Licence Appeal Tribunal File Number: 23-006168/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:
Sophie Boucher (A minor by their litigation guardian, Renee Boucher)
Applicant
and
Co-operators General Insurance Company
Respondent
DECISION
ADJUDICATOR: Lisa Holland
APPEARANCES:
For the Applicant: Patrick Poupore, Counsel
For the Respondent: Peter Durant, Counsel
HEARD: By Way of Written Submissions
OVERVIEW
1Sophie Boucher, the applicant, was involved in an automobile accident on July 21, 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, 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 $1,921.00 for an occupational therapy assessment, proposed by Lajeunesse Rehabilitation Services in a treatment plan/ OCF-18 (“plan”) dated June 8, 2021?
ii. Is the applicant entitled to $535.00 ($1,832.30 less $1,297.32 approved) for occupational therapy services, proposed by Lajeunesse Rehabilitation Services in a plan dated June 23, 2021?
iii. Is the applicant entitled to $5,537.00 for a psychological assessment, proposed by Allied Medical Assessments in a plan dated Feb. 14, 2023?
iv. Is the applicant entitled to $5,876.00 for an orthopaedic assessment, proposed by Allied Medical Assessments in a plan dated Mar. 20, 2023?
v. Is the applicant entitled to $4,772.22 ($5,201.62 less $429.40 approved) for workplace modification devices, proposed by Lajeunesse Rehabilitation Centre in a plan dated Sept. 3, 2021?
RESULT
3I find that the applicant has not demonstrated that the proposed treatment plans are reasonable and necessary and, as a result, the treatment plans in dispute are not payable.
ANALYSIS
Issue #1- Plan dated June 8, 2021 for an occupational therapy assessment
4I find that the applicant has not established on a balance of probabilities that she is entitled to the occupational therapy assessment proposed in the June 8, 2021 plan.
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.
6The applicant seeks payment for a plan dated June 8, 2021 for an occupational therapy assessment, in the amount of $1,921.00 submitted by Alina Tassone, occupational therapist of Lajeunesse Rehabilitation Services. The goals of the treatment plan are to determine the need for assistive devices, complete an ergonomic assessment of the applicant’s home workstation, and return the applicant to her activities of daily living.
7The applicant submits that she continued to attend school full-time after the accident, and the proposed occupational therapy assessment is necessary to consider her accommodations at school. The applicant further submits that before the accident, she did not have a dedicated workspace at home during COVID restrictions. The applicant has not provided any medical evidence from a treating physician of an accident-related cognitive impairment, or academic records, which establish a decline in her academic performance after the accident.
8The respondent submits that the proposed plan does not provide the hourly rate of the provider. The respondent further submits that there is no evidence that the applicant was unable to attend school after the accident.
9I find that the evidence does not support the need for the disputed plan or the stated goals of the plan to determine the applicant’s needs for a home workstation because the medical evidence suggests that the applicant did not require accommodations. In the consultation report dated September 10, 2021, by Dr. Tara Baldisera, treating specialist in concussion management, the applicant was discharged from concussion treatment, because she reported functional recovery in all her pre-accident activities without accommodations at school.
10Therefore, I find that the applicant has not met her burden of establishing on a balance of probabilities that the disputed plan for an occupational therapy assessment is reasonable and necessary for her accident-related injuries.
Issue #2- Plan dated June 23, 2021 for the outstanding amount of $535.00
11I find that the applicant is not entitled to the unapproved portion of the plan dated June 23, 2021.
12The applicant submitted a plan dated June 23, 2021, for occupational therapy services in the amount of $1,832.32, proposed by Veronique Bouchard, social worker, of Lajeunesse Rehabilitation Services. The respondent partially approved the treatment plan in the amount of $1,297.32, which included 10 yoga sessions at $58.19, planning services by social worker at $137.15, assistive devices, including a heating pad, massage gun and body braid, totaling $389.98, kivi park membership for $240.00, bike rack for $329.00, and completion of the OCF-18 for $200.00. The respondent denied a canoe club membership with 3 lessons for $310.00, and 1.5 hours of planning services by a social worker for $225.00, totaling $1,012.79.
13The applicant submits that after the accident she has not engaged in activities that involve the use of her leg. The applicant submits that she returned to school after the accident with accommodations for physical activities in gym class. The applicant submits that the proposed canoe club membership and lessons will provide her with a physical activity without the use of her leg. The applicant makes no submissions regarding the proposed social worker planning services in the amount of $225.00.
14The respondent submits that there is no medical evidence in support of a canoe club membership, lessons and the proposed rate of $225.00 for 1.5 hours of social worker planning services, which exceeds the Guideline for an unregulated provider. The respondent relies on the clinical notes and records (“CNRs”) of Dr. Tara Baldesira, of the Sudbury Sports and Exercise Medicine Concussion Program, dated August 10, 2021, which indicates that the applicant reported resolved neck pain and full range of motion.
15I find there is a lack of medical evidence in support the applicant’s inability to use her left leg, or restrictions in her level of physical activity to require a canoe membership. The consultation report dated January 14, 2021, by treating orthopaedic specialist, Dr. Kevan Saidi confirms the absence of any injury to the peroneal nerve of the applicant’s left leg. I also find that the applicant made no submissions to explain how the proposed social worker services are reasonable and necessary.
16I find that the medical evidence suggests that the applicant has been active in sporting activities that require the use of her left leg. In the report dated September 10, 2021 by Dr. Tara Baldisera discharged the applicant from treatment because she achieved functional recovery in all her pre-accident activities without accommodations at school. The CNRs of Dr. Mikael Levesque, family physician, indicates that on September 28, 2021, the applicant injured her finger playing football. Dr. Levesque further indicates in his note dated December 12, 2022, that the applicant has returned to school sports and working in a retail store, and in his note dated October 31, 2023, that the applicant participates in cross country running.
17I 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 this plan for a canoe club membership, lessons, and social worker planning services of $225.00.
Issue #3- Plan dated February 14, 2023 for a psychological assessment
18I find that that the applicant has not established on a balance of probabilities that she is entitled to the psychological assessment proposed in the February 14, 2023 plan.
19The applicant seeks payment for a plan dated February 14, 2023 in the amount of $5,537.00 submitted by Dr. Gloria Fiati, psychologist, of Allied Medical Assessments, which consists of a psychological assessment in the amount of $2,000.00 and preparation services for $2,900.00, plus tax. The goals of the psychological assessment are not mentioned in the proposed plan.
20The applicant relies on the psychological report dated April 16, 2023, by Dr. Fiati. The applicant submits that Dr. Fiati opined that she has cognitive impairments which impact her academic performance.
21The respondent submits that the proposed plan is a duplication of services, since a plan dated September 30, 2022 by Elisa Richer, psychological assistant of Mariana and Associates, was approved for a psychological assessment and 6 1.5-hour counselling sessions, which have not been incurred.
22I find that the proposed psychological assessment by Dr. Fiati is a duplication of a previously approved psychological assessment proposed by Elisa Richer in a plan dated September 30, 2022.
23I find that the applicant has not proven on a balance of probabilities that she is entitled to a further psychological assessment, where the respondent already approved funding for a psychological assessment.
Issue #4- Plan dated March 20, 2023 for an orthopaedic assessment
24I find that the applicant has not established on a balance of probabilities that she is entitled to the orthopaedic assessment proposed in the plan dated March 20, 2023.
25The applicant seeks payment for a plan dated March 20, 2023 for an orthopaedic assessment, in the amount of $5,876.00 submitted by Dr. Michael West, orthopaedic surgeon of Allied Medical Assessments. The plan consists of an orthopaedic assessment for $2,000.00, and preparation services of $3,200.00, plus tax. The goals of the orthopaedic assessment are not mentioned in the proposed plan.
26The applicant submits that she has continuing difficulties with her left leg, as a result of the accident. The applicant relies on the opinion of Dr. West in his report dated April 27, 2023, and his opinion that the applicant suffers from chronic pain syndrome, ongoing pain in her leg, neck and back, and a permanent deformity of scar tissue on her left lower leg.
27The respondent submits that an orthopaedic assessment is not reasonable and necessary since the applicant is participating in sports activities and she has a treating orthopaedic specialist, Dr. Kevan Saidi.
28I find that the consultation reports from treating orthopaedic specialist, Dr. Kevan Saidi, indicate that the applicant has made good progress in healing from her left leg injury, and there is no mention of chronic pain syndrome. On December 8, 2020, Dr. Saidi confirms that the applicant’s infected skin laceration on her left lower leg has resolved. After reviewing the results of an MRI of the applicant’s left leg dated January 5, 2021, Dr. Saidi confirms in his report dated January 14, 2021, that there is no indication of an injury to the peroneal nerve, or nerve damage in the applicant’s left leg. In his final report dated July 29, 2021, Dr. Saidi indicates that the applicant’s left leg sensitivity has decreased, and therefore, no follow-up is required. I also find that there is no corroborating evidence that the applicant suffers from chronic pain syndrome. Again, Dr. Baldisera’s report dated September 10, 2021 indicates that the applicant has reached functional recovery.
29I find there is not a condition that warrants further investigation by way of an orthopaedic assessment. The purpose of an assessment is to determine whether a condition exists. For an insured, they bear the onus to demonstrate that there are grounds on which to believe that a condition exists that would warrant further investigation by way of an assessment.
30I find that the applicant has not proven on a balance of probabilities that she is entitled to an orthopaedic assessment because her treating orthopaedic specialist, Dr. Saidi discharged her from his care in July 2021 because the applicant has made good progress in her recovery.
Issue #5- Plan dated September 3, 2021 for the outstanding amount of $4,772.22
31I find that the applicant has not established that the outstanding balance of the plan dated September 3, 2021 is payable.
32Sections 15(1)(g) and s.16(3)(k) of the Schedule provide for medical and rehabilitation benefits that are reasonable and necessary which include transportation for the insured person to and from treatment sessions, including transportation for an aide or attendant. Sections 15(2)(c) and 16(4)(f) provide that the insurer is not liable to pay medical and rehabilitation benefits for transportation expenses other than authorized expenses.
33Under 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”).
34The September 3, 2021 plan submitted by Alina Tassone sought various assistive devices, three 1.5 hour sessions of occupational therapy, with travel time, planning services, preparation services, brokerage services and documentation support activity in the amount of $5,201.62. The respondent partially approved the treatment plan in the amount of $429.40 for three float pod sessions at $60.00 each and completion of the OCF-18. The outstanding amount of $4,772.22 was comprised of:
i. Assistive devices- including a desk, ergonomic chair, wireless mouse, keyboard, adjustable keyboard tray, adjustable monitor riser, laptop, noise cancelling headphones, totalling $2,568.00;
ii. Planning services-3 hours at a rate of $99.75 per hour, totaling $299.25;
iii. Brokerage services-3.75 hours at a rate of $24.94 per hour, totaling $374.10;
iv. Provider travel time- 3 trips at a rate of $149.63 per hour at 1 hour each, totaling $299.25;
v. Therapy-three 1.5 hour sessions at a rate of $149.63 per hour, totaling $448.89, and;
vi. Documentation support activity-1 hour at a rate of $299.25 per hour.
a) Assistive devices
35The applicant submits that the assessor, Alina Tassone recommended computer equipment and a desk for school and therapy work because of COVID restrictions. However, the applicant also submits that she returned to school full-time after the accident, and she needed to borrow home computer equipment before the accident during COVID.
36The respondent submits that after the accident, the applicant returned to in school classes, and there is no evidence that home computer equipment was necessary for the applicant’s success at school due to the accident.
37I find that the evidence suggests that the applicant returned to school after the accident, and she did not have her own home computer equipment before the accident during COVID restrictions. The applicant has suggested that a home workspace would be beneficial for her academic performance after the accident. However, the applicant has not pointed to any academic records or medical records from her treating physicians in support of an accident-related decline in her ability to function in school. Again, the report of Dr. Baldisera confirms the applicant returned to her pre-accident functional abilities at school without accommodations by September 2021.
38I find that the applicant has not demonstrated on a balance of probabilities, that she is entitled to the unapproved amount of $2,568.00 of the September 3, 2021 plan.
b) Planning services
39I find that the applicant has not provided any specific submissions or evidence to establish that the outstanding amount for planning services of $299.25 is reasonable and necessary.
40The respondent submits that the proposed planning services increases the hourly rate of the service provider, and the increased rate is not payable under the Guideline.
41I agree with the respondent that the applicant has not provided an explanation for the additional planning services. I find that the Guideline specifically excludes expenses related to professional services such as administration costs, overhead, and related costs.
42I find that the applicant has not demonstrated, on a balance of probabilities, that she is entitled to the unapproved portion of $299.25 of the September 3, 2021 plan.
c) Brokerage service
43I find that the applicant has not provided any specific submissions or evidence to establish that the outstanding amount for brokerage services of $374.10 is reasonable and necessary.
44The respondent submits that the proposed brokerage services increases the hourly rate of the services provider, and therefore exceeds the hourly rate payable under the Guideline.
45I find that the applicant has not provided an explanation for the additional amount of $374.10 for brokerage services. I find that the Guideline, specifically excludes expenses related to professional services such as administration costs, overhead, and related costs.
46I find that the applicant has not demonstrated, on a balance of probabilities, that she is entitled to the unapproved portion of $374.10 of the September 3, 2021 plan.
d) Provider travel time
47I find that the applicant has not provided any specific submissions or evidence to establish that the outstanding amount for provider travel time of $299.25 is reasonable and necessary.
48Pursuant to s. 15(2)(c) of the Schedule, the insurer is not liable to pay medical benefits for transportation expenses other than authorized transportation expenses. Section 3(1) of the Schedule defines “authorized transportation expenses” as expenses related to transportation (a) that are authorized by, and calculated by applying the rates set out in the most recent transportation expense guideline published by the Financial Services Regulatory Authority of Ontario, and (b) that unless the insured person sustained a catastrophic impairment as a result of the accident, relate to transportation expenses incurred only after the first 50 kilometres of a trip.
49I find that the applicant has not established how the provider travel time is payable since there is no provision in the Schedule for payment of provider mileage, and provider mileage is not payable under s.3(1) and s.15(2)(c) of the Schedule.
50Therefore, I find that the applicant has not demonstrated on a balance of probabilities, that she is entitled to the unapproved portion of $299.25 of the September 3, 2021 plan.
e) Documentation support activity
51I find that the applicant has not provided any specific submissions or evidence to establish that the outstanding amount for documentation support activity of $299.25 is reasonable and necessary.
52I find that the applicant has not provided an explanation for the additional 1 hour of documentation support activity beyond the amounts which have already been paid.
53Therefore, I find that the applicant has not established on a balance of probabilities that she is entitled to the unapproved portion of $299.25 of the September 3, 2021 plan.
ORDER
54For the reasons set out above, I find that:
i. The applicant is not entitled to the disputed treatment plans.
ii. The application is dismissed.
Released: April 1, 2025
Lisa Holland Adjudicator