Release date: 09/16/2021
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:
Adebayo Michael Boluwaji
Applicant
and
Aviva General Insurance
Respondent
DECISION
ADJUDICATOR:
Daniela Corapi
APPEARANCES:
For the Applicant:
Adebayo Michael Boluwaji, Applicant
Loreto Scarola, Paralegal
For the Respondent:
Louise Kanary, Counsel
HEARD:
By way of written submissions
OVERVIEW
1The applicant was involved in an automobile accident on December 21, 2018, and sought benefits pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 20101 (the ''Schedule'').The applicant was denied certain benefits by the respondent and submitted an application to the Licence Appeal Tribunal - Automobile Accident Benefits Service (“Tribunal”).
2On or about July 18, 2019, the applicant submitted an OCF-18 from Dr. Shaul, psychologist, to the respondent. The treatment plan proposed a psychological assessment in the amount of $2,200.00. The OCF-18 was partially approved in the amount of $1,696.10, and the outstanding amount of $503.90 was denied by the respondent.
3The applicant is seeking the full costs of the subject assessment and is claiming interest on the balance owing in accordance with section 51 of the Schedule. The applicant is also seeking an Award pursuant to Regulation 664.
ISSUES
a. Is the applicant entitled to $503.90 ($2,200.00 less the partially approved amount of $1,696.10) for a psychological assessment, proposed by Dr. Shaul of West Queensway Health Centre Inc. in a treatment plan dated July 18, 2019 and denied by the respondent on September 24, 2019?
b. Is the respondent liable to pay an award under Regulation 664 because it unreasonably withheld or delayed payments to the applicant?
c. Is the applicant entitled to interest on any overdue payment of benefits?
RESULTS
4Based on the totality of the evidence before me, I find that the applicant is not entitled to payment for the balance of the cost of the psychological assessment, for the reasons set out below. As these amounts are not payable, no interest is due with respect to this treatment plan.
5The applicant is not entitled to an Award pursuant to Regulation 664.
ANALYSIS
6Dr. Shaul, psychologist, prepared a treatment plan dated June 25, 2019, recommending a psychological assessment in the amount of $2,200.00.
7On September 18, 2019, Dr. Cindy Goodfield, psychologist, performed a paper review to consider whether the Dr. Shaul’s proposed assessment is reasonable and necessary. In her report, Dr. Goodfield confirmed the applicant’s diagnosis of adjustment disorder with mixed anxiety and depressed mood. Dr. Goodfield found that the proposed cost of the subject assessment to be “somewhat excessive”.
8Based upon Dr. Goodfield’s recommendation, the respondent partially approved the subject treatment plan on September 24, 2019. The respondent provides the following details regarding the partial approval: “please find enclosed the psychological paper review report dated September 18, 2019. It is the opinion of the assessor (that) the above treatment plan is partially reasonable therefore approved partially up to $1696.10”.
9The applicant submits that Dr. Goodfield’s recommendation for partial approval of the subject assessment, along with the respondent’s corresponding partial approval, are unreasonable and flawed for the following reasons: 1) no breakdown for the amounts recommended were provided; 2) no reasons were provided for the proposed cost; 3) no hourly amounts were provided in her calculation; 4) Dr. Goodfield simply proposed a number without explanation or break-down; 5) the respondent did not request particulars of the breakdown from Dr. Goodfield or scrutinize the recommendation prior to issuing their partial approval of the assessment; 6) the respondent failed its fiduciary duty; 7) Dr. Goodfield did not take into consideration the HST payable; and 8) Dr. Shaul’s assessment incorporated different elements, such as an interview, and included elements not considered by Dr. Goodfield.
10I find these allegations ambiguous and unsubstantiated in evidence. The applicant has failed to produce particulars to support these allegations.
11The respondent states that Dr. Goodfield previously met with the applicant in and around July 24, 2019, approximately one month prior to the section 44 paper review, for an in-person psychological examination. The respondent states that Dr. Goodfield also performed a detailed review of medical documentation, including an applicant interview and psychometric testing.
12The respondent relies on Dr. Goodfield’s opinion that a mental health assessment for the purpose of treatment planning could reasonably be conducted within an eight to ten-hour timeframe. Dr. Goodfield provided particulars regarding this time frame and indicated that the cost of an assessment which includes interview, testing, interpretation, and report writing, should not exceed $1,496.10. Broken down, this includes 10 hours of time multiplied by $149.61 per hour, plus a $200 fee for completion of the OCF-18.
13The respondent relied on Dr. Goodfield’s opinion and a letter dated September 24, 2019 was sent to the applicant providing a partial approval of the subject assessment in the amount of $1,696.10; leaving the denied portion of $503.90 outstanding.
14I have no evidence before me to suggest that the respondent unreasonably relied on Dr. Goodfield’s opinion. I am not persuaded by the applicant’s submissions on this issue. The applicant bears the onus of establishing that the claimed expenses are reasonable and necessary. The applicant states that he has discharged that onus and is entitled to the $2,200.00; however, there is no evidence before me to suggest that the unapproved amount of $503.90, which equates to an additional 3.36 hours, is necessary.
15The applicant has failed to adduce evidence to counter the opinion of Dr. Goodfield that the fees claimed in the treatment plan are excessive. Dr. Shaul provided no particulars to justify claiming the maximum amount permitted under s. 25(5)(a) of the Schedule for any one assessment and the preparation of related reports.
16The applicant attempts to establish that by virtue of the respondent’s determination that he is entitled to the psychological assessment, then it must follow that the applicant’s claim for the maximum assessment fee permitted under the Schedule must also be reasonable and necessary. This reasoning is not supported by the Schedule. To the contrary, s. 38(3)(c) of the Schedule provides that each constituent part of a plan must meet the threshold of reasonableness and necessity, “the goods, services, assessments and examinations described in the treatment and assessment plan and their proposed costs”2 be reasonable and necessary for treatment or rehabilitation.
17I conclude that the applicant has failed to discharge his onus of establishing, on a balance of probabilities, that the full amount claimed for the proposed psychological assessment is reasonable and necessary. As such, the applicant is not entitled to the outstanding $503.90 in dispute.
18I do not find that the respondent’s denial was unreasonable to the extent that would attract an award.
ORDER
19Pursuant to s.280(2) of the Act, and for the reasons outlined above, I order that this application be dismissed.
Released: September 16, 2021
_________________________
Daniela Corapi, Adjudicator
Footnotes
- O. Reg. 34/10 as amended.
- Schedule, s. 38(3)(c).