Licence Appeal Tribunal File Number: 23-005505/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:
Yong Yu Lisa Yuan
Applicant
and
Co-operators General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Lisa Holland
APPEARANCES:
For the Applicant:
Sareena Samra, Counsel
For the Respondent:
Jonathon Kahane-Rapport, Counsel
HEARD:
By Way of Written Submissions
OVERVIEW
1Yong Yu Lisa Yuan, the applicant, was involved in an automobile accident on November 15, 2018, 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, Co-operators General 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 psychological services, proposed by Somatic Assessments & Treatment Clinic in treatment plans/OCF-18 (“plan”), as follows:
a) $1,802.52 ($5,611.22 less $3,808.70 approved), in a plan dated September 14, 2022;
b) $1,802.52 ($5,611.22 less $3,808.70 approved), in a plan dated November 9, 2022;
c) $1,802.52 ($5,611.22 less $3,808.70 approved), in a plan dated December 12, 2022;
d) $1,802.52 ($5,611.22 less $3,808.70 approved), in a plan dated January 16, 2023?
ii. Is the applicant entitled to occupational therapy services, proposed by Total Recovery Rehab Centre in plans as follows:
a) $2,872.80 ($8,339.60 less $5,466.80 approved), in a plan dated April 11, 2023;
b) $1,077.36 ($6,544.16 less $5,466.80 approved), in a plan dated July 3, 2023;
c) $2,243.26 ($5,611.22 less $3,367.96 approved), in a plan dated May 15, 2023?
iii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant is not entitled to the outstanding amounts of the disputed treatment plans, interest, or an award.
ANALYSIS
Denied outstanding amount of $1,802.52 for the provider rate in each of the plans dated September 14, 2022, November 9, 2022, December 12, 2022 and January 16, 2023
4I find that the applicant has not established that she is entitled to the unapproved portion of the difference between $176.00 per hour less $109.24 per hour, or $1,802.52, for eighteen 1.5-hour sessions by Xiao Lan Yang, psychotherapist in each of the plans dated September 14, 2022, November 9, 2022, December 12, 2022, and January 16, 2023.
5To 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. 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 same are reasonable.
6Under s.25(3) of the Schedule, an insurer is not liable to pay for expenses for professional services that exceed the Professional Services Guideline, Superintendent’s Guideline No.03/14 (“Guideline”).
7The applicant submits that the proposed plans for psychological services are reasonable and necessary for her accident-related injuries, however, the applicant makes no submissions regarding the proposed rate in the plans for psychological counselling provided by Xiao Lan Yan, a psychotherapist, nor do they explain why the psychotherapist should be paid an hourly rate above the Guideline. Accordingly, I find the applicant has not demonstrated that the higher hourly rate proposed is reasonable and necessary.
Issue #1- Plan dated September 14, 2022 for the outstanding amount of $1,802.52
8The September 14, 2022 plan completed by Dr. Sharleen McDowall, of Somatic Assessments & Treatment Clinic (“SOMA”) sought eighteen 1.5-hour sessions of psychological treatment, with a progress report, communication with team and completion of the OCF-18, in the amount of $5,611.22. The respondent partially approved the treatment plan in the amount of $3,808.70 for eighteen 1.5-hour sessions at a rate of $109.24, plus the progress report, communication with team and completion of the OCF-18. The outstanding amount of $1,802.52 comprised of eighteen 1.5-hour psychological therapy sessions at a rate of $176.00 per hour less $109.24 per hour approved.
Issue #2- Plan dated November 9, 2022 for the outstanding amount of $1,802.52
9The applicant submitted a plan dated November 9, 2022, for psychological services in the amount of $5,611.22, completed by Dr. Sharleen McDowall, with service provider Xiao Lan Yang, psychotherapist. The respondent partially approved the treatment plan in the amount of $3,808.70, which included eighteen 1.5-hour therapy sessions at a reduced rate of $109.24 per hour, progress report, communication with team and completion of the OCF-18. The respondent denied the proposed rate of $176.00 per hour for eighteen 1.5-hour sessions, and paid a rate of $109.24 per hour for eighteen 1.5-hour sessions with treatment provider, Xiao Lan, psychotherapist.
Issue #3- Plan dated December 12, 2022 for the outstanding amount of $1,802.56
10The applicant submitted a plan dated December 12, 2022, for psychological services in the amount of $5,611.22, completed by Dr. Sharleen McDowall, with service provider Xiao Lan Yang, psychotherapist. The respondent partially approved the treatment plan in the amount of $3,808.70, which included eighteen 1.5-hour therapy sessions at a reduced rate of $109.24 per hour, progress report, communication with team and completion of the OCF-18. The respondent denied the proposed rate of $176.00 per hour for eighteen 1.5-hour sessions and paid a rate of $109.24 per hour for eighteen 1.5-hour sessions with treatment provider, Xiao Lan Yang, psychotherapist.
Issue #4- Plan dated January 16, 2023 for the outstanding amount of $1,802.52
11The applicant submitted a plan dated January 16, 2023, for psychological services in the amount of $5,611.22, completed by Dr. Sharleen McDowall, with service provider Xiao Lan Yang, psychotherapist. The respondent partially approved the treatment plan in the amount of $3,808.70, which included eighteen 1.5-hour therapy sessions at a reduced rate of $109.24 per hour, progress report, communication with team and completion of the OCF-18. The respondent denied the proposed rate of $176.00 per hour for eighteen 1.5-hour sessions and paid a rate of $109.24 per hour for eighteen 1.5-hour sessions with treatment provider, Xiao Lan, psychotherapist.
12The applicant makes no submissions to explain how the services of Xiao Lan Yang are the same or similar to a psychologist on the basis of the provider’s education, training, and experience, and are therefore payable at the proposed rate of $176.00 per hour.
13The respondent submits that although the plan dated September 14, 2022 indicated Dr. Sharleen McDowall as the treatment provider, it received an invoice from SOMA which identified the treatment provider as Xiao Lan Yang, a psychotherapist.
14The respondent further submits that psychotherapists are unregulated health care professionals under the Guideline, and as such, the services of Xiao Lan Yang are payable at a rate of $89.07 per hour. The respondent submits that it paid a fair rate of $109.24 per hour for Xiao Lan Yang, as a psychotherapist, since the hourly rate of a psychotherapist is not payable at the same rate of a psychologist, which it argues is fair under the circumstances for the services of an unregulated health care professional.
15I agree with the respondent. The applicant has not established how the hourly rate of the treatment provider Xiao Lan Yang, as a psychotherapist, should be equivalent to a psychologist, and therefore, payable at the maximum rate of $176.00 per hour.
16I find that the applicant has not met her burden of establishing on a balance of probabilities that she is entitled to the unapproved portion of the plans dated September 14, 2022, November 9, 2022, December 12, 2022, and January 16, 2023.
Denied brokerage services in plans dated April 11, 2023 and July 3, 2023
17I find that the applicant has not established that the outstanding balance of the plans dated April 11, 2023 and July 3, 2023 are payable.
Issue #5- Plan dated April 11, 2023 for the outstanding amount of $2,872.80
18The April 11, 2023 plan submitted by Raymond Wong, occupational therapist of Total Recovery Rehab sought twelve 1-hour sessions of social skills training; twelve 1-hour sessions of cognitive therapy; with 12 hours of travel time; 6 hours of planning services; 24 hours of brokerage services; 2 hours of documentation support activity; and completion of the OCF-18, in the amount of $8,339.60. The respondent partially approved the treatment plan in the amount of $5,466.80 for twelve 1-hour sessions each of social skills training and cognitive therapy; travel time; planning services; documentation support activity; and completion of the OCF-18. The outstanding amount of $2,872.80 was comprised of brokerage services, at 24 hours at a rate of $119.70 per hour.
Issue #6- Plan dated July 3, 2023 for the outstanding amount of $1,077.36
19The July 3, 2023 plan submitted by Raymond Wong, of Total Recovery Rehab sought twelve 1-hour sessions of social skills training; twelve 1-hour sessions of cognitive therapy; with 12 hours of travel time; 6 hours of planning services; 24 hours of brokerage services; 2 hours of documentation support activity; and completion of the OCF-18, in the amount of $6,544.16. The respondent partially approved the treatment plan in the amount of $5,466.80 for twelve 1-hour sessions each of social skills training and cognitive therapy; travel time; planning services; documentation support activity; and completion of the OCF-18. The outstanding amount of $1,077.36 was comprised of brokerage services, at 9 hours at a rate of $119.70 per hour.
20I find that the applicant has not provided any specific submissions or evidence to establish that the outstanding amount for brokerage services of $2,872.80 and $1,077.36 are reasonable and necessary.
21The respondent submits that the applicant has not provided an explanation for why the proposed brokerage services are reasonable and necessary, which are not payable under the Schedule.
22I find that the applicant has not provided an explanation for the additional amount of $2,872.80 and $1,077.36 for brokerage services beyond the amounts already approved. I find that the Guideline specifically excludes expenses related to professional services such as administration costs, overhead, and related costs.
23I find that the applicant has not demonstrated, on a balance of probabilities, that she is entitled to the unapproved portion of $2,872.80 of the April 11, 2023 plan or the unapproved portion of $1,077.36 of the July 3, 2023 plan.
Issue #7- Plan dated May 15, 2023 for the outstanding amount of $2,243.26
24I find that the applicant has not established that the outstanding balance of the plan dated May 15, 2023 is payable.
25The applicant has made no submissions regarding the outstanding amount of plan dated May 15, 2023, and the plan is not in evidence.
26Therefore, I find that the applicant has not demonstrated on a balance of probabilities that she is entitled to the unapproved portion of $2,243.26 of the May 15, 2023 plan.
Interest
27Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since no benefits have been unreasonable withheld or delayed, there is no interest payable.
Award
28The 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. Since no benefits have not been unreasonably withheld or delayed, there is no basis for an award.
ORDER
29For the reasons set out above, I find that:
i. The applicant is not entitled to the outstanding amounts of the disputed treatment plans.
ii. The applicant is not entitled to interest or an award.
iii. The application is dismissed.
Released: April 1, 2025
Lisa Holland
Adjudicator