Licence Appeal Tribunal
RECONSIDERATION DECISION
Before: Craig Mazerolle, Vice-Chair
Licence Appeal Tribunal File Number: 23-010971/AABS
Case Name: Alice Agulefo v. Allstate Canada
Written Submissions by:
For the Applicant: Terio Francis, Counsel
For the Respondent: Alexander Dos Reis, Counsel
OVERVIEW
1On October 14, 2025, the respondent requested reconsideration of the Tribunal’s decision released September 23, 2025 (“decision”).
2Stemming from an accident on January 7, 2020 and a request for benefits made pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 2010 (including amendments effective June 1, 2016) (“Schedule”), the parties participated in a written hearing. In the decision, the Tribunal found the applicant was entitled to several treatment plans, including the plan for a catastrophic assessment totaling $25,280.00. This plan comprised of several different assessments from a variety of disciplines, including neurology, psychiatry, etc.
3The grounds for a request for reconsideration are found in Rule 18.2 of the Licence Appeal Tribunal Rules, 2023 (“Rules”). To grant a request for reconsideration, the Tribunal must be satisfied that one or more of the following criteria are met:
a) The Tribunal acted outside its jurisdiction or committed a material breach of procedural fairness;
b) The Tribunal made an error of law or fact such that the Tribunal would likely have reached a different result had the error not been made; or
c) There is evidence that was not before the Tribunal when rendering its decision, could not have been obtained previously by the party now seeking to introduce it, and would likely have affected the result.
4The respondent relies on Rule 18.2(b) to support its position that the Tribunal erred in its conclusion about the quantum of the multi-disciplinary catastrophic assessment treatment plan. It is seeking an order finding the applicant’s entitlement to this plan should be reduced from $25,280.00 to $14,916.00.
5The applicant asks the Tribunal to dismiss the request, as well as an award of interest on overdue amounts.
RESULT
6The respondent’s request for reconsideration is granted, in part.
7Pursuant to Rule 18.4, the decision is varied at paragraph 134(ii) as follows:
The applicant is entitled to the remaining plans in dispute, with interest pursuant to section 51 of the Schedule, though only in the amount of $17,176.00, plus interest, for the catastrophic assessment proposed in the plan dated November 29, 2022.
ANALYSIS
8The test for reconsideration under Rule 18.2 involves a high threshold. The reconsideration process is not an opportunity for a party to re-litigate its position where it disagrees with the Tribunal’s decision, or with the weight assigned to the evidence. The requestor must show how or why the decision falls into one of the categories in Rule 18.2.
9I find the respondent has met the criteria for reconsideration under Rule 18.2(b).
10The respondent argues there are two main errors in the Tribunal’s analysis of this plan. First, the respondent claims the Tribunal ignored the statutory limit for how much a party can be paid for an individual assessment, pursuant to s. 25(5) of the Schedule. The respondent highlights how there are several instances where the Tribunal granted an amount over this $2,000.00 limit, e.g., $4,000.00 for an orthopaedic assessment. There were also separate amounts granted for duplicative assessments, e.g., $2,000.00 for a psychiatric assessment, and $2,000.00 for psychiatric testing. Yet, despite raising these arguments during the hearing, the respondent submits that the applicant did not “make any statements or arguments at all relating to the appropriate quantum for the CAT psychiatry, CAT orthopaedic, or CAT neurological assessments”.
11Citing cases like Moffatt v. Aviva General Insurance, 2025 CanLII 69523 (ON LAT), the applicant disputes the request as an improper attempt to re-litigate arguments and evidence considered at first instance. According to the applicant, it is not enough for a party to disagree with the outcome, but they must show there was a legal or factual error that would have impacted the result. The applicant argues that the respondent has not met this standard, as it is clear the Tribunal engaged in a detailed analysis of the evidence that was grounded in s. 25 and s. 45 of the Schedule. Specifically, the applicant argues that multidisciplinary catastrophic assessments are complex, multi-step evaluations, so the Tribunal correctly found that assessors from the same discipline may be called upon to do different, distinct assessments.
12When the Tribunal is considering whether an assessment is payable, the applicant has the onus to show that the proposal is both reasonable and necessary. This test comprises of two factors: is the assessment necessary for the applicant’s recovery, and are the proposed costs reasonable? This second part of the test is guided, in part, by s. 25 of the Schedule, which provides limits on how much an insurer will be expected to pay for an assessment. Specifically, s. 25(5)(a) states that an insurer shall not pay:
more than a total of $2,000 plus the amount of any applicable harmonized sales tax payable under Part IX of the Excise Tax Act (Canada) for accidents that occur on or after June 3, 2019 in respect of fees and expenses for conducting any one assessment or examination and for preparing reports in connection with it…
13The Tribunal’s analysis of the applicant’s catastrophic assessment treatment plan can be mainly found at paragraphs 113 + 114 of the decision:
I am satisfied that the applicant has provided sufficient medical evidence to establish a reasonable basis for pursuing a CAT determination. The findings from both treating and assessing professionals offer objective support for the possibility that the applicant’s impairments meet the catastrophic threshold. In particular, I find the reports from Drs. Shahmalak and Getahun are credible due to their detailed clinical observations, consistency with the applicant’s reported symptoms, and the use of recognized assessment methodologies. While the respondent raises concerns about the timing and consistency of the assessments, I do not consider these concerns sufficient to undermine the overall reliability of the evidence. The assessments were conducted within a reasonable timeframe after the accident and reflect a coherent picture of the applicant’s ongoing impairments. Therefore, I conclude that the medical evidence supports a credible possibility of catastrophic impairment.
I also reject the respondent’s argument that the applicant must exhaust her non-CAT benefits before seeking CAT assessments. The Schedule does not impose such a requirement, and early identification of catastrophic impairment can be essential for appropriate treatment planning.
14I am satisfied that these reasons provide a comprehensive accounting of the Tribunal’s determination for why the multi-disciplinary assessments proposed in the treatment plan are necessary for the applicant’s recovery. However, aside from rejecting the respondent’s argument about the need to “exhaust her non-CAT benefits before seeking CAT assessments”, I find there is no analysis about the reasonableness of the proposed expenses. Specifically, despite being raised in several sections of the respondent’s submissions, there is no discussion about the statutory cap for assessments under s. 25(5), nor is there any reference to the argument that certain assessments are duplicative.
15While it is well-settled that a decision-maker is not expected to address every submission—however minor—they do have an obligation to address all the parties’ key arguments. I am satisfied that the respondent’s arguments about the reasonableness of these proposed expenses were not made as passing references in its submissions, but they formed a key aspect of its theory of the case. Therefore, by not explicitly addressing this important aspect of the respondent’s argument, I find the Tribunal erred.
16I further find that, had this error not occurred, the outcome would likely have been different. Due to the centrality of these arguments to its case (as well as the fact that they are grounded in the language of the Schedule), I find the outcome of the decision would likely have been different if the Tribunal had explicitly addressed this part of the respondent’s submissions.
17The applicant’s reconsideration submissions do not persuasively challenge this finding. The respondent does not simply disagree with the outcome, but rather it has identified a key aspect of its case that is missing from the decision. While I accept that the Tribunal engaged in a detailed weighing of the medical evidence to determine that the proposed assessments are necessary, the reasonableness of the plan was raised by the respondent, but not addressed in the decision.
18I do note though that the respondent did not raise any argument in its written hearing submissions about how the applicant was seeking separate payments for a neurological assessment and neurological testing. Parties are expected to put their best foot forward during the hearing, and there was no reason why this argument could not have been presented at first instance, especially as a similar argument was being made about the psychiatric assessment and psychiatric testing. The absence of any similar argument about these neurological aspects of the plan would have reasonably led the applicant (and the Tribunal) to assume that the costs of this part of the treatment plan was not being contested, nor was there any concern about duplication. Taken together, I find the respondent has not demonstrated any error in this section of the decision.
19The second main error that the respondent alleges is that the Tribunal granted a $2,000.00 fee for a file review, a finding that runs counter to the established case law. Aside from her general argument about how the reconsideration process is not a venue for re-litigating arguments from the hearing, the applicant did not make any specific submissions about this part of the respondent’s request.
20Once again, I find the Tribunal did not address a key argument raised by the respondent in its written hearing submissions. This argument was not a throwaway comment, but rather it formed an essential part of the respondent’s position on this plan. By not explicitly addressing this submission, I again find that the respondent has shown an error in the decision that would likely have impacted the outcome.
Rule 18.4 – Varying the Decision
21Having found the respondent successfully engaged Rule 18.2, I must now determine the appropriate remedy under Rule 18.4. Considering the contrast between the number of issues that were decided during the written hearing (and the relatively narrow scope of this reconsideration request), I find the most appropriate remedy is for me to review the parties’ arguments and evidence from the written hearing. After completing this review, I am satisfied that, pursuant to Rule 18.4, I will vary the decision to reduce the applicant’s entitlement to the catastrophic assessment treatment plan from $25,280.00 to $17,176.00.
22In its written hearing submissions, the respondent detailed several arguments related to the quantum of the catastrophic assessment treatment plan. For instance, at paragraph 45, it argues that:
… even if a s. 25 CAT psychiatry assessment was payable… at most, only $2,000 would be payable, not the $6,000 sought for Lines 3 and 4 combined. To find otherwise would violate s. 25(1) of the SABS, which limits the cost of a s. 25 assessment to $2,000.00
23At paragraph 46, the respondent disputes the proposed cost of $4,000.00 for the orthopaedic assessment, arguing that the Schedule limits this payment to $2,000.00. Then, citing several Tribunal cases to support this position, the respondent contests the applicant’s request for a separate file review fee at paragraph 48.
24I find these arguments are persuasive defenses against the expenses being proposed in these sections of the plan. Not only does s. 25(5) clearly state that there is a $2,000.00 limit for any individual assessment, but the respondent has identified a potential level of duplication in the overlap between the proposed psychiatric assessment and the proposed psychiatric testing. Additionally, though Tribunal decisions are not binding, the case law presented by the respondent about the file review is persuasive, namely, K.Y.C. v. Unica Insurance Inc., 2020 CanLII 30388 (ON LAT) and Berisha v Certas Home and Auto Insurance Company, 2020 CanLII 103692 (ON LAT). In both cases, the adjudicators reasoned that assessors must review the available medical evidence before rendering an opinion, such that allowing for payment of a separate file review would breach the statutory limit under s. 25(5). I agree with this reasoning.
25Despite raising these persuasive defenses, I find the applicant does not address any of these arguments in reply. For instance, there is no explanation for why she is entitled to payments over the $2,000.00 limit, nor does she address why separate payments are needed for the psychiatric assessment and testing.
26Once again, the applicant has the onus to demonstrate the reasonable and necessary nature of the disputed treatment plans, an onus that extends to the different assessments proposed in her catastrophic assessment treatment plan. Considering the persuasive defenses were laid out in the respondent’s submissions, it was imperative for the applicant to address them in reply. By not addressing the arguments, I am satisfied, on a balance of probabilities, that the applicant has not met her onus to show the reasonableness of the expenses proposed for the psychiatric assessment, the psychiatric testing, the orthopaedic assessment, and the file review.
27I will use Rule 18.4 to make the following variations to the order concerning entitlement to the catastrophic assessment treatment plan:
a. Remove the cost of the file review;
b. Reduce the cost of the psychiatric assessment and psychiatric testing to a single, total payment of $2,000.00; and,
c. Reduce the cost of the orthopaedic assessment to $2,000.00.
28The applicant is now entitled to a total payment of $17,176.00, plus interest, for this treatment plan. In accordance with s. 25(5) of the Schedule, this total amount includes HST.
CONCLUSION & ORDER
29The respondent’s request for reconsideration is granted, in part.
30Pursuant to Rule 18.4, the decision is varied at paragraph 134(ii) as follows:
The applicant is entitled to the remaining plans in dispute, with interest pursuant to section 51 of the Schedule, though only in the amount of $17,176.00, plus interest, for the catastrophic assessment proposed in the plan dated November 29, 2022.
Craig Mazerolle
Vice-Chair
Released: November 26, 2025