Licence Appeal Tribunal File Number: 23-013703/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:
Tiana Brown
Applicant
and
Belair
Respondent
DECISION
ADJUDICATOR:
Harouna Saley Sidibé
APPEARANCES:
For the Applicant:
Anthony Appadoo, Counsel
For the Respondent:
Robbie Brar, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Tiana Brown, the applicant, was involved in an automobile accident on July 4, 2023, 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, Belair, 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 an income replacement benefit in the amount of $400.00 per week (quantum is at issue) from February 7, 2024, to ongoing?
ii. Is the applicant entitled to $1,995.50 for physiotherapy services, proposed by Iscope Concussion and Pain Clinics in a treatment plan/OCF-18 (“plan”) dated August 8, 2023?
iii. Is the applicant entitled to $700.00 for optometric services, proposed by Iscope Concussion and Pain Clinics in a treatment plan dated August 8, 2023?
iv. Is the applicant entitled to $2,620.00 for optometric services, proposed by Iscope Concussion and Pain Clinics in a treatment plan dated October 19, 2023?
v. Is the applicant entitled to $2,191.88 for occupational therapy assessment, proposed by Rehab First Inc. in a treatment plan dated October 26, 2023?
vi. Is the applicant entitled to $1,496.75 for concussion therapy services, proposed by Iscope Concussion and Pain Clinics in a treatment plan dated January 10, 2024?
vii. Is the applicant entitled to $2,543.84 ($4,239.55 less $1,695.71 approved) for psychological therapy sessions proposed by McDowall Integrative Psychology in a treatment plan dated May 10, 2024?
viii. Is the applicant entitled to $1,200.00 for pharmacotherapy therapy proposed by Iscope Concussion and Pain Clinics, dated June 6, 2024?
ix. Is the applicant entitled to $1,102.48 for physiotherapy proposed by Woodlawn Wellness Rehabilitation, dated July 25, 2024?
x. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
xi. Is the applicant entitled to interest on any overdue payment of benefits?
3A Motion Order dated June 17, 2024, added the issue pertaining to the treatment plan for psychological therapy sessions proposed by McDowall Integrative Psychology dated May 10, 2024. A subsequent Motion Order, dated November 24, 2024, added two additional treatment plans: one for pharmacotherapy services, dated June 6, 2024, and the other for physiotherapy services, dated July 25, 2024, as set out above.
4In its submissions, the respondent indicated that the issues concerning the occupational therapy sessions and devices, totalling $3,723.79, and the rehabilitation therapy, totalling $3,455.24, have been approved and paid to the applicant on January 24 and 27, 2025. The applicant acknowledged in her reply submissions that the payment had been made. Therefore, these plans are no longer in dispute.
RESULT
5For the reasons below, I find that:
The applicant is not entitled to an additional IRB of $377.94.
The applicant is not entitled to the outstanding balance of the plan for psychological therapy sessions.
The applicant is entitled to the remaining treatment and assessment plans, with interest.
The applicant is not entitled to an award.
ANALYSIS
Is the applicant entitled to the disputed treatment and assessment plans?
6To receive payment for a treatment and assessment plan under s. 15 and 16 of the Schedule, the applicant bears the burden of demonstrating on a balance of probabilities that the benefit is 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.
7Regarding assessments, the purpose is to determine whether a condition exists that warrants further investigation. The applicant must show that there is a reasonable basis to believe that such a condition exists and that the assessment is necessary to clarify the diagnosis or guide treatment.
8I find that both disputed treatment plans for physiotherapy services are reasonable and necessary.
9The first treatment plan, dated August 8, 2023, totals $1,995.51 and is signed by Linda Johnson, Nurse Practitioner, and Mahalakshmi Pasupathy, Physiotherapist. It recommends 16 sessions of physical rehabilitation, support activity documentation, med rehab, and four planning services. The stated goals include reducing post-concussion symptoms and improving the applicant’s tolerance for daily activities.
10The second treatment plan, dated July 25, 2024, totals $1,102.48 and is signed by Aisha Mohammad, Chiropractor. This plan aims to reduce pain, improve range of motion, and facilitate the applicant’s return to pre-accident work and daily functioning.
11The applicant submits that the proposed treatments are consistent with the Ontario Neurotrauma Foundation Guidelines, particularly in relation to vestibular therapy for post-concussion symptom management. Medical records document persistent and severe symptoms, including nausea, dizziness, light sensitivity, and photophobia. These symptoms were confirmed by Dr. Paul Ranalli, Neurologist, during his examination, notwithstanding his opinion that the initial injury was minor.
12The respondent relies on Independent Examination (IE) reports from Dr. Mohamed Lamine, General Practitioner, and Dr. Ranalli to support its denial of the treatment plans. The respondent argues that the concussion diagnosis was provisional and that the proposed treatment plans are not reasonable or necessary. It further contends that the presence of concussion-like symptoms alone does not justify approval of the plans.
13Emergency department records dated July 4, 2023, indicate that the applicant presented with backache, left shoulder pain, neck pain, headache, photophobia, and phonophobia following the accident. Dr. Neil Michael Dilworth, an emergency medicine specialist, recommended physiotherapy for the applicant.
14On July 6, 2023, the applicant’s family physician, Dr. Andrew Ritchie, also recommended physiotherapy. A referral form dated January 18, 2024, from Dr. Ritchie to Trillium Health Partners recommends continuation of vestibular therapy on a bi-weekly basis.
15Clinical notes dated April 10, 2024, from Dr. Ryan Punambolam, Neurologist, further support the recommendation for vestibular therapy.
16The IE report from Dr. Lamine, dated November 1, 2023, concludes that the applicant sustained soft tissue injuries to the cervical and lumbar spine, left shoulder, and arm. He opines that the prognosis is good and anticipates full recovery. He observed no objective accident-related musculoskeletal or neurological impairments during his assessment.
17Dr. Ranalli’s report states the applicant’s pain is normal, with no central vestibular issues or BPV causing her dizziness. He reports a good neurological prognosis and no significant impairments. While acknowledging post-concussion symptoms, he believes the initial concussion doesn't fully explain their severity. He suggests emotional factors from the accident, such as depression, fear, nightmares, and sleep problems, may contribute to her ongoing symptoms.
18I assign less weight to the IE reports of Drs. Lamine and Ranalli. Their conclusions are inconsistent with the diagnoses and treatment recommendations of the applicant’s treating professionals, whose assessments are supported by clinical documentation and direct observation over time.
19I find that the treatment plans are supported by consistent and credible medical evidence from multiple treating professionals, including emergency physicians, neurologists, and rehabilitation specialists. The applicant’s symptoms are persistent and functionally limiting, and the proposed interventions are aligned with best practice guidelines for concussion and musculoskeletal injury management.
20Accordingly, I find that, on a balance of probabilities, both treatment plans are reasonable and necessary.
21I find that both proposed treatment plans for optometric services are reasonable and necessary.
22The first treatment plan, dated August 8, 2023, is in the amount of $700.00 and is signed by Linda Johnson and Dr. Manbir Randhawa, Optometrist. It proposes a Post-Traumatic Vision Syndrome (PTVS) assessment to evaluate ocular motor function and identify trauma-related visual impairments. The plan includes documentation of support activities and medical rehabilitation services.
23The second treatment plan, dated October 19, 2023, is in the amount of $2,620.00 and is signed by Dr. Randhawa. It includes 12 sessions of vision therapy, a progress report, and preparation of the treatment plan. The stated goals are to reduce post-traumatic visual symptoms, restore ocular motor function, and improve the applicant’s ability to perform visually demanding tasks, such as computer use.
24The applicant claims the respondent unfairly and medically unjustifiably denied her treatment plans, relying on Dr. Lamine's generalist opinion that ignored her visual symptoms. Despite signs of visual dysfunction noted by Dr. Ranalli, the respondent deemed an optometric assessment unnecessary. The applicant argues this contradicts Dr. Randhawa’s diagnosis of Post-Trauma Vision Syndrome and his rehab recommendation, and she criticizes the disregard of updated specialist records. She concludes that relying solely on a paper review questions procedural fairness.
25The respondent contends that both treatment plans are unreasonable and unnecessary, citing the opinions of Drs. Lamine and Ranalli that the applicant’s concussion was a provisional diagnosis and that the treatments were not justified. It mentions the applicant’s pre-existing myopia, suggesting that symptoms could be related to that. It also states that PTSD has been addressed, making further treatment unnecessary. The respondent defends relying on a paper review, noting that the assessor only saw the applicant a month earlier.
26On August 23, 2023, the applicant reported to her family physician that she was experiencing spasms around her right eye and was unable to drive due to blurred vision.
27On October 10, 2023, Dr. Randhawa, a neuro-optometrist, diagnosed the applicant with Post-Trauma Vision Syndrome. He explained that this condition is present in over 90% of individuals with acquired or traumatic brain injuries and recommended neuro-ocular rehabilitation therapy, citing its demonstrated effectiveness in improving visual symptoms following traumatic brain injury.
28On April 10, 2024, Dr. Ryan Punambolam, a Neurologist, noted that the applicant continued to experience blurry vision and had difficulty driving and reading. He confirmed the diagnosis of Post-Trauma Vision Syndrome and recommended ocular-motor and cervicogenic treatment.
29I assign less weight to the reports of Drs. Lamine and Ranalli. Their conclusions are inconsistent with the diagnoses and treatment recommendations of the applicant’s treating professionals, whose opinions are supported by clinical observations and longitudinal care. I prefer the evidence of Dr. Randhawa, a neuro-optometrist, whose expertise is directly relevant to the applicant’s visual impairments, and whose findings are corroborated by other treating specialists.
30I accept the evidence of the applicant’s treating specialists, including Dr. Randhawa and Dr. Punambolam, who have consistently diagnosed Post-Trauma Vision Syndrome and recommended targeted optometric rehabilitation. While the respondent raised concerns regarding pre-existing myopia, I find that the visual impairments described are accident-related and supported by contemporaneous medical documentation.
31Accordingly, on a balance of probabilities, I find that both optometric treatment plans are reasonable and necessary.
32I find that the proposed treatment plan dated January 10, 2024, for concussion therapy services is reasonable and necessary.
33The plan totals $1,496.75 and is signed by Mahalakshmi Pasupathy. It outlines 12 sessions of physical rehabilitation, support activity documentation, and medical rehabilitation. The stated goals are to reduce post-concussion symptoms and improve the applicant’s tolerance for daily activities.
34The applicant submits that the proposed treatment is medically necessary and supported by multiple treating professionals. She asserts that the recommendations are consistent with the Ontario Neurotrauma Foundation Guidelines, which emphasize the importance of vestibular therapy in managing post-concussion symptoms. The applicant is currently receiving Botox injections, and her symptoms, including nausea, dizziness, light sensitivity, and photophobia, are well documented. She argues that Dr. Ranalli’s characterization of her symptoms as minor is contradicted by his own observations during the IE. The applicant further contends that the respondent’s denial of the plan without a current in-person assessment fails to account for the evolving nature of her condition and undermines procedural fairness.
35The respondent maintains that the treatment plan is not reasonable or necessary. It states that the denial, communicated on January 24, 2024, is based on the same rationale used in its previous assessment of attendant care needs. The respondent argues that no new IE is required, as the prior findings, particularly those of Dr. Lamine, are sufficient to assess the necessity of the proposed treatment. It asserts that existing IE reports can be used to evaluate future treatment plans and that the applicant has not provided new evidence to justify the proposed concussion therapy.
36Emergency department records dated July 4, 2023, indicate that the applicant was experiencing symptoms consistent with a concussion, including headache, photophobia, and phonophobia. Conservative management was recommended, including rest and symptom monitoring.
37On July 6, 2023, the applicant’s family physician, Dr. Andrew Ritchie, referred her for a concussion assessment.
38The Disability Certificate (OCF-3) dated August 2, 2023, confirms diagnoses of concussion, cervical strain with reduced range of motion, left shoulder injury, and aggravation of chronic back pain.
39On August 8, 2023, the applicant underwent a concussion evaluation by Dr. Manu Mehdiratta, a Neurologist, who recommended interdisciplinary concussion management.
40On April 10, 2024, Neurologist Dr. Ryan Punambolam diagnosed the applicant with a mild traumatic brain injury resulting from the accident and similarly recommended interdisciplinary concussion management.
41I assign less weight to the IE reports of Drs. Lamine and Ranalli. Their conclusions are inconsistent with the diagnoses and treatment recommendations of the applicant’s treating professionals, whose opinions are supported by clinical documentation and direct observation over time.
42I accept the evidence provided by the applicant’s treating professionals, which consistently supports the presence of post-concussion symptoms and the need for targeted rehabilitation. While the respondent relies on prior IE findings, I find that the applicant’s condition has evolved and that updated clinical assessments provide a more accurate reflection of her current needs. The respondent’s reliance on a previous denial, without a current examination or consideration of updated medical records, does not adequately address the applicant’s documented impairments.
43Accordingly, on a balance of probabilities, I find that the treatment plan dated January 10, 2024, is reasonable and necessary.
The Outstanding Balance of the Treatment Plan for Psychological Therapy Sessions
44I find that the applicant is not entitled to the outstanding amount, as it is not reasonable and necessary.
45The disputed portion of the treatment plan amounts to $2,543.84, which is the remainder of a $4,239.55 plan that was only partially approved. The plan, signed by Dr. Sharleen McDowall, Psychologist, includes 15 sessions of mental health and addiction therapy, two support activity documentation services, and 16 preparation sessions. The treatment goals, as outlined in the psychological assessment, aim to address symptoms of PTSD, depression, anxiety, and trauma-related chronic pain.
46The applicant contends that full approval of the psychological therapy plan is medically necessary to support her recovery. She argues that partial approval, without consideration of her financial constraints, effectively denies her access to care. She states that paying out of pocket has caused financial hardship, delayed her recovery, and negatively affected her emotional well-being and ability to participate in treatment.
47The respondent asserts that the plan was partially approved, as communicated in correspondence dated May 22, 2024. It maintains that the denied portions were adjusted in accordance with the Financial Services Commission of Ontario (FSCO) Professional Services Guideline and that the adjustments are consistent with applicable standards. The respondent argues that the partial denial is justified and should be upheld.
48The Guideline establishes the maximum expenses payable by automobile insurers under the Schedule related to services provided by health care professions or health care providers listed within the Guideline. Insurers are not prohibited from paying above any maximum amount or hourly rate established in the Guideline. It is also noted within the Guideline that services provided by health care professionals/providers, unregulated providers and other occupations not listed within the Guideline are not covered by the Guideline. For services not covered by the Guideline, the amounts payable by an insurer are to be determined by the parties involved. The Guideline further notes that automobile insurers are not liable to pay expenses for services rendered to an insured person which exceed the maximum hourly rates set out in the Guideline’s Appendix.
49Pursuant to section 25(3) of the Schedule, insurers are not required to pay for professional services that exceed the limits set out in the Guideline (Superintendent’s Guideline No. 03/14). Based on the evidence, I find that the applicant has not proven that the respondent’s payment calculation was incorrect. Therefore, no additional payment is warranted.
50Although the applicant asserts that the proposed psychological services are reasonable and necessary for her accident-related injuries, she does not address the hourly rate proposed for services by Dr. McDowall, Psychologist. Nor does she explain why this rate should exceed the limits set out in the Guideline.
51Accordingly, I find that on a balance of probabilities, the applicant has not established that the respondent’s payment calculation was incorrect. Therefore, no additional payment is warranted beyond what has already been paid.
52I find that the proposed pharmacotherapy treatment plan dated June 6, 2024, is reasonable and necessary.
53The plan totals $1,200.00 and is signed by Dr. Aaron Kirschner. It includes pharmacotherapy services and documentation of support activities. The stated goals are to reduce pain, increase range of motion, facilitate return to daily activities, and support resumption of pre-accident and modified work tasks.
54The applicant submits that pharmacotherapy is medically necessary to manage her chronic pain, as recommended by her treating specialist. She states that the insurer’s denial forced her to pay out of pocket for platelet-rich plasma (PRP) injections, resulting in financial hardship and delayed recovery. She further argues that the insurer failed to consider the broader scope of her pain condition and did not approve alternative treatments, raising concerns about procedural fairness.
55The respondent relies on the IE report of Dr. Lamine, dated July 19, 2024, to support its denial of the treatment plan. The denial was communicated on August 13, 2024. The respondent asserts that Dr. Lamine’s assessment, conducted over a year after the accident and based on a comprehensive review of the applicant’s condition, concluded that the proposed pharmacotherapy was not necessary. The respondent maintains that this assessment provides sufficient medical justification for the denial, regardless of the applicant’s personal belief in the treatment’s necessity.
56On June 10, 2024, Dr. Rami Kamel, an anesthesiology and pain medicine specialist, administered pain injections to the applicant’s left common flexor tendon and left supraspinatus tendon. He recommended continued treatment and reassessment until the applicant’s pain syndrome is better managed.
57In his IE report dated July 31, 2024, Dr. Lamine noted that the applicant demonstrated a normal range of motion across all tested joints. Positive findings included tenderness in the lumbar facets and muscle tenderness in the left quadratus lumborum and paraspinal region. He opined that, given the time elapsed since the accident and the expected recovery period for the diagnosed conditions, the applicant’s musculoskeletal injuries should have significantly improved. He suggested that the persistence of pain may be influenced by psychosocial factors or pre-existing conditions rather than ongoing accident-related impairments.
58I assign less weight to Dr. Lamine’s report. His use of speculative language, such as “may be,” indicates a lack of diagnostic certainty. Furthermore, as a general practitioner, his expertise is not directly aligned with the specialized pain management provided by Dr. Kamel. I prefer the evidence of the treating pain specialist, who has conducted direct interventions and provided a clear recommendation for continued pharmacological treatment.
59Accordingly, on a balance of probabilities, I find that the pharmacotherapy treatment plan dated June 6, 2024, is reasonable and necessary.
60I find that the proposed occupational therapy assessment dated October 26, 2023, is reasonable and necessary.
61The plan totals $2,191.88 and is signed by Carter Roby, Occupational Therapist. It includes medical rehabilitation services, an environmental assessment, provider travel time, and mileage. The stated goals are to assess pain, functional capacity, safety, and independence in activities of daily living, and to support safe participation in those activities.
62The applicant submits that the assessment is medically necessary to evaluate her post-accident functional limitations. She argues that the respondent failed to conduct its own examination and relied on outdated assessments. The in-home assessment completed by Ms. Neha Hasan Gill, an occupational therapist, provides detailed evidence supporting the need for occupational and rehabilitation therapy to enhance the applicant’s safety, independence, and functional capacity. The applicant contends that without intervention, her impairments pose a risk to her well-being.
63The respondent states that the plan was denied in correspondence dated November 9, 2023, on the basis that it pertained to an Attendant Care Assessment, which was deemed inappropriate for the applicant’s claim. The respondent maintains that an IE was not required and relies on prior findings from Dr. Lamine’s IE. It argues that previous assessments are sufficient to evaluate future treatment needs and that the denial is supported by existing medical evidence.
64The in-home occupational therapy assessment, dated January 10, 2024, completed by Ms. Gill, recommended occupational therapy services to enhance the applicant’s participation in meaningful activities and to explore alternative social and leisure options tailored to her current level of function. Rehabilitation therapy was also advised to enhance activity tolerance, socialization, and community reintegration, tailored to the applicant’s functional limitations.
65The respondent’s denial letter dated November 9, 2023, states that the plan includes charges for an Attendant Care Needs Assessment, which is not payable under the Minor Injury Guideline (“MIG”). The respondent relies on Dr. Lamine’s IE report dated November 1, 2023, which found no objective accident-related musculoskeletal or neurological impairments.
66I accept the evidence provided by the applicant’s treating occupational therapist, which demonstrates a clear need for further assessment and intervention to support her recovery and daily functioning. While the respondent relies on prior assessments, I find that the applicant’s condition warrants an updated evaluation. The respondent’s reliance on outdated findings, without conducting a current examination, does not adequately address the applicant’s evolving needs.
67Additionally, the applicant is no longer subject to the MIG, and the rationale provided in the denial letter is therefore no longer applicable.
68Accordingly, on a balance of probabilities, I find that the occupational therapy assessment dated October 26, 2023, is reasonable and necessary.
Is the applicant entitled to an additional Income Replacement Benefit payment of $377.94?
69The issue before me is whether the applicant has established entitlement to an additional IRB payment of $377.94. The respondent has already paid IRB for the period beyond 104 weeks, and there is no dispute regarding entitlement. Therefore, my decision is limited to the amount of the claimed outstanding balance.
Quantum of the IRB
70The applicant states that she is owed a deficit or outstanding IRB payment of $377.94. To support her claim, she references an accounting report prepared by Davis Martindale LLP, dated October 8, 2024.
71The respondent contends that the applicant has not met her burden of proof concerning the alleged deficit. Specifically, the respondent notes that the Davis Martindale report was not disclosed prior to the applicant’s written submissions being filed, and that these submissions are limited to two sentences without an explanation of the report’s methodology or assumptions.
72The respondent further argues that the late disclosure of the Davis Martindale report caused prejudice because it was unable to assess or respond to its contents in a timely manner. Additionally, the respondent emphasizes that it did not receive complete documentation from Sun Life or the Healthcare of Ontario Pension Plan (HOOPP), which is necessary to determine any applicable offsets to the IRB calculation.
73The applicant did not explain the late disclosure of the Sun Life documentation dated May 14, 2024. This omission has limited the respondent’s ability to verify the accuracy of the claimed deficit and evaluate the impact of potential offsets.
74While the HOOPP determination and the fact that the applicant continues to receive long-term disability benefits from Sun Life may be relevant to her overall disability status, they do not directly address the amount of IRB payable under the Schedule. Moreover, the medical evidence, including the insurer’s examination by Dr. Lamine, does not support a finding of a complete inability to engage in employment, which further undermines the basis for the claimed deficit.
75Ultimately, the applicant has not provided enough evidence or detailed submissions to support the claimed shortfall of $377.94. The Davis Martindale report was filed late, without prior disclosure, and its contents were not adequately explained or put into context. Without complete financial documentation and a clear explanation of the calculation, I cannot accept the report as reliable proof of an outstanding IRB amount.
76Accordingly, I find that the applicant has not met her burden of proof to establish that she is entitled to any further IRB beyond what has already been paid.
Interest
77Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. The applicant is entitled to interest on any overdue payment of benefits in accordance with section 51.
Award
78The applicant seeks 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. The Tribunal has determined that an award is justified where the delay or withholding of benefits by the insurer is unreasonable conduct, meaning “behaviour which is excessive, imprudent, stubborn, inflexible, unyielding or immoderate.” [See, for e.g., 17-006757 v. Aviva Insurance Canada, 2018 CanLII 81949 (ON LAT); and S.M. v. Unica Insurance Inc., 2020 CanLII 61460 (ON LAT Reconsideration]. The onus is on the applicant to prove, on a balance of probabilities, that the respondent’s conduct meets this threshold.
79The applicant submits that the respondent failed to conduct updated IEs or paper reviews for several treatment plans, despite the submission of new medical evidence. She argues that the respondent ignored recommendations from qualified specialists and relied on assessments that lacked appropriate expertise. As a result, she incurred significant out-of-pocket expenses and experienced worsening physical, cognitive, and emotional symptoms due to delayed treatment.
80The respondent submits that the applicant did not comply with procedural requirements, specifically failing to provide particulars of the Award claim within 30 days of receiving the Adjuster’s Log Notes. It argues that all denials were issued in good faith, supported by medical assessments, and that the respondent should not be expected to conduct examinations for every treatment request, especially when medical documentation was delayed.
81The legal threshold for an Award is high and requires showing conduct that is excessive, imprudent, stubborn, inflexible, unyielding, or immoderate. In this case, the respondent conducted insurer examinations and issued correspondence indicating that the applicant’s file was under review and adjustment. There is no requirement for an insurer to subject every individual benefit claim to an independent review. Furthermore, the respondent approved two previously denied treatment plans in January 2025, after the applicant had submitted her written submissions. However, the timing of these approvals alone does not establish unreasonable conduct. Taken together, the respondent’s actions do not meet the threshold of unreasonably withholding or delaying payment.
82Consequently, I find that the applicant is not entitled to an award.
ORDER
83For the above reasons, it is ordered that:
i. The applicant is not entitled to an additional IRB of $377.94.
ii. The applicant is not entitled to the outstanding balance of the plan for psychological therapy sessions.
iii. The applicant is entitled to the remaining treatment and assessment plans, with interest.
iv. The applicant is not entitled to an award.
Released: November 10, 2025
__________________________
Harouna Saley Sidibé
Adjudicator