McRae Hill, Counsel
For the Respondent:
Paul Omeziri, Counsel
HEARD:
Via written submissions
OVERVIEW
1The applicant was injured in an automobile accident on May 1, 2018 and sought a medical benefit for psychological treatment under the Statutory Accident Benefits Schedule – Effective September 1, 2010 (the “Schedule”). The respondent partially approved the treatment plan but denied the remaining portion based on the hourly rate to be paid for the treatment plan.
2The applicant disagreed and submitted an application to the Tribunal for resolution of the dispute.
ISSUES IN DISPUTE
3The issues to be decided in the hearing are:
Is the applicant entitled to a medical benefit in the amount of $2,393.72 (representing $4,538.77 less partial approval in the mount of $2,145.05) for psychological treatment recommended by Novo Medical Services in a treatment Plan (OCF-18) submitted on December 13, 2018, and denied on January 12, 2019?
Is the applicant entitled to interest on any overdue payment of benefits?
RESULTS
4The applicant is not entitled to any medical benefit for psychological treatment.
5The applicant is not entitled to interest.
BACKGROUND
6The applicant was involved in a rear end motor vehicle accident on May 1, 2018, wherein he collided with another vehicle that cut suddenly in front of him. He saw his family doctor the next day. He was referred for physiotherapy at Activa Clinic where he began attending two days after the accident. The applicant attended three times per week until September 2018 and felt 60% better. He had been in a previous accident in 2016 where he injured his neck back and head.
7Dr. H. Rockman, Psychologist, in her report dated November 6, 2018 diagnosed the applicant with adjustment disorder and Specific Phobia (driver in a car). She noted that the applicant’s pre-existing disorders where mildly exacerbated by the accident. The applicant was also struggling with marital stress after the 2016 accident and Dr. Rockman recommended 12 weekly sessions of psychological treatment.1
8The applicant attended at Novo Medical Services from April 16, 2019 to August 21, 2019. The applicant’s alleged physical complaints and fatigue were the focus, with references to discussing Cognitive Behavioural Therapy on many of the meetings.2 The Treatment and Assessment Plan (OCF-18) was to have Dr. R. Vitelli, Psychologist, as provider, with Ms. Angela Ross as the social worker involved with the applicant at his sessions.
9In her Psychotherapy Progress Report, Ms. Ross noted on August 30, 2019 that the applicant was “exploring cognitive behavioural therapy.”
ANALYSIS
10I find that the applicant is not entitled to medical benefits for psychological treatment for the reasons set out below.
11The only issue between the parties is the hourly rate for the service provider for the psychological services, as recommended in the treatment plan at issue.
12The applicant’s position is that the service provider should be paid at the same rate as a psychologist. The applicant argues that the social worker, Ms. Ross, has extensive experience in dealing with claimants struggling with psychological issues. The respondent’s position is that Ms. Ross should not be paid the same rate as a psychologist as she did not have the experience or specialized training in psychotherapy or cognitive behavioural therapy and did not administer the same to the applicant.
13Section 15(2) of the Schedule states that the insurer is not required to pay medical benefits in excess of the amount set out in the Guidelines.
14The Professional Service Guideline issued as Superintendent’s Guideline No. 03/14 establishes the maximum expenses payable for a range of health care services, medical benefits and case management services. The guideline allows insurers the discretion to pay above the maximum or hourly rate established in the Guideline but makes it clear that insurers are not liable to pay for expenses that exceed the maximum hourly rates set out in the Appendix.
15The rate set out in the Appendix is $58.19 for counsellors, including family, rehabilitation, vocational, and psychometrists. The rate set out in the Appendix is $149.61 for psychologists and for psychological associates.
16Section 27(4) of the Regulated Health Professions Act provides that a social worker may provide psychotherapy services.
17This Tribunal has already made findings that psychotherapists can be paid the unregulated rate in certain situations: where the psychotherapist has a high level of experience, education, training, specialized qualifications; where the psychotherapist charges a rate in their non-MVA related private practice that is the same rate or higher than the rate applicable to psychologists in the Guideline; or where the treatment plan lists the services to be provided by a psychologist instead of a psychotherapist and the applicant incurred the Treatment Plan after the insurer agreed to pay the unregulated rate.3
18The respondent approved the treatment plan in January 2019 at the rate of $99.75 and increased the hourly rate in May 2020, to $112.22. The Treatment Plan was incurred from May 2019 to August 2019. The applicant did not dispute the rate.
19I do not know of the qualifications of Ms. Ross in having specialized training in psychotherapy or cognitive behavioural training. The evidence before me also does not clarify whether cognitive behavioural therapy was applied or just explored with the applicant. I have no evidence before me as to what hourly rate Ms. Ross would charge in private practice.
20Accordingly, since the rate was agreed to by both parties and an insurer is not required to pay for treatment above the Guideline rates, I find therefore that the rate was reasonable and was the appropriate rate.
INTEREST
21The applicant is not entitled to interest under s. 51 as no benefits are owing.
CONCLUSION
22For the reasons set out above, the application is dismissed.
Released: January 18, 2021
Robert Watt
Adjudicator
Footnotes
- November 6, 2018 report of Dr. Rockman, Psychologist Applicant’s Submissions P. 46-65
- Records of Novo Medical Services Applicant’s Submissions pages 66-73
- See, A.A v Aviva General Insurance Company, 2020 CanLII 34491 (ON LAT); M.R. v. Belair Direct, 2020 ON LAT 18-011614/AABS.