Cheng v. Northbridge General Insurance Company, 2024 CanLII 140

Citation: Cheng v. Northbridge General Insurance Company, 2024 ONLAT 20-013769/AABS

Licence Appeal Tribunal File Number: 20-013769/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:

Sui Ping Cheng

Applicant

and

Northbridge General Insurance Company

Respondent

DECISION

ADJUDICATOR: Ludmilla Jarda

APPEARANCES:

For the Applicant: Philip Kai Kwong Yeung, Paralegal

For the Respondent: Nicholas M. Wine, Counsel Caleb Medeiros, Counsel

HEARD: By Written Submissions

OVERVIEW

1Sui Ping Cheng (the “applicant”) was involved in an automobile accident on September 20, 2019 and sought benefits pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 2010 (the “Schedule”). The applicant was denied benefits by Northbridge General Insurance Company (the “respondent”) and applied to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

2The applicant was deemed to be catastrophically impaired as a result of the accident.

ISSUES

3The issues in dispute are:

1. Is the applicant entitled to $1,047.34 ($3,981.88 less $2,934.54 approved) for psychological services, proposed by Somatic Assessments and Treatment Clinic in a treatment plan/OCF-18 (“treatment plan”) dated February 19, 2020, and submitted to the respondent on March 20, 2020?

2. Is the applicant entitled to $1,047.34 ($3,981.88 less $2,934.54 approved) for psychological services, proposed by Somatic Assessments and Treatment Clinic in a treatment plan dated June 22, 2020, and submitted to the respondent on June 22, 2020?

3. Is the applicant entitled to $5,000.00 ($16,712.81 less $11,712.81 approved) for catastrophic assessments, proposed by Somatic Assessments and Treatment Clinic in a treatment plan dated April 12, 2021, and submitted to the respondent on April 30, 2021?

4. Is the respondent liable to pay an award under s. 10 of Regulation 664 because it unreasonably withheld or delayed payments to the applicant?

5. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

4For the reasons that follow, I find that the applicant is not entitled to the unapproved balances of the disputed treatment plans. As no benefits are overdue, the applicant is not entitled to interest nor an award.

ANALYSIS

The Treatment Plans

5To receive payment for the disputed plans under s. 15 and 16 of the Schedule, the applicant bears the burden of demonstrating on a balance of probabilities that the benefits are reasonable and necessary as a result of the accident. To do so, 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 them are reasonable.

6The applicant submits that she suffers from psychological impairments as a result of the accident and that due to the ongoing severity of her impairments, the disputed treatment plans are reasonable and necessary.

7The applicant relies on a psychological assessment report dated January 28, 2020 completed by Dr. Sharleen McDowall, psychologist, two psychological assessment reports dated March 20, 2020 and January 19, 2021 respectively, both completed by Dr. Marjan Saghatoleslami, psychologist, and a psychological evaluation catastrophic impairment determination report dated February 22, 2022 completed by Dr. Sedigheh Naisi, psychologist.

8In response, the respondent submits that it partially approved the treatment plans in dispute and argues that the overall costs of the treatment plans are not reasonable and necessary. The respondent submits that the applicant has not met her evidentiary burden to prove that the unapproved balances of the treatment plans are reasonable and necessary.

9The respondent relies on an insurer examination catastrophic impairment determination psychology assessment report dated November 9, 2022 completed by Dr. Giorgio Ilacqua, psychologist, and the above described reports of Dr. McDowall and Dr. Saghatoleslami.

The unapproved balances of the treatment plans for psychological services are not reasonable and necessary

10I find that the applicant has failed to demonstrate, on a balance of probabilities, that the unapproved balances of the treatment plans for psychological services are reasonable and necessary. As such, the applicant is not entitled to $1,047.34 for the treatment plan dated February 19, 2020 and to $1,047.34 for the treatment plan dated June 22, 2020.

11Both treatment plans propose 14 weekly psychological counselling sessions, a progress report, completion of the treatment plan, and transportation services for each session. The proposed length of the sessions is 1.5 hours, and the hourly rate for the sessions is $224.42.

12As explained in the respondent’s submissions, the amount approved for both treatment plans for psychological services was based in part on the proposed length of psychological counselling sessions being reduced to 60-minute sessions, and the hourly rate for the sessions being reduced to $149.61.

13I find that the applicant’s submissions and evidence are lacking in demonstrating that the overall cost of the treatment plans are reasonable and necessary. Indeed, the applicant has provided no evidence or submissions to suggest that the proposed length of 1.5 hours for psychological counselling sessions and the hourly rate of $224.42 are reasonable and necessary. As a result, I find that the applicant has not met her evidentiary burden.

14Further, it is well established that the Professional Services Guidelines issued by the Financial Services Commission of Ontario as Superintendent’s Guideline No. 03/14 (the “PSG”) sets out the maximum expenses payable for a range of healthcare services under the Schedule. As noted by the respondent, based on the PSG, the maximum hourly rate for psychological services is $149.61. This is consistent with the rate approved by the respondent.

15Accordingly, I find that the applicant has not proven that the unapproved balances of the treatment plans are payable.

The unapproved balance of the treatment plan for catastrophic impairment assessments is not reasonable and necessary

16I find that the applicant has failed to demonstrate, on a balance of probabilities, that the unapproved balance of the treatment plan for catastrophic impairment assessments is reasonable and necessary. As such, the applicant is not entitled to $5,000.00 for the treatment plan dated April 12, 2021.

17The balance of $5,000.00 is made up of the following assessments, fees, and services:

1. Clinical File Review Assessment of Dr. Shobhan Vachhrajani, neurosurgeon - $2,000.00;
2. Clinical File Review Assessment of Raymond Wong, occupational therapist - $1,000.00;
3. Clinical File Review Assessment of Dr. Sharleen McDowall, psychologist - $1,000.00; and
4. Clinical File Review Assessment of Dr. Georgia Palantzas, chiropractor - $1,000.00.

18As explained in the respondent’s submissions and evidence, the unapproved balance of the treatment plan was denied on the basis that these assessments constitute duplication of services.

19I find that the applicant has provided insufficient evidence to support that the cost of the clinical file review assessments is reasonable and necessary. The applicant acknowledges that the respondent is not required to pay more than a total of $2,000.00 plus any applicable tax for fees and expenses for conducting an assessment and for preparing the corresponding report pursuant to s. 25(5)(a) of the Schedule. Yet, she does not explain how the clinical file review assessments differ from the approved neurological assessment, in-home occupational therapy assessment, psychological assessment, and chiropractor assessment that will be conducted by the above practitioners, nor does she explain why the clinical file review assessments were not captured in the approved assessments.

20As such, I find that the applicant has not proven that the balance of the treatment plan is payable.

Interest

21Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Given that no benefits are overdue, no interest is payable.

Award

22Pursuant to s. 10 of Regulation 664, the respondent may be liable to pay an award if the Tribunal finds that it unreasonably withheld or delayed the payment of a benefit. As the applicant has been found to not be entitled to the treatment plans in dispute, it follows that no benefits were unreasonably withheld or delayed. Accordingly, the respondent is not liable to pay an award.

ORDER

23For the reasons outlined above, I find that the applicant is not entitled to the unapproved balances of the disputed treatment plans. As no benefits are overdue, the applicant is not entitled to interest nor an award.

24The application is dismissed.