Licence Appeal Tribunal File Number: 23-011250/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:
My H Ngo
Applicant
and
Co-operators General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Roderick Walker
APPEARANCES:
For the Applicant:
Christina Martin, Counsel
For the Respondent:
Daniel M Himelfarb, Counsel
HEARD:
By Way of Written Submissions
OVERVIEW
1Hanh My Ngo, the applicant, was involved in an automobile accident on October 21, 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 totalling $1,732.80, as set out in the treatment plan (“plan”) of Martha Josephian, of Pursuit Health Management Inc., denied on September 22,2021?
ii. Is the applicant entitled to psychological services totalling $1,995.32, as set out in the t plan of Dr. Michael MacDonald, of MacDonald & Bryant Psychology Professional Corp.,denied on March 14, 2022?
iii. Is the applicant entitled to a special award under s. 10 of Regulation 664?
iv. Is the applicant entitled to interest pursuant to s. 51 of the Schedule?
RESULT
3The applicant is not entitled to the psychological plans in dispute.
4The applicant is entitled not to interest under s. 51 of the Schedule.
5The respondent is not liable to pay an award.
ANALYSIS
The applicant is not entitled to the psychological plans.
6I find that the applicant is not entitled to the treatment plans in dispute.
7To 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.
Analysis
Is the applicant entitled to the disputed psychological services?
8The applicant submitted two treatment plans for psychological assessments, the first in the amount of $1,732.80 from Pursuit Health Management Inc., denied on September 22, 2021 and secondly in the amount of $1,995.32 from MacDonald & Bryant Psychology Professional Corp., denied on March 14, 2022.
9To establish her claim of accident-related psychological impairments, the applicant relies on , clinical notes and records (“CNRs”) of her family doctor, Dr. Aatika Imran, a report of Diane Hrovat, social worker, CNR’s of Dr. Itoro Vdo, psychiatrist, CNR’s of Dr. Bobbie Ross, psychiatrist and the report of Marianne Lee, social worker.
10The respondent relies on Dr. Peter Cobrin’s, psychologist report dated October 3, 2019 and on Dr. Abram in his report dated May 19, 2019.
11The applicant states she underwent a social work initial assessment, with a report dated August 21, 2019, where social worker Diane Hrovat found that the applicant was struggling with pain, cognitive difficulties, and severe emotional impairments and difficulty coping as a result of the accident. Ms. Hrovat noted that testing scores were in severe levels of depression and extreme levels of anxiety, as well as potential posttraumatic stress disorder (“PTSD”). A lack of sleep and other functional impairments in her activities of daily living were reported.
12Also, the applicant saw Ms. Marianne Lee, social worker, in her assessment dated March 10, 2022. Ms. Lee noted that the applicant was extremely tearful throughout the interview. Her scores on administered psychometric testing indicated severe levels of depressive symptoms, severe levels of anxiety symptoms, and score of 41/80 on the PCL-5, above the commonly used cut-point for specialized PTSD treatment.
13The applicant was subsequently assessed by Dr. Itoro Udo, psychiatrist, on November 7, 2022, based on a referral from her family doctor, Dr. Imran due to suspected PTSD secondary to the accident. Dr. Udo ultimately diagnosed the applicant with PTSD (moderate), moderate depression, and chronic pain. He noted the applicant’s complaints of initial insomnia, low mood, reduced appetite, reduced energy, reduced enjoyment in doing her nails, cooking, and playing with her children.
14The applicant underwent a subsequent s. 25 assessment with Dr. Bobbie Ross, psychiatrist, who prepared a report dated January 5, 2023. Dr. Ross stated that the applicant’s diagnoses of posttraumatic stress disorder is “definite”. Dr. Ross summarized that the applicant experienced acute injuries that have transitioned to chronic sequelae injuries, with comorbid psychiatric conditions. As for prognosis of the applicant, Dr. Ross opined the that the applicant’s psycholoical injuries are unlikely to improve.
15In a clinical note dated, December 5, 2023, Dr. Imran noted the applicant with low mood, depression, PTSD, complex regional pain syndrome, and made an OT referral for a safety assessment. Dr. Imran referred the applicant for general adult urgent psychiatric consultation service due to passive suicidal thoughts and a sudden decline in her mood.
16The applicant also submits that a January 12, 2024, consultation note from Dr. Li, psychiatrist confirms a diagnosis of PTSD and provides a summary of her psychiatric symptoms and impairments as a result of the accident..
17Finally, the applicant relies on Dr. MacDonald’s psychological assessment report dated March 30, 2022. He states there is clear evidence of significant psychological injuries, subsequent to her car accident in 2018. The applicant feels especially nervous at times of increased pain. She is experiencing high levels of pain and limitation frightens her. She is afraid that her injuries, disabilities and pain will never go away. She does not feel normal, as she feels like a different person who is easily upset, and this occurs more often with higher levels of pain. Dr. MacDonald states that there is clear evidence of trauma from her car accident in 2018. She experiences posttraumatic anxiety in the form of driving anxiety which was described above. She also experiences symptoms of a post-traumatic stress disorder including re-experiencing, dreams, and avoidance of thoughts and driving, mood changes and emotional reactivity.
18The respondent relies on Dr. Peter Cobrin’s, psychological report dated October 3, 2019, who diagnosed the applicant with an adjustment disorder. He concluded that from a psychological perspective that the applicant is not suffering a complete inability to carry on a normal life as a result of accident-related psychological difficulties
19The respondent relies on Dr. Abram, who assessed the applicant on May 13, 2019 regarding entitlement to NEBs and an OCF-18 for physical therapies. Given the issues in dispute are psychological in nature, the respondent has refrained from providing a synopsis of this report. Notwithstanding, the respondent notes that Dr. Abram agreed that the applicant was not suffering a complete inability to carry on a normal life as a result of the accident, and recommended the applicant fully engage in all activities of daily living.
20The respondent also submits that the applicant was assessed by Ms. Lee on March 10, 2022. The applicant ‘s testing scores were lower than her previous scores on the psychometric, Burns Anixiety inventory and the BD-II test. Ms. Lee administered psychometric testing that as was done by Ms. Hrovat.The respondent submits that there is nothing in the report that speaks to why a second social work assessment was completed.
21The respondent relies on the case of Zhang v Aviva Insurance Canada, 2023 CanLII 87436 (ONLAT) , The tribunal considered if an impugned OCF-18 for a psychological assessment was reasonable and necessary. The respondent argued that the impungned OCF-18 was redundant, as the respondent had partially approved a previous psychological assessment (which had been incurred). Vice Chair Ciriello agreed with the respondent, stating, “clearly, a previous psychological assessment and treatment was approved by the respondent.” The OCF-18 fails to specify how this assessment would differ from the psychological assessment previously funded. I cannot infer how the proposed assessment of Dr. Lindal [the first incurred assessment] differs from the proposed assessment of Dr. Gabidulina [the second proposed assessment]. Therefore, I find this assessment to be duplicative, and not reasonable and necessary. “
22The respondent reiterates its position, arguments and case law relied upon for the denial of the OCF-18 for $1,732.80 for a social work assessment and states the claim for his assessment is flawed. The respondent suggests that the plan is redundant and duplicative as well. The respondent suggests that there had already been a social work assessment by Ms. Hrovat in 2019, and there was no evidence of any change in her medical status by the time Dr. MacDonald did his assessment. The respondent states that Dr. Cobrin had assessed the applicant, and he diagnosed a mental health impairment in the form of an adjustment disorder, howver despite these findings, no claim for counselling was ever submitted.
23I find that I am persuaed by the respondent’s evidence because the two plans for psychological treatment in dispute mirror each other.. I find that there is no evidence from Ms. Lee or Dr. MacDonald as to specify how these assessments would differ from the psychological assessment previously funded by the insurer as in the case of Zhang v Aviva Insurance Canada, 2023 CanLII 87436 (ONLAT).
24I also find that the plans are over three to four years post accident. I find that there is no evidence that would pursuaed me given the elaspsed time frame that these plans are reasonable and necessary. Also I find in the CNR’s of Dr. Imran that there is no contemporaneous evidence in his notes to support a need for a mental health assessment. There is only one entry for a mental health complaint of a mood fluctuations from the date of the accident until January 2022. There is then no further entry of a psychological symptom during the rest of 2022, and none in 2023.
25I find for the above reasons given, that the applicant has not met her onus and I find that the plans are not reasonable and necessary.
Interest
26The applicant is not entitled to interest because there are no benifets payable.
Award
27The respondent is not liable to pay an award because the insurer has not been impurdent, stubborn or inflexible in this matter.
ORDER
28On the totality of the evidence, I find:
i. The applicant is not entitled to the two psychological treatment plans.
ii. The applicant is not entitled to interest.
iii. The respondent is not liable to pay an award.
iv. The application is dismissed.
Released: May 26, 2025
Roderick Walker
Adjudicator