Qian v. Aviva Insurance Company
Licence Appeal Tribunal File Number: 20-010179/AABS
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:
Min Jie Qian
Applicant
and
Aviva Insurance Company
Respondent
DECISION
ADJUDICATOR: Ulana Pahuta
APPEARANCES:
For the Applicant: Yu Jiang, Paralegal
For the Respondent: Jessica Rogers, Counsel
HEARD: BY WAY OF WRITTEN SUBMISSIONS
OVERVIEW
1Min Jie Qian (the “applicant”) was involved in an automobile accident on September 25, 2018, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016)1. The applicant was denied certain benefits by Aviva Insurance Company (the “respondent”) and submitted an application to the Licence Appeal Tribunal - Automobile Accident Benefits Service (“Tribunal”).
ISSUES IN DISPUTE
2The following issues are to be decided:
I. Is the applicant entitled to a medical benefit in the amount of $1,041.88 ($3,701.88 less amount approved of $2,660.00) for psychological services recommended in a treatment plan dated April 17, 2020?
II. Is the applicant entitled to a medical benefit in the amount of $1,041.88 ($3,981.88 less amount approved of $2,940.00) for psychological services recommended in a treatment plan dated June 26, 2020?
III. Is the applicant entitled to interest on overdue payment of benefits?
3In their submissions, the applicant and respondent had identified different outstanding amounts related to the disputed treatment plans (“OCF-18”s). However, upon my review of the tribunal file, namely the Case Conference Report and Order dated April 1, 2021, the two OCF-18s and the Explanation of Benefits letters from the respondent to the applicant, I agree with the applicant that the amounts in dispute are as listed in paragraph 2 above.
BACKGROUND
4The applicant was involved in a rear end motor vehicle accident on September 25, 2018. He subsequently attended at the office of his family physician, Dr. Rosalind Ward-Smith, with accident-related complaints of poor sleep, poor concentration, driving anxiety, reduced energy levels and neck pain2. Dr. Ward-Smith assessed the applicant as suffering from an adjustment reaction post-accident and referred him for counselling support.
5On April 14, 2020, the applicant underwent a psychological assessment with Dr. Maneet Bhatia, psychologist, who diagnosed the applicant with an adjustment disorder with mixed anxiety and depressed mood and specific phobia – automobile anxiety3. Dr. Bhatia recommended that the applicant receive therapeutic support by way of cognitive behavioural therapy. The applicant submitted two treatment plans for psychological services, dated April 17,2020 and June 26, 2020.
6The respondent partially approved both treatment plans, with the exception of: i) $360.00 for the cost of progress reports; and ii) the difference between the hourly rate proposed for the psychological services – namely the respondent approved the rate of $100 per hour as opposed to $149.61 per hour as requested in the treatment plans4.
7At the case conference, the respondent agreed to pay for the cost of the progress reports. Therefore, the parties agree that the only issue in dispute in these proceedings is the hourly rate for the service provider of the psychological services, namely, whether the respondent is liable to pay $100 per hour or $149.61 per hour for the psychological services.
RESULT
8I find that the applicant is not entitled to the unapproved balance of the disputed treatment plans. No interest is payable.
ANALYSIS
9The fee for services provided through the Schedule is governed by the Professional Services Guideline issued as Superintendent’s Guideline No. 03/14 (the “PSG”). The PSG establishes the maximum expenses payable for a range of health care services, medical benefits and case management services. The maximum hourly rate for psychologists and psychological associates is $149.62 per hour. The rate provided for unregulated professionals is $58.19 per hour. The amounts payable by an insurer related to professional services not covered by the PSG are to be determined by the parties involved.5