Licence Appeal Tribunal File Number: 22-009064/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:
Russell Trafton
Applicant
and
Aviva Insurance Company
Respondent
DECISION
VICE-CHAIR:
Julian DiBattista
APPEARANCES:
For the Applicant:
Yanira E Monterroza, Paralegal
For the Respondent:
Jessica Rogers, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Russell Trafton, the applicant, was involved in an automobile accident on January 21, 2020, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”). The applicant was denied benefits by the respondent, Insurer, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issues in dispute are:
i. Is the applicant entitled to $200.00 for the cost of a Disability Certificate (OCF-3), proposed by Scarborough Health & Wellness Centre dated February 26, 2020?
ii. Is the applicant entitled to $639.32 ($2,200.00 less $1,560.68 approved) for a Psychological Assessment, proposed by Paramount Medical Assessments in a treatment plan dated September 10, 2021?
iii. Is the applicant entitled to $794.54 ($2,094.54 less $1,300.00 approved) for psychological services, proposed by Paramount Medical Assessments in a treatment plan dated February 8, 2022?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
WITHDRAWN ISSUES
3In written submissions, the applicant has withdrawn issues i and ii above.
RESULT
4The applicant is not entitled to any additional benefits.
ANALYSIS
The respondent is not liable for treatment incurred before submitting an OCF-18
5The sole issue in dispute is the hourly rate payable for psychological treatment.
6On February 8, 2022 a treatment plan was submitted for psychological treatment.
7This treatment plan proposed that Dr. Bita Sharifzadeh, psychologist, would provide 12 one-hour session of cognitive behavioural psychotherapy at $149.61 an hour, a two-hour psychological re-assessment at $149.61 per hour and a two-hour progress report at 149.61 per hour.
8This fee aligns with the Professional Services Guideline (“Guideline”) issued by the Superintendent of the Financial Services Commission of Ontario (FSCO) which outlines maximum rates payable for certain professions under the Schedule. The guideline sets the maximum rate a psychologist or psychological associate can bill at $149.61 per hour.
9This treatment plan was approved by the respondent on February 15, 2022.
10It subsequently came to light that Dr. Sharifzadeh did not provide the treatment proposed in the OCF-18. Instead, the applicant received psychotherapy sessions provided by Ms. Anusha Gowda, registered social worker.
11The Guideline does not specify a rate for registered social workers, instead the Guideline states that fees for non-specified provider types will be agreed upon by the parties.
12As treatment was not provided by a psychologist as proposed in the OCF-18, the respondent funded the treatment received at $100 per hour, the rate that they say is customary for a registered social worker.
13The applicant is seeking the full $149.61 per hour proposed in the OCF-18.
14I note that treatment proposed in the OCF-18 was approved by the insurer on the basis that it was provided by the service provider indicated in Part 11. This is Dr. Sharifzadeh, a psychologist.
15There were two deviations from this treatment plan. Firstly, the individual providing treatment was changed from Dr. Sharifzadeh to Ms. Gowda. Secondly, the provider type was changed from a psychologist to registered social worker.
16It is reasonable to expect that the person who provides the services may differ from the person identified in the treatment plan proposing to provide the services. In situations such as vacations, changes of employment, or illness, a colleague of the provider could be substituted.
17The provider substituted must be the same provider type as the person proposed in the OCF-18 to deliver treatment.
18In this case, the services were approved for a psychologist, but delivered by a registered social worker.
19This is a material difference and a significant deviation from the approved OCF-18. The approval for treatment by a psychologist cannot be interpreted as approval for treatment by a registered social worker. Registered social workers do not have the same scope of practice as psychologists.
20The respondent, in their reply, submits that Dr. Sharifzadeh is providing services as the supervising psychologist. They further submit that the rate should be apportioned $100 to Ms. Gowda and $49.61 to Dr. Sharifzadeh. I reject this premise.
21The OCF-18 is specific. Dr. Sharifzadeh is identified to provide 12 sessions of Cognitive Behavioural Psychotherapy. If Ms. Gowda is providing the psychotherapy and Dr. Sharifzadeh is completing supervisory tasks, then these tasks should be itemized and documented in the OCF-18 for approval by the insurer. Each provider will then be subject to the Guideline for the tasks they complete, or their rate will be mutually agreed upon in the case of Ms. Gowda.
22The treatment provided by Ms. Gowda was not the treatment that was approved in the OCF-18 submitted February 8, 2022 by Dr. Sharifzadeh.
23There has been no evidence provided to demonstrate an OCF-18 was submitted seeking approval for treatment to be provided by Ms. Gowda.
24Therefore, under s. 38(2) of the Schedule the respondent is not liable to pay an expense in respect to a medical or rehabilitation benefit that was incurred before the insured person submits a treatment and assessment plan.
25The respondent has paid $100 per hour for treatment provided by Ms. Gowda. They submit this amount is their customary rate for a Registered Social Worker.
26The applicant is not entitled to any further amount, as the treatment approved, 12 sessions of cognitive behavioural psychotherapy, provided by Dr. Sharifzadeh, a psychologist, was not provided.
Interest
27As no benefits are payable there is no entitlement to interest.
ORDER
28For the reasons above I find that:
i. The applicant is not entitled to the disputed treatment;
ii. No interest is payable; and
iii. This application is dismissed.
Released: November 4, 2024
Julian DiBattista
Vice-Chair