Licence Appeal Tribunal File Number: 22-013862/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:
Yan Jiang
Applicant
and
Allstate Insurance Company of Canada
Respondent
DECISION
ADJUDICATOR: Gareth Neilson
APPEARANCES:
For the Applicant: Anil Hampole, Counsel
For the Respondent: Yalda Aziz, Counsel
HEARD: By way of written submissions
OVERVIEW
1Yan Jiang, the applicant, was involved in an automobile accident on July 26, 2021, 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 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 $3,981.74 for psychological services, proposed by Somatic Assessments and Treatment Clinic in a treatment plan/OCF-18 (“plan”) dated May 27, 2022?
ii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
iii. Is the applicant entitled to interest on any overdue payment of benefits?
3The evidence before me shows that the applicant was removed from the MIG on January 22, 2024, so this issue is no longer in dispute. Also on January 22, 2024, the respondent approved $2,200.00 for a psychological assessment so this issue is no longer in dispute. I note that the respondent provided evidence to support that these issues had been resolved, and the applicant did not file a reply submission disputing this.
RESULT
4The applicant has been partially approved for psychological services ($3,178.14) leaving an amount in dispute of $876.86. I find that the applicant is not entitled to the remaining portion of this treatment plan.
5The respondent is not liable to pay an award under s. 10 of Reg. 664.
6As no benefits are overdue, the applicant is not entitled to interest.
ANALYSIS
The applicant is not entitled to $523.60 ($3,981.74 less $3,458.14 approved) for psychological services.
7On January 24, 2024, the respondent approved $3,178.14 of the treatment plan leaving a balance of $803.60. The respondent has further agreed in their submissions to pay $280.00 in travel costs leaving a balance of $523.60.
8To 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.
9The remaining balance of the treatment plan of $523.60 is for communication sessions. The applicant’s submissions do not address the reasonableness or the necessity of these sessions.
10As the applicant has failed to specifically address the reasonableness of these communications sessions in their submissions, I agree with the respondent that the applicant has not met their burden of proof that the remaining portion of this treatment plan is reasonable and necessary.
11I find, on a balance of probabilities, that the applicant is not entitled to the balance of $532.60.
Interest
12Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no payments are overdue, no interest is payable.
Award
13The 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. The respondent has acted in good faith and therefore no award is due.
ORDER
14I order the following:
i. The applicant is not entitled to the balance of $523.60 for psychological services.
ii. As there are no overdue benefits, no interest is payable.
iii. The applicant is not entitled to an award.
Released: April 3, 2025
Gareth Neilson
Adjudicator