Licence Appeal Tribunal File Number: 24-001616/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:
Ting Chen
Applicant
and
Allstate Insurance Company of Canada
Respondent
DECISION
ADJUDICATOR:
Brian Norris
APPEARANCES:
For the Applicant:
Sareena Samra, Counsel
For the Respondent:
Derek Yap, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Ting Chen (“the Applicant”) was involved in an automobile accident on April 2, 2020 and sought benefits from Allstate Insurance Company of Canada (“the Respondent”) 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 and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issues to be decided in the hearing are:
Is the Applicant entitled to a medical benefit in the amount of $11,324.56, less $8,617.36 approved by the Respondent, for chiropractic services, proposed by Total Recovery Rehab Centre in a treatment plan/OCF-18 (“plan”) dated May 15, 2023?
Is the Applicant entitled to a medical benefit in the amount of $8,926.16 for chiropractic services, proposed by Total Recovery Rehab Centre in a plan dated November 20, 2023?
Is the Applicant entitled to a medical benefit in the amount of $7,873.46, less $6,920.82 approved by the Respondent, for occupational therapy services, proposed by Somatic Assessments & Treatment Clinic in a plan dated May 23, 2023?
Is the Applicant entitled to a medical benefit in the amount of $7,873.46, less $6,920.82 approved by the Respondent, for occupational therapy services, proposed by Somatic Assessments & Treatment Clinic in a plan dated September 5, 2023?
Is the Applicant entitled to a medical benefit in the amount of $7,873.46, less $6,920.82 approved by the Respondent, for occupational therapy services, proposed by Somatic Assessments & Treatment Clinic in a plan dated November 2, 2023?
Is the Applicant entitled to attendant care benefits in the monthly amount of $1,186.50, less $952.36 approved by the Respondent, for the period from June 1, 2023 to June 30, 2023?
Is the Applicant entitled to attendant care benefits in the monthly amount of $2,373.00, less $932.56 approved by the Respondent, for the period from July 1, 2023 to July 31, 2023?
Is the Applicant entitled to attendant care benefits in the monthly amount of $2,966.25, less $952.36 approved by the Respondent, for the period from August 1, 2023 to August 31, 2023?
Is the Applicant entitled to attendant care benefits in the monthly amount of $2,373.00 less $952.36 approved by the Respondent, for the period from September 1, 2023 to September 30, 2023?
Is the Applicant entitled to attendant care benefits in the monthly amount of $2,570.75, less $952.36 approved by the Respondent, for the period from October 1, 2023 to October 31, 2023?
Is the Applicant entitled to attendant care benefits in the monthly amount of $2,768.50, less $952.36 approved by the Respondent, for the period from November 1, 2023 to date and ongoing?
Is the Applicant entitled to a medical benefit in the amount of $14,750.81, less $12,490.81 approved by the Respondent, for a catastrophic assessment, proposed by Somatic Assessments and Treatment Clinic in a plan dated August 4, 2022?
Is the Applicant entitled to a medical benefit in the amount of $2,200.00 for an in-home OT assessment, proposed by Somatic Assessments and Treatment Clinic in a treatment plan dated May 23, 2023?
Is the Applicant entitled to a medical benefit in the amount of $7,873.00, less $7,160.66 approved by the Respondent, for psychological services, proposed by Somatic Assessments & Treatment Clinic in a plan dated May 23, 2024?
Is the Respondent liable to pay an award under section 10 of Regulation 664 because it unreasonably withheld or delayed payments to the Applicant?
Is the Applicant entitled to interest on any overdue payment of benefits?
RESULT
3The Applicant has not demonstrated entitlement to any of the benefits claimed.
4No interest or award is payable.
BACKGROUND
5The Applicant sustained catastrophic mental and behavioural impairments as a result of an accident. She also claims to have sustained physical injuries as a result of the accident. At issue is her entitlement to the benefits claimed.
ANALYSIS
6The Applicant bears the onus of demonstrated that the benefits claimed are reasonable and necessary as a result of the accident.
Chiropractic and physiotherapy services proposed by Total Recovery Rehab
7I find that the Applicant has not demonstrated that she is entitled to the chiropractic and physiotherapy treatment plans.
8The plan in the amount of $11,324.56, dated May 15, 2023, proposes 20 four-hour treatment sessions, plus travel time and other fees. The Respondent partly approved this plan for up to three-hour sessions. The plan in the amount of $8,926.16, dated November 20, 2023, proposes 16 four-hour sessions, plus 1.5 hours per session for travel time, as well as other fees. The Respondent denied this plan in full.
9The Applicant submits that these plans are reasonable and necessary because her treatment providers at Total Recovery Rehab recommended physical therapy. The Respondent submits that the Applicant has not led any evidence to demonstrate that these plans are reasonable and necessary as a result of the accident and that the Applicant has not provided evidence of any prolonged physical impairment as a result of the accident. It highlights that the Applicant has not complained of any accident-related issues to her family physician since about a year after the accident, and that the orthopaedic and physiatry insurer’s examination (“IE”) reports concluded that the Applicant does not demonstrate any objective evidence of a musculoskeletal impairment.
10I find that the Applicant has not demonstrated that the unapproved chiropractic and physiotherapy services are reasonable and necessary as a result of the accident. The Applicant has led no evidence and made no submissions addressing the length of the treatment sessions and why they are reasonable and necessary. While the treatment facility recommends ongoing physical therapy, the Applicant has led no other evidence to suggest that she requires ongoing physical therapy or chiropractic treatment, or that she has physical issues that require ongoing physiotherapy or chiropractic treatment.
11I find the opinions of Dr. O. Safir, orthopaedic surgeon, and Dr. R. Soric, physiatrist, to be more persuasive than the Applicant’s treatment records. Dr. Safir assessed the Applicant as part of the catastrophic impairment assessment report, dated May 1, 2023. Dr. Safir concluded that, from a physical perspective, the Applicant sustained soft tissue injuries are as result of the accident, and that at the time of the assessment she exhibited functional range of motion in her spine and shoulders. Dr. Safir concluded that there was no objective evidence of any musculoskeletal impairment as a result of the accident. Dr. Soric, in the May 23, 2024 IE report, noted that the Applicant reported no sustained benefit from physical rehabilitation since the accident and questioned why the treatment continues to be provided in light of no improvement. Nevertheless, Dr. Soric diagnosed the Applicant with soft tissue trauma complicated by the development of chronic pain disorder. Dr. Soric opined that the Applicant’s physical treatment went on far too long and that additional physical treatment is not reasonable and necessary given that the Applicant has not respondent to such treatment in the past.
12Accordingly, I find that the Applicant has not met her onus to demonstrate that these plans are reasonable and necessary as a result of the accident.
Psychological services proposed by Somatic Assessments & Treatment Centre
13I find that the Applicant has not demonstrated that the unapproved portion of the psychological treatment plans is reasonable and necessary as a result of the accident.
14The denied portion of each of the psychological treatment plans relates to $712.80 for “correspondence and note taking” and $239.84 for transporting the Applicant to treatment. The Respondent denied these fees because, it submits, correspondence and note taking is part of the treatment and is included in the maximum hourly rate, as prescribed by the Professional Services Guideline (“the PSG”). The Applicant never addressed the reasons for the denied portions and, instead, made general submissions that her treating practitioners’ opinions should be given more weight than those of the independent assessors.
15I find that the fees for correspondence and note taking are an attempt to increase the effective hourly rates of the service provider. Note taking is a hallmark of not only psychological services, but all health care services, and is included in the hourly rate of a service provider.
16I find that the fees for transporting the Applicant to treatment are unnecessary considering that the service provider was approved for transportation. It is not reasonable and necessary for an insurer to pay for the Applicant’s travel time as well as the treatment provider’s travel time – only one of the two fees are reasonable and necessary.
17Accordingly, I find on a balance of probabilities that the Applicant has not demonstrated that she is entitled to the unapproved balances of the psychological treatment plans.
Attendant care services
18I find that the Applicant has not demonstrated that she is entitled to ACBs as claimed.
19The Applicant submits that the Respondent has approved all ACBs, but unreasonably withheld payment. She makes no submissions on whether the expenses are reasonable and necessary. In fact, the Applicant never directed me to a completed Form-1, and the only completed Form-1 in her evidence is by OT R. Wong, dated May 1, 2021, in the amount of $1,107.65 per month.
20The Respondent submits that I should prefer the Form-1 by OT Kaul, dated August 23, 2023. It submits that this is a more reasonable amount relative to the Applicant’s Form-1, submitted June 5, 2023, because that Form-1 allocates 12 hours per day for supervision in the bedroom. The Respondent submits there is no explanation as to why the Applicant requires 12 hours a day in supervision and that the amount it proposes, $952.36 per month, is in line with that notion.
21The Applicant had an opportunity to reply to the Respondent’s position but chose not to.
22I find the Applicant’s submissions on this issue to be disingenuous and/or misleading. There is no evidence to support her submission that all her ACB expenses have been approved and that regular breakdowns of the services provided to her have been submitted to the Respondent. The Applicant has not provided a letter or any other evidence to indicate that the Respondent approved her for ACBs as claimed, and I have not found one in the evidence. Likewise, the Applicant has submitted invoices for the services rendered which only list the days that services were provided. The invoices do not provide a list of the services provided for each day.
23Overall, I find that the Applicant has not met her onus to demonstrate that ACBs above the amounts approved and paid by the Respondent are reasonable and necessary in light of her accident-related impairments. The Applicant has not directed me to any evidence to support a finding that she requires any ACBs, let alone ACBs up to the maximum monthly amount payable. I highlight that having sustained a catastrophic impairment does not automatically entitle a person to ACBs – the Applicant remains required to provide evidence demonstrating that the expenses are reasonable and necessary as a result of the accident. Likewise, submitting invoices with no breakdown of the services rendered is insufficient to establish that ACBs are reasonable and necessary as a result of the accident.
24Considering the above, I find on a balance of probabilities that the Applicant has not demonstrated entitlement to ACBs above any amounts paid to-date.
Catastrophic impairment assessments
25I find that the Applicant has not demonstrated that the unapproved balance of the catastrophic impairment assessments is reasonable and necessary as a result of the accident.
26The catastrophic impairment assessment plan seeks funding for physiatry, occupational therapy, as well as a psychological assessment. The plan also includes two requests for file reviews in addition to the assessments. The Applicant made no submissions addressing whether the unapproved balance of the catastrophic impairment assessments is reasonable and necessary as a result of the accident. The Respondent submits that a file review is included in the $2,000.00 cap per modality for catastrophic assessments.
27I agree with the Respondent and find that the Applicant has not demonstrated entitlement to the unapproved portion of the catastrophic impairment assessment plan. I agree with the reasoning in 17-007215 v Aviva General Insurance, 2018 CanLII 141011 (ON LAT) that a file review is included in the $2,000.00 funding limit prescribed by section 25(5)(a) of the Schedule. The Applicant has not provided any reasons why she would be entitled to fees above the funding limit.
28Accordingly, I find that the Applicant is not entitled to the unapproved balance of the catastrophic impairment assessment plan.
Occupational therapy plan, dated May 23, 2023
29I find that the occupational therapy plan is not reasonable and necessary as a result of the accident.
30This plan seeks funding for an in-home assessment and the completion of a Form-1 to determine the monthly amount of ACBs the Applicant may be entitled to. The Respondent submits that this plan is duplicative. It submits that the same service was completed a week prior to the submission of the plan and there is no explanation why another assessment is reasonable and necessary. The Applicant never addressed why this plan is reasonable and necessary other than to say that her treating practitioners recommended it in light of her catastrophic injuries. The Applicant never addressed the Respondent’s submissions that this plan is duplicative, despite having an opportunity to do so.
31I agree that the plan is not reasonable and necessary as a result of the accident because it is duplicative to the attendant care re-assessment that occurred on May 16, 2023. The May 16, 2023 reassessment included a form-1 and there are no submissions or information before me to suggest that the Applicant’s condition or life circumstances changed in any measurable way after the form-1 was completed.
32Accordingly, I find on a balance of probabilities that the Applicant is not entitled to the occupational therapy plan, dated May 23, 2023.
Interest
33Interest applies on the payment of any overdue benefits pursuant to section 51 of the Schedule. Having found no benefits payable, it follows that no interest is payable.
Award
34The Applicant sought an award under section 10 of Regulation 664. Under section 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.
35The Applicant claimed entitlement to an award in order to “investigate the reasonableness of the denials and provider a deterrence to insurers in acting in a high-handed manner”. The Respondent disagrees and submits that it has acted appropriately throughout the handling of the Applicant’s claim.
36I find no basis for an award. Awards are payable only when benefits are unreasonably withheld or the payment of same is delayed. Having found no benefits payable, it follows that none of the benefits were unreasonably withheld or delayed, and no award is payable.
CONCLUSION AND ORDER
37The Applicant has not demonstrated entitlement to any of the benefits claimed.
38No interest or award is payable.
39The Application is dismissed.
Released: November 6, 2025
Brian Norris
Adjudicator