Licence Appeal Tribunal File Number: 21-012174/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:
Yi Zhong Pan
Applicant
and
Unica Insurance Inc.
Respondent
DECISION
VICE-CHAIR:
Monica Ciriello
APPEARANCES:
For the Applicant:
Sareena Samra, Counsel
For the Respondent:
Olga Zemlinsky, Counsel
HEARD:
By Way of Written Submissions
OVERVIEW
1Yi Zhong Pan, the applicant, was involved in an automobile accident on July 15 2019, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (the “Schedule”). The applicant was denied benefits by the respondent, Unica Insurance Inc, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The following issues are to be decided:
i. Is the applicant entitled to receive a psychological assessment in the amount of $2200.00 in a treatment plan dated November 14, 2019?
ii. Is the applicant entitled to a special award under Ontario Regulation 664?
iii. Is the applicant entitled to interest?
RESULT
3I find that:
i. The applicant is not entitled to $2200.00 for a psychological assessment.
ii. The applicant is not entitled to an award
iii. The applicant is not entitled to interest.
ANALYSIS
Applicant’s onus to establish a Treatment Plan is reasonable and necessary
4To receive payment from an insurer for a medical benefit sought under sections 14 and 15 of the Schedule, an applicant must establish on a balance of probabilities that he has suffered an impairment from the accident and that the medical benefit is a reasonable and necessary expense as a result of the accident.
5There must be objective medical evidence demonstrating a causal connection between the accident and injuries giving rise to a claim for benefits. A treatment plan on its own does not prove that the benefits sought are reasonable and necessary.
6In demonstrating the reasonableness and necessity of a benefit sought, the applicant should identify the goals of treatment, how the goals would be met to a reasonable degree and that the overall costs of achieving the goals are reasonable.
The applicant is not entitled to $2200.00 for a psychological assessment
7I find that the proposed psychological assessment is not reasonable and necessary.
8The applicant relies on a pre-screening report included in the November 14, 2019 treatment plan by Dr. Maneet Bhatia, psychologist, the November 3, 2020, psychological assessment of Dr. Sharleen McDowell, psychologist, and the April 22, 2023 consultation report of Dr. Sho Xiang, psychiatrist for support.
9The pre-screen report was completed by Xiao Lan Yang, M.Ed, R.P. under the supervision of Dr. Bhatia. It was recommended that the applicant undergo a full psychological assessment to determine his clinical diagnosis and psychological treatment needs.
10The psychological assessment of Dr. McDowell relied on the applicant’s self-reporting of his inability to work, driving anxiety, and inability to play with his son. I am persuaded by the submissions of the respondent that the applicant’s self- reporting is in direct contradiction to the surveillance of the applicant obtained by the respondent in May 2020, August 2022, and September 2022. For example, the surveillance reveals the applicant engaging in activities such as: driving frequently, work-like activities, errands, walking/jogging, playing with his son, and gardening. Furthermore, Dr. McDowell’s report states that the applicant cannot drive for more than one hour at a time because of unbearable pain. I find that even if I were persuaded by Dr. McDowell’s report, I find it suggests that the applicant’s driving limitations are physical and not psychological.
11The applicant also relies on the referral of his family physician, Dr. Christopher Tan, to psychiatrist, Dr. Sho Xiang, for concerns of stress and unhappiness. Dr. Xiang’s consultation report is not fully translated into English, yet the applicant submits that Dr. Xiang diagnosed the applicant with post-traumatic stress disorder. I find it challenging to decipher Dr. Xiang’s report and as such I give it little weight in my final consideration because large parts of the report are not translated and the applicant did not get the report translated to assist the Tribunal.
12I agree with the respondent that the treatment plan is not reasonable and necessary as there is a lack of continuous and corroborating complaints by the applicant to his treating physicians. It is the respondent’s position that there is no medical evidence in the clinical notes and records (“CNRs”) of Dr. Tan that demonstrate the applicant suffers from an accident-related psychological impairment justifying the OCF-18 in dispute.
13For example, the CNRs of Dr. Tan indicate the applicant attended various appointments from August 2019 to July 2022 but he did not report any psychological concerns. Furthermore, Dr. Tan did not prescribe any medication and only referred the applicant to Dr. Xiang in 2023 for psychological complaints, however he does not indicate that the subject accident is the reason for the referral.
14The respondent also relies on the September 23, 2020, Insurer Examination of Dr. Gary Challis, psychologist, who assessed the applicant’s entitlement to income replacement benefits. Dr. Challis opined that the applicant did not present symptoms of a psychological nature, including anxiety, trauma, or depression to warrant a diagnosis or further investigation.
15I am persuaded by the respondent’s submissions. I find that the pre-screen results from a non-psychologist do not provide sufficient evidence that the costs of a full psychological assessment are, by default, reasonable and necessary. Especially, when there is a lack of medical evidence to support the findings. A review of Dr. Tan’s CNRs make no mention that the applicant suffered a psychological impairment as a result of the accident. Dr. McDowell’s findings based on the applicant’s self-reporting was in contradiction to evidence presented to the Tribunal, and as mentioned above, Dr. Xiang’s report was challenging to decipher.
16As a result, I find that the applicant has failed to establish on a balance of probabilities that he has suffered a psychological impairment from the accident and that this treatment plan is reasonable and necessary.
Award and Interest
17Given that there is no unreasonable delay in payments to the applicant or overdue payments of benefits, the applicant is not entitled to an award or interest.
ORDER
18The application is dismissed, and I find that:
i. The applicant is not entitled to $2200.00 for a psychological assessment.
ii. The applicant is not entitled to an award;
iii. The applicant is not entitled to interest.
Released: November 3, 2023
__________________________
Monica Ciriello
Vice-Chair