Licence Appeal Tribunal File Number: 24-004837/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 Shi
Applicant
and
The Personal Insurance Company
Respondent
AMENDED DECISION
ADJUDICATOR: Jeff Chatterton
APPEARANCES:
For the Applicant: Aylina Dhanji, Counsel
For the Respondent:
Melanie Sousa Leanne Zabudsky, Counsel
HEARD: In Writing
OVERVIEW
1The applicant, Wei Shi’s father was involved in an automobile accident on March 16, 2021. The applicant claimed to have developed psychological symptoms as a result of her father’s accident, 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, The Personal Insurance Company, and applied to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issues in dispute are:
Is the applicant entitled to $2,918.96 for psychological services, proposed by Healthcare Management Group in a treatment plan/OCF-18 (“plan”) dated February 9, 2023?
Is the applicant entitled to $3,701.74 for psychological services, proposed by Somatic Assessments and Treatment Clinic in a treatment plan dated May 27, 2024?
Is the respondent liable to pay an award under s. 10 of Reg. 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 met the onus to demonstrate entitlement to the treatment plans for psychological services. No award or interest are payable.
ANALYSIS
Is the applicant entitled to the treatment plans for psychological services?
4The applicant is not entitled to psychological services.
5To 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.
6In dispute are two OCF-18s for psychological services, dated approximately 15 months apart. The first, authored by Psychologist Lixian Bao, calls for 12 one-hour sessions of psychotherapy. The second, authored by Psychologist Svetlana Gabidulina, calls for 14 one-hour sessions. It was unclear from the evidence provided whether these service providers were involved with prior psychological services provided to the applicant, or if they had reviewed prior psychological reports.
7The applicant submits she should be entitled to both treatment plans because she has provided corroborating evidence depicting her accident-related psychological impairments, and that she has not yet returned to her pre-accident state. To support her claim, the applicant relies on two Psychological Progress Reports, authored by Psychotherapist Jian Su and supervised by Psychologist Dr. Olivera Bojic-Ognjenovic, dated January 11, 2022 and September 27, 2021. Of note - the applicant was removed from the Minor Injury Guideline due to her accident-related psychological injury. The only other supporting medical evidence provided was a Psychological Assessment Report from Dr. Bojic-Ognjenovic, dated May 26, 2021.
8The progress reports state that the applicant still suffers significant symptoms of anxiety and depression, as well as somatic symptoms, and recommended an additional 14 treatment sessions.
9The respondent disagrees, and relies on a s.44 Insurer’s Examination (“IE”) conducted by Clinical and Forensic Psychologist Dr. Arnold Rubenstein, dated April 13, 2022. In the IE, Dr. Rubenstein notes that the applicant’s symptoms were likely due to “symptom magnification.”
10In his IE report, Dr. Rubenstein reports that the applicant failed validity testing on the Structured Inventory of Malingered Symptomology test. Dr. Rubenstein opined it was impossible to lend validity to scores on other psychometric tests. He reported the applicant a) endorsed a high-rate of symptoms rarely found in individuals with bona-fide neurological disorders, b) that she endorsed symptoms that were illogical, bizarre and rarely reported by psychiatric patients, and c) demonstrated symptoms which “do not generally occur in a constellation.”
11I find the respondent’s evidence convincing, for two reasons. Dr. Rubenstein relied on objective testing, which the applicant failed. Further, as the goal of psychiatric treatments is to address psychological symptoms, I note that Dr. Rubenstein’s report is more contemporaneous to the disputed OCF-18s in question where he reports that the applicant does not “meet criteria for any diagnosis.”
12I do not prefer the applicant’s evidence, because the applicant’s primary medical evidence in support of the OCF-18 is the Psychological Progress Reports, which would have been well over a year and two years old at the time of the creation of the OCF-18s. I further note that neither of the Progress Reports contain any testing data, be it self-analysis or objective, other than an opinion that “the applicant has been responsive to psychotherapy.’
13Although the onus is on the applicant to prove entitlement, I have not been led to contemporaneous medical evidence to support the applicant’s claim, nor a convincing reason provided for the gap in treatment.
14For these reasons, I find the applicant has not met the onus, on a balance of probabilities, to establish entitlement to the psychological services in dispute.
Interest
15Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no benefits are overdue, no interest is payable.
Award
16The 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. As I have not found that the insurer unreasonably withheld or delayed benefits, no award is payable.
ORDER
17The application is denied.
i. The applicant is not entitled to the psychological services in dispute.
ii. Neither interest nor an award are payable.
Released: December 23, 2025
Jeff Chatterton
Adjudicator