Licence Appeal Tribunal File Number: 22-005718/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:
Wei Zhang
Applicant
and
TD General Insurance Company*
Respondent
DECISION
ADJUDICATOR: Kieffer Norton
APPEARANCES:
For the Applicant: Wei Zhang, Applicant Yu Denise Jiang, Counsel
For the Respondent: TD General Insurance Company, Francine Papadopoulos, Counsel
HEARD: In Writing July 2, 2024
OVERVIEW
1Wei Zhang, the applicant, was involved in an automobile accident on January 14, 2019, 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.
2The applicant was involved in a motor vehicle accident on January 14, 2019. He was the driver and sole occupant of a vehicle when he was struck by another vehicle. The applicant suffers claims to suffer injuries to his shoulders, lower back and has psychological impairments as a result of the accident.
ISSUES
3The issue(s) in dispute is/are:
i. Is the applicant entitled to the amount of $748.10 ($2804.20 less $2056.10 approved) for psychological services set out in the OCF-18 dated June 4, 2021?
ii. Is the applicant entitled to the amount of $748.10 ($2804.20 less $2056.10 approved) for psychological services set out in the OCF-18 dated November 26, 2021?
iii. Is the applicant entitled to the amount of $748.10 ($2804.20 less $2056.10 approved) for psychological services set out in the OCF-18 dated September 20, 2022?
iv. Is the Applicant entitled to a special award under Ontario Regulation 664?
v. Is the Applicant entitled to receive 1% compound interest as per section 51?
RESULT
4I find that on a balance of probabilities applicants psychological treatments proposed by Dr. Cook of Somatic Assessments & Treatment Clinic to be reasonable and necessary.
5The application is granted.
ANALYSIS
Psychological Services in Dispute
6The respondent submits that the treatment plans submitted by Dr. Cook are reasonable, however it takes exception to the 1.5 hour session length as opposed to the 1 hour session length proposed by Dr. Moshiri.
The OCF-18s for psychological services are reasonable and necessary
7I find that the treatment plan proposed by Dr. Cook to be reasonable. Both Dr. Cook and Dr. Moshiri concluded that there was improvement in the applicant’s psychological condition as a result of the treatment plans and both concluded the applicant would benefit from additional sessions from Dr. Cook.
8I find on a balance of probabilities that the treatment plan proposed by Dr. Cook was necessary. In Dr. Moshiri’s review dated January 7, 2022 Dr. Moshiri concluded that the applicant was improving and that 10 additional hours of treatment would be reasonable and necessary.
9I find that Dr. Moshiri report to be compelling as it was written after the applicant had already completed 2 treatment plans using sessions of 1.5 hour duration. Dr. Moshiri’s report concluding that an additional 10 hours of treatment plan are to be required gives validity to the necessity of the 1.5 hour treatment plans prescribed by Dr. Cook.
10I find that the treatment plans proposed by Dr. Cook to be reasonable and necessary. While the duration of the sessions was disputed neither side disputed their reasonability. The respondent argues that no reasons were provided as to why 1.5 hour sessions would be necessary for the applicant’s recovery. While the applicant does not provide any reason as to the necessity of the 1.5-hour sessions, I find that both Dr. Cook and Dr. Moshiri agreed that the applicant would benefit from additional sessions. Therefore, I find that the duration of the sessions was necessary.
Interest
11I find that Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule.
Award
12The applicant sought an award under s. 10 of Reg. 664. Under s. 10, the Tribunal may grant an award of up to 50 per cent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits. Provide the basis for the award. Identify the response.
13I find that the Respondent did not unreasonably withhold or delay payments to the applicant.
14The applicant submits that the respondent ignored the medical records of the treating practitioners and assessors. I find that the respondent did not act unreasonably in requesting compelling reasons for the necessity of the 1.5 hour psychological therapy times from the applicants provider.
ORDER
i. I find the applicant is entitled to the amount of $748.10 ($2804.20 less $2056.10 approved) for psychological services set out in the OCF-18 dated June 4, 2021.
ii. I find the applicant entitled to the amount of $748.10 ($2804.20 less $2056.10 approved) for psychological services set out in the OCF-18 dated November 26, 2021.
iii. I find the applicant entitled to the amount of $748.10 ($2804.20 less $2056.10 approved) for psychological services set out in the OCF-18 dated September 20, 2022.
iv. I find the Applicant is not entitled to a special award under Ontario Regulation 664.
v. I find the Applicant entitled to receive 1% compound interest as per section 51.
Released: December 13, 2024
Kieffer Norton
Adjudicator