Chandra Ramdass v. Intact Insurance Company, 2025 CanLII 18215

Citation: Ramdass v. Intact Insurance Company, 2025 ONLAT 23-003973/AABS - A

Licence Appeal Tribunal File Number: 23-003973/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:

Chandra Ramdass

Applicant

and

Intact Insurance Company

Respondent

AMENDED DECISION

ADJUDICATOR:

Jonathon Dick

APPEARANCES:

For the Applicant:

Kate Baretto, Counsel

For the Respondent:

Maryam Younes, Counsel

Daniel J Holland, Counsel

HEARD:

By way of written submissions

OVERVIEW

1Chandra Ramdass, the applicant, was involved in an automobile accident on June 10, 2020, 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, Intact 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:

i. Is the applicant entitled to $6,556.75 for physiotherapy services, proposed by Mackenzie Medical Rehabilitation Centre in a treatment plan/OCF -18 (“plan”) dated May 19, 2021?

ii. Is the applicant entitled to $784.82 ($4,239.55 less $3,454.73 approved) for psychological services, proposed by Dr. Sharleen McDowall in a plan dated April 5, 2022?

iii. Is the applicant entitled to $50.39 ($2,296.05 less $2,245.66 approved) for psychological services, proposed by Dr. Sharleen McDowall in a plan dated January 17, 2022?

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

3Both parties submitted that the respondent approved issues 2 and 3 in the CCRO, dated November 8, 2023, and both issues are withdrawn.

RESULT

4I find the applicant is not entitled to $6,556.75 for physiotherapy services, proposed by Mackenzie Medical Rehabilitation Center in a plan dated May 19, 2021.

5I find the applicant is entitled to $224.42 of the unapproved amount of $784.82 in the plan for psychological services, proposed by Dr. Sharleen McDowall in a plan dated April 5, 2022.

6I find the applicant is entitled to the unapproved amount of $50.39 for psychological services, proposed by Dr. Sharleen McDowell in a plan dated January 17, 2022.

7I find that the applicant is entitled to interest on the amounts I have awarded.

ANALYSIS

8To receive payment for a treatment plan under sections 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.

9To do so, the applicant should identify the goals of treatment, how the goals would be met to a reasonable degree and the overall costs of achieving them are reasonable.

The applicant is not entitled to payment for the treatment plan for physiotherapy services in the amount of $6,556.75.

10The treatment plan dated May 19, 2021, co-authored by Dr. Julian Chen, Chronic Pain Specialist, and Dr. Jennifer Violante, Chiropractor, seeks to achieve the following goals: pain reduction, increased strength, increased range of motion, return to activities of normal living, and return to modified work activities.

11The plan recommends the following treatments to meet the stated goals: 1 total body assessment, 1 Botox treatment, 1 PRP treatment, 15 exercise sessions, 15 manipulation sessions, 15 therapy sessions, 1 acupuncture session, and 1 low lumbar support.

12The applicant submits that all the doctors who treated the applicant support ongoing physiotherapy.

13The applicant submits that she attended her family physician, Dr. Ramesh Asirwathan, within two days after the accident and twice further in the following weeks. At those times, Dr. Asirwathan noted the applicant had pain in her head, neck, low back and right shoulder, as a result of whiplash from the accident and recommended physiotherapy and counselling.

14In addition, the applicant submitted Dr. C.P. Chang’s report of July 30, 2020. Dr. Chang, an orthopaedic surgeon, finds that the applicant has sustained a possible whiplash injury from the accident and recommends conservative treatments, not surgery. Continuing pain management and therapy are encouraged. To assist in the applicant’s work, Dr. Chang recommends an ergonomic assessment and a higher chair.

15In Dr. Chang’s report dated July 12, 2021, the doctor recommends continued pain management, physiotherapy, massage, and chiro, and referred the applicant to a surgeon for a right rotator cuff tear.

16The respondent submits that the goals of the treatment plan are not reasonable and necessary because they have already been met. Dr. Choi, IE assessor, reporting on February 25, 2021 opines that the applicant is independent in her activities of daily living. Dr. Choi opines further that it is unlikely that the applicant’s current complaints are a direct result of the accident, but due to a significant history of chronic pain.

17The applicant submits that Dr. Choi does not address the other stated goals of the treatment plan, such as pain reduction and increased range of motion and does not address each modality in the plan. Dr. Choi maintains that the applicant’s injuries are minor and can be treated within the MIG, but the MIG no longer applies as the respondent has removed the applicant from the MIG.

18The respondent submits that physiotherapy is not helping the applicant, as the applicant’s Family Physician, Dr. Ramesh Asirwatham, noted on March 30, 2021 that the applicant complained that physiotherapy was making her worse.

19I find that the applicant has not met her onus to demonstrate how the plan’s goals would be met to a reasonable degree and that the overall costs of achieving them are reasonable because the reporting of Dr. Chang and Dr. Choi does not corroborate the need for services such as Botox and PRP and the applicant reported to her family physician in March 2021 that physiotherapy was making her worse.

20I find on a balance of probabilities that the applicant is not entitled to the treatment plan for physiotherapy services.

The applicant is entitled to $149.61, which is part of the unapproved amount for the treatment plan for psychological treatment in the amount of $748.82.

21The treatment plan of Dr. Sharleen McDowall, Psychologist, for psychological treatment, dated April 5, 2022 essentially sets out the following goals: to return the applicant to activities of normal living; to reduce negative thought patterns; and to learn coping skills for improved daily function.

22Dr. McDowall recommends the following treatments: 15 (one hour) therapy sessions at a cost of $2,244.15; 15 (half hour) preparation/notetaking at a cost of $1,122.15; 1 (four and a half hours) mental health test at a cost of $673.25; and $200.00 for preparing the insurance claim form.

23The insurer disputes the following parts of the treatment plan: the number of hours to conduct mental health testing; the number of hours to prepare for a therapy session; and the number of hours to make post-session notes.

24The applicant submits that the evidence for the reasonability of 4.5 hours for conducting a mental health test is found in the s. 44 assessment of Dr. Al-Hage, dated October 14, 2022, wherein Dr. Al-Hage conducted a clinical interview and administered 3 clinical tests, which itself took 4 hours.

25The applicant submits that 15 minutes (.25) before and after each of the 15 sessions is reasonable for preparation and post-session notetaking.

26The respondent submits that 3 hours for testing and .25 hour for both preparation and note-taking are reasonable, based on Dr. Al-Hage’s s.44 report dated October 14, 2022.

27I am persuaded by the applicant, in part. If Dr. Al-Hage took four hours to administer three clinical tests, then it would seem reasonable for the applicant’s psychologist to take approximately four hours as well. I find that four and a half hours is reasonable.

28I am not persuaded, however, that half an hour per session for preparation and notetaking is reasonable. I concur with the respondent that a quarter hour per session, as approved, is reasonable for preparation and notetaking.

29The respondent submitted that applicant did not provide the clinical notes of Dr. McDowall prior to producing submissions. The applicant acknowledged that the CNRs were not provided, adding that it was an oversight. I have considered this in making my decision and find that it does not prejudice the respondent in relation to the issues in dispute.

30I find on a balance of probabilities that the applicant is entitled to four and a half hours to administer psychological testing, which is one and a half hours more than approved. Therefore, the applicant is entitled to $224.42 for the treatment plan for psychological treatment, which represents the maximum hourly rate pursuant to the Guidelines.

The applicant is entitled to the unapproved amount of a treatment plan for psychological treatment in the amount of $50.39.

31The respondent partially approved the treatment plan/OCF-18 of Dr. Sharleen McDowell, dated January 17, 2022, leaving $50.39 unapproved. The dispute is over whether Dr. McDowall’s claimed fee of $200.00 plus HST for preparing the OCF-18 is reasonable and necessary.

32The applicant submits that Dr. McDowall’s $200.00 fee essentially represents one hour and 20 minutes at an hourly rate of $149.61, which is the maximum hourly rate according to the Professional Service Guidelines. I note that $200.00 plus HST is the maximum allowable fee under the Guidelines for completing an OCF-18.

33The applicant submits that the maximum fee is appropriate as this OCF-18 is more detailed and onerous than a brief pro forma OCF-18 form. Specifically, completion of this OCF-18 included a mini-assessment and drafting a report.

34The respondent submits that only one hour is reasonable and necessary to complete the OCF-18 and, as a result, approved $149.61. The respondent submits that Dr. McDowell did not adequately justify why more than one hour is required to complete the form.

35I am persuaded by the applicant and find on a balance of probabilities that it is reasonable and necessary for completion of this OCF-18 to take one hour and 20 minutes, which results in a maximum fee of $200.00 plus HST. Since the respondent has already approved $149.61, I award the applicant the amount of $50.39.

Interest

36Interest on $224.42 and $50.39 is payable pursuant to s. 51 of the Schedule.

ORDER

37I find:

i. The applicant is not entitled to $6,556.75 for physiotherapy services, proposed by Mackenzie Medical Rehabilitation Centre in a plan dated May 19, 2021.

ii. The applicant is entitled to $224.42 for psychological services, proposed by Dr. Sharleen McDowall in a plan dated April 5, 2022.

iii. The applicant is entitled to $50.39 for psychological services, proposed by Dr. Sharleen McDowall in a plan dated January 17, 2022.

iv. The applicant is entitled to interest on the payments for the plans for psychological services dated April 5, 2022 and January 17, 2022.