Citation: Chen v. Pembridge Insurance Company, 2025 ONLAT 22-012411/AABS
Licence Appeal Tribunal File Number: 22-012411/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:
Guang You Chen
Applicant
and
Pembridge Insurance Company
Respondent
DECISION
ADJUDICATOR: Harouna Sidibé
APPEARANCES:
For the Applicant: Yu Denise Jiang, Paralegal
For the Respondent: Oliver Gorman-Asal, Counsel
HEARD: By way of Written Submissions
OVERVIEW
1Guang You Chen, (the “applicant"), was involved in an automobile accident on July 29, 2022, 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, Pembridge Insurance Company (the “respondent”) and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
2As a result of injuries sustained from the accident, the applicant was later removed from the Minor Injury Guideline (“MIG”).
ISSUES
3The issues in dispute are:
i. Is the applicant entitled to $3,989.56 for physiotherapy services, proposed by Total Recovery Rehab Centre in a treatment plan/OCF-18 (“plan”) dated November 24, 2022?
ii. Is the applicant entitled to $3,989.56 for physiotherapy services, proposed by Total Recovery Rehab Centre in a plan dated January 12, 2023?
iii. Is the applicant entitled to $4,303.90 for chiropractic services, proposed by Total Recovery Rehab Centre in a plan dated March 9, 2023?
iv. Is the applicant entitled to $3,959.56 for physiotherapy services, proposed by Total Recovery Rehab Centre in a plan dated April 27, 2023?
v. Is the applicant entitled to $3,701.88 for psychological services, proposed by Somatic Assessments and Treatment Clinic in a plan dated January 4, 2023?
vi. Is the applicant entitled to $2,200.00 for psychological assessment, proposed by Somatic Assessments and Treatment Clinic in a plan dated August 1, 2022?
vii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
viii. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
4For the reasons below, I find that:
i. The applicant is not entitled to the treatment plans in dispute.
ii. The applicant is not entitled to s.51 interest or an award under s.10 of Reg. 664.
ANALYSIS
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.
6The applicant was involved in a motor vehicle accident on July 29, 2022, sustaining various injuries, including rib fractures and psychological distress. Following the accident, the applicant sought treatment and submitted multiple treatment plans for coverage under his insurance policy with Pembridge Insurance Company. The respondent denied the treatment plans, arguing they were not reasonable or necessary based on the medical evidence presented.
7The applicant did not distinguish between the different treatment plans in his argument. Therefore, I will approach my analysis in a similar manner. I will first examine physiotherapy and chiropractic services, then move on to psychological services and psychological assessment, and finally conclude with a discussion of interests and the award.
Physiotherapy and Chiropractic Services
8I find, on a balance of probabilities, that the applicant has not established entitlement to $3,989.56 for physiotherapy services provided by Total Recovery Rehab Centre in plans dated November 24, 2022; January 12, 2023; and April 27, 2023. I also find that the applicant is not entitled to $4,303.90 for chiropractic services proposed by Total Recovery Rehab Centre in a plan dated March 9, 2023.
9The applicant contends that these treatment plans are both reasonable and necessary to address ongoing pain, reduced range of motion, and functional impairments resulting from the accident. Additionally, he notes that the treating practitioners, including Dr. Georgia Palantzas, a chiropractor, and Dr. Ahmed Afifi, a physiotherapist, support these treatment plans.
10The respondent argues that the applicant has not adequately demonstrated the necessity for these treatments. It claims that the applicant's submissions lack detail and rely solely on the treatment plans, which are insufficient to prove their reasonableness and necessity. Furthermore, a s. 44 assessment conducted by Dr. Alfonse Marchie, a physiatrist, concluded that additional facility-based physical therapy would not lead to long-lasting symptom relief.
11For physiotherapy services, the first treatment plan, dated November 24, 2022, was for $3,989.56 and involved 48 (16 x 3) sessions of multiple body site therapy. The second treatment plan, dated April 27, 2023, was for $3,959.56, seeking the same number of sessions for multiple body site therapy. The applicant did not submit the third treatment plan, dated January 12, 2023, as evidence for the hearing.
12For chiropractic services, the treatment plan dated March 9, 2023, was for $4,303.90, seeking 16 sessions of multiple body-site manipulation, 16 sessions of spinal vertebra exercises, and 16 sessions of multiple body-site acupuncture.
13I find that the applicant has not demonstrated, on a balance of probabilities, that the treatment plans are reasonable and necessary. The applicant based his argument on the treatment plans. While the applicant has provided some evidence of ongoing pain, as outlined in Mr. Raymond Wong’s Occupational Therapy Home Safety Assessment Report and Dr. Alfonse Marchie’s Physiotherapist Report, I find that he has not discussed whether the recommended treatment will aid in his recovery. In contrast, all the provided treatment plans indicate that there are barriers to recovery, such as frail elderly and diabetes.
14In his report dated December 28, 2022, Dr. Marchie concluded that the applicant has participated in facility-based physical therapy sessions that have not provided any lasting relief from his symptoms. Therefore, Dr. Marchie does not believe that further treatment will offer any significant improvement for the applicant’s musculoskeletal pain at this time, and such treatment is not medically necessary. I place greater weight on Dr. Marchie’s report, as it was based on extensive medical records, imaging results, and structured physical examinations, which he relies on to conclude that further physiotherapy and chiropractic care would not yield meaningful improvement. In contrast, Mr. Wong relied heavily on self-reported symptoms. Lastly, I find that Dr. Marchie, as a board-certified physiatrist, is more qualified to assess musculoskeletal injuries than an occupational therapist like Mr. Wong.
15I find that the medical evidence does not establish that the treatment plans are reasonable and necessary. The OCF-18s seek approval for 96 sessions of multiple body site therapies, and no medical documentation has been presented to corroborate the need for such a high number of sessions. I assign little weight to the OCF-18s, as they are not sufficient evidence on their own without supporting medical analysis. It is neither reasonable nor necessary to approve multiple identical treatment sessions in succession without demonstrating their effectiveness or addressing recurring issues. The lack of a ramp-down in sessions, treatments, and costs indicates insufficient documented progress. Repeating the same treatment without a progress report or evidence of benefit does not align with what is considered reasonable and necessary.
16I find that corroborating medical evidence is necessary to validate the reasonableness and necessity of treatment plans. The applicant's reliance solely on treatment plans, without adequate supporting medical documentation, does not satisfy the burden of proof. Also, the applicant did not submit as evidence the OCF-18 dated January 12, 2023.
17Accordingly, I find on a balance of probabilities that the available evidence does not show that the recommended treatment plans for physiotherapy and chiropractic services were reasonable and necessary.
Psychological Services and Assessment
18I find, on a balance of probabilities, that the applicant has not established entitlement to $3,701.88 for psychological services proposed by the Somatic Assessments and Treatment Clinic in a plan dated January 4, 2023.
19I also find that the applicant is not entitled to $2,200.00 for a psychological assessment proposed by the Somatic Assessments and Treatment Clinic in a plan dated August 1, 2022.
a) Psychological Services
20The applicant is seeking funding for psychological treatment due to diagnoses of PTSD, major depressive disorder, and specific phobia. He submits that the claims are supported by reports from Dr. Sharleen McDowall, psychologist (psychological assessment) and Mr. Raymond Wong (attendant care needs assessment). The applicant did not submit the disputed OCF-18 dated January 4, 2023, as evidence for the hearing.
21The respondent contends that the psychological services do not justify the requested amounts and that the medical evidence does not support the need for these services. Furthermore, the respondent argues that the applicant has not distinguished between different treatment plans or provided appropriate medical evidence to substantiate the necessity of their claims.
22I find that although the applicant has been diagnosed with PTSD, the evidence presented remains unclear regarding the need for the specific psychological services requested. Also, the applicant’s expert, Dr. Sharleen McDowall, states that there was no evidence of any thought disorder or psychotic process.
23On the other hand, Dr. Shulamit Mor’s report, dated November 29, 2022, concluded that he would diagnose the applicant at most with adjustment difficulties, which are not severe enough to warrant a formal Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) diagnosis. He adds that the applicant does not require any psychological support interventions.
24I place more emphasis on the latter report because Dr. Mor’s psychological conclusions were consistent with previous hospital assessments, which did not support a severe trauma-related disorder. Dr. McDowall’s findings emphasized psychological symptoms while not addressing external factors such as pre-existing medical or psychological conditions, age-related cognitive and emotional changes, etc., which affected her recommendations for prolonged treatment. Furthermore, the applicant's submissions did not clarify the goals he seeks from his psychological treatments and did not sufficiently differentiate between the various types of psychological treatments or reference relevant medical records to support his claims.
b) Psychological assessment
25The purpose of an assessment is to determine whether a condition exists. For an insured, they bear the onus of demonstrating that there are grounds on which to believe that a condition exists that would warrant further investigation by way of an assessment.
26The applicant submitted an OCF-18, dated August 1, 2022, to seek funding for a psychological assessment.
27The respondent argues that the applicant has not distinguished between different treatment plans or provided appropriate medical evidence to substantiate their necessity.
28The OCF-18 submitted as evidence is relevant to an attendant care assessment, attendant care needs FORM1, the completion of the OCF-18, planning services (OT), education, and promoting health, which aims to seek attendant care and facilitate a return to normal living activities. I cannot assess the need for a psychological assessment without having proper information on the goals of treatment, how the goals would be met to a reasonable degree and that the overall costs of achieving them are reasonable.
29I find that the OCF-18 submitted by the applicant as evidence lacks helpful information concerning the need for a psychological assessment, which is distinct from the attendant care assessment. Consequently, I have been unable to fully evaluate the reasonableness and necessity of the disputed treatment plan. Therefore, I conclude that he has not met his burden of proving that the treatment plan is reasonable and necessary. The applicant has not demonstrated that requesting an additional psychological assessment is reasonable and necessary.
30For all these reasons, I find that the applicant has failed to meet his onus of proving that the disputed treatment plans are reasonable and necessary. Accordingly, I conclude, on a balance of probabilities, that the applicant has not established entitlement to the treatment plans in question.
Interest
31Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule.
32Since there are no overdue payments, no interest is owed.
Award
33The applicant sought an award under s. 10 of Reg. 664. Under s. 10, the Tribunal may grant an award of up to 50 percent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits.
34The applicant argues that an award is justified because the respondent has a duty to take all necessary steps to demonstrate the “utmost trust" that defines the relationship between an insurer and an insured individual. He also points out that the respondent did not assure the applicant that he could truly trust the investigation and assessment process.
35The respondent indicates that the applicant has provided no evidence of overlooked specifics or ignored records.
36The applicant bears the burden of proof to show that the denial of benefits was unreasonable, which has not been demonstrated in this case. An award necessitates evidence of conduct that is “excessive, imprudent, stubborn, inflexible, unyielding, or immoderate.” I find no evidence that the respondent’s actions reached this level. However, I find that the respondent has provided reasonable grounds for disputing the treatment plans based on the available medical evidence and assessments.
37Consequently, based on the above points, the applicant did not meet the onus of demonstrating that the respondent has unreasonably withheld or delayed the payment of benefits. Therefore, I find that the applicant is not entitled to an award.
ORDER
38For the reasons outlined above, I find that:
i. The applicant is not entitled to the treatment plans in dispute.
ii. The applicant is not entitled to s.51 interest.
iii. The respondent is not liable to pay an award under s.10 of Reg. 664.
Released: March 12, 2025
Harouna Sidibé
Adjudicator