Pelikan v. Belair Insurance Company Inc., 2025 CanLII 58810

Citation: Pelikan v. Belair Insurance Company Inc., 2025 CanLII 58810

Licence Appeal Tribunal File Number: 23-010503/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:

Christine Pelikan

Applicant

and

Belair Insurance Company Inc.

Respondent

DECISION

ADJUDICATOR: Tami Cogan

APPEARANCES:

For the Applicant: Sundeep Singh, Counsel

For the Respondent: Omar Sewhdat, Counsel

HEARD: By way of written submissions

OVERVIEW

1Christine Pelikan, the applicant, was involved in an automobile accident on May 12, 2023, 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, Belair Insurance Company Inc., and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

ISSUES

2The issues to be decided are:

1. Is the applicant entitled to $2,200.00 for an in-home assessment, proposed by Mind Connections Inc., in a treatment plan/OCF-18 (“plan”) dated May 17, 2023?
2. Is the applicant entitled to $2,200.00 for an attendant care assessment, proposed by Scarborough Physiotherapy & Rehabilitation Clinic, in a plan dated June 20, 2023?
3. Is the applicant entitled to $2,200.00 for a neurological assessment, proposed by Scarborough Physiotherapy & Rehabilitation Clinic, in a plan dated June 7, 2023?
4. Is the applicant entitled to $2,486.00 for a concussion assessment, proposed by Complete Balance Health Centre, in a plan dated May 14, 2023?
5. Is the applicant entitled to $5,661.28 for concussion treatment, proposed by Complete Balance Health Centre, in a plan dated July 27, 2023?
6. Is the applicant entitled to $3,680.33 for chiropractic treatment services, proposed by Mackenzie Medical Rehabilitation Centre, in a plan dated June 6, 2023?
7. Is the applicant entitled to $284.71 ($1,300.00 less $1,015.29 approved) for chiropractic treatment services, proposed by Mackenzie Medical Rehabilitation Centre, in a plan dated August 17, 2023?
8. Is the applicant entitled to $1,691.57 for chiropractic treatment services, proposed by Mackenzie Medical Rehabilitation Centre, in a plan dated November 16, 2023?
9. Is the applicant entitled to $2,023.03 for physiotherapy treatment services, proposed by Mackenzie Medical Rehabilitation Centre, in a plan dated September 22, 2023?
10. Is the applicant entitled to $2,768.77 ($4,215.13 less $1,446.36 approved) for psychological treatment services, proposed by Princeton Hills Medical Assessments Inc., in a plan dated September 11, 2023?
11. Is the applicant entitled to $87.57 for prescription medication and parking expenses at Credit Valley Hospital, submitted by receipt dated July 6, 2023?
12. Is the applicant entitled to $11.75 for parking expenses at Credit Valley Hospital, submitted by receipt dated August 4, 2023?
13. Is the applicant entitled to interest on any overdue payment of benefits?
14. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?

RESULT

3For the reasons below, I find the following:

1. The applicant is not entitled to the treatment plans in dispute.
2. The applicant is entitled to $44.80 for the prescription medication Zopiclone, but she is not entitled to $27.77 for the prescription medication Cambia, nor is she entitled to $15.00 for parking expenses at Credit Valley Hospital, submitted by OCF-6/receipt dated July 6, 2023.
3. The applicant is not entitled to $11.75 for parking expenses at Credit Valley Hospital, submitted by OCF-6/receipt dated August 4, 2023.
4. The applicant is entitled to interest on any overdue payment of benefits.
5. The applicant is not entitled to an award under s. 10 of Reg. 664.

ANALYSIS

4To 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.

5As for an assessment, by their nature, assessments are speculative. They are conducted to determine if an applicant has a specific condition or meets a specific threshold. There is a possibility that the assessment will prove negative. Nonetheless, there must be some evidence that the specified condition exists, and that further investigation is reasonable and necessary.

Issues 1 & 2: In-home Assessment and Attendant Care Assessment

6For the reasons that follow, I find the applicant is not entitled to either the in-home assessment plan or the attendant care assessment plan.

7I have reviewed the in-home assessment plan completed by Meeta Gugnani, occupational therapist, dated May 17, 2023. The goals of the plan are identified as pain reduction, coping with stress from the accident, return to activities of normal living, return to pre-accident work activities and increased independence in activities of daily living. The evaluation methods listed are subjective reporting, objective findings, standardized and non-standardized assessments. The services proposed are for the completion of the claim form (“OCF-18”) and an in-home assessment with completion of a Form 1. The cost of the proposal is $2,200.00.

8Further, I have reviewed the attendant care assessment plan completed by Janice Kim, occupational therapist on June 20, 2023. The goals of the plan are identified as pain reduction, increase in strength, return to activities of normal living, and to identify the patient's present ability to perform his/her pre-accident self-care activities for the purpose of completing a Form 1. The evaluation method listed is ongoing monitoring of needs, complaints and barriers. The services proposed are for the completion of documentation and a home-site assessment, at a total cost of $2,200.00.

9The applicant submits the goals of the plans are in line with her rehabilitative needs. Further she submits an in-home assessment completed by Ms. Kim on July 20, 2023 (report dated July 24, 2023) supports the applicant’s restrictions of her in-home activities and is evidence that the plans are reasonable and necessary. The applicant has received attendant care from Complex Care Medical & Health Services in the months of September, October and November 2023.

10The respondent submits that the ambulance report and Credit Valley Hospital Emergency Room (ER) records from May 12, 2023 indicate the only injuries sustained by the applicant were abrasions on her knees and back strain. Further, the clinical notes and records of Dr. Ehsaneddin Nasirzadeh, family physician, from May 15, 2023 indicate the applicant reported scraped knees and overall body soreness. The respondent relies on the general practitioner assessment report completed by Dr. Isa Mohammed, dated July 26, 2023, which concludes that the in-home assessment is not reasonable and necessary based on a documentation review and an examination of the applicant. Further, the respondent relies on Dr. Mohammed’s general practitioner paper reviews for attendant care benefits reports dated October 19, 2023 and February 29, 2024, which conclude the attendant care assessment is not reasonable or necessary.

11In reviewing the in-home assessment report of Ms. Kim, dated July 24, 2023, I note that the assessor was not provided with any records for review. The self-reporting of the applicant was the source of information regarding her pre-accident health, the mechanics of the accident, and her post-accident medical care. The applicant reported to Ms. Kim that the vehicle ran over her left foot, and that she experienced immediate pain and headaches. However, this reporting (done two and a half months post-accident) is different than the records created at and within three days after the accident. Ms. Kim’s report also relied on the assessor’s observations of the applicant’s demonstrated abilities. Ms. Kim recommended $10,408.29 per month for attendant care, 17 hours per week for housekeeping and home maintenance, and 32 hours per week for caregiving. The Form 1 specifies 1,495 minutes or 24.92 hours per week of level 1 care; 8,187 minutes or 136.45 hours per week of level 2 care; 395 minutes of 6.58 hours per week of level 3 care; for a total of 10,077 minutes or 167.95 hours of care per week.

12I note that that Complex Care Medical & Health Services records indicate the applicant received services 11 days in September, 13 days in October, and 9 days in November, each for 180 minutes per day.

13I find the report of Dr. Mohammed to be more persuasive than the report of Ms. Kim. Where Ms. Kim relied on the applicant’s subjective reporting and observations of the applicant’s movements, Dr. Mohammed conducted a medical file review and objective testing of the applicant. Dr. Mohammed notes there is no conclusive evidence from imaging studies or specialist’s reports to support the applicant having a significant disability or requiring assistive devices for rehabilitation or that validates the necessity for attendant care in her rehabilitation. Further, he opines that the subjectively described and demonstrated, self-imposed functional limitations of the applicant were greater than what would be expected on the basis of the objective, accident-related musculoskeletal injuries sustained. Dr. Mohammed concluded that, considering the available information and the absence of compelling evidence, the applicant's condition does not merit the provision of attendant care.

14I find that the in-home assessment plan and attendant care assessment plan are not reasonable and necessary, because I am persuaded by the conclusions drawn by Dr. Mohammed. Specifically, after objective testing was conducted, this assessor concluded that the testing does not support that the applicant has functional limitations, other than those which are self-reported by the applicant.

15I find the applicant has not proven, on a balance of probabilities, that the in-home assessment plan is reasonable and necessary. Further, the applicant has not proven, on a balance of probabilities, that the attendant care assessment plan is reasonable and necessary.

Issue 3: Neurological Assessment

16For the reasons that follow, the applicant is not entitled to the neurological assessment plan.

17I have reviewed the neurological assessment plan completed by Shireen Sundrani, physiotherapist, on June 6, 2023. The goals of the plan are identified as pain reduction, increased range of motion, increase in strength, and a neurological assessment to investigate and determine prognosis and treatment options available. The evaluation method listed is to follow the recommendations by the neurologist and re-assess in six months if needed. The services proposed are for completion of the OCF-18 by the physiotherapist, and a total body examination by Dr. Andrew Gomes Vargas, neurologist, at a total cost of $2,200.00.

18The applicant submits a neurological assessment was completed by Dr. Olga Finlayson, neurologist, dated August 25, 2023. The assessment indicates that the applicant has been diagnosed with headaches and migraines, depression and anxiety, post-concussion syndrome, somatic symptom disorder with predominant pain and sleep disturbances. Dr. Finlayson opined that follow up is required to determine conclusions and identify possible future investigations. Further, the applicant submits the neurological assessment is reasonable and necessary to determine treatment options.

19The respondent submits that the neurological assessment report completed by Dr. Davar Nikneshan, neurologist, on July 26, 2023, and the general practitioner assessment report completed by Dr. Mohammed on July 26, 2023 should be preferred. The respondent relies on the opinion of Dr. Nikneshan that the treatment plan is not reasonable or necessary.

20I note that Dr. Finlayson relies on a medical note of May 17, 2023 in Dr. Nasirzadeh’s records, which states the applicant needs help at home for her daily activities due to the accident. However, I have reviewed Dr. Nasirzadeh’s records, and I find the SOAP notes do not support the need for assistance with daily activities because the records do not contain notes from Dr. Nasirzadeh indicating subjective reports from the applicant nor objective findings upon examination of the applicant regarding limitations following the accident.

21I also note that Dr. Finlayson does not reference the ambulance report or the ER records during the initial period of the applicant’s admittance. It is unclear if Dr. Finlayson was aware of the applicant’s original descriptions of the accident, of being knocked to the ground and scraping her knees with some pain, having no impact to her head, and no loss of consciousness or other symptoms reported. In her report, Dr. Finlayson recalls the applicant’s reporting of the accident as follows:

[The applicant] reports that she was standing by her parked car when a third-party vehicle struck her from behind with significant force and knocked her to the ground. The car continued to move, and the client was pushed forward and dragged. The client believes that the tire of the third-party vehicle rolled over her left foot. She was trying to push the car away with her right hand. [The applicant] did not anticipate the accident and did not brace herself for impact. She reports hitting her head against the ground and losing consciousness for a few seconds. Immediately after the impact, she was feeling disoriented, dizzy, nauseous, lightheaded and pain in the head. She was unable to ambulate independently.

22Dr. Finlayson documents the applicant reporting “significant functional limitations”. However, I do not find Dr. Finlayson’s report to be persuasive, because I note she acknowledges that all diagnostic imaging was normal, and, during the assessment, the objective testing results are predominately described as normal, with the exception of the applicant declining some of the test maneuvers. Further, I find Dr. Finlayson’s diagnoses relied heavily on the applicant’s subjective reporting of the mechanics of the accident, specifically that she struck her head, briefly lost consciousness, and suffered immediate symptoms of a concussion, all of which are unsupported by the medical records from the day of the accident. Also, I find there is no reference in Dr. Finlayson’s report of having reviewed Dr. Mohammed’s or Dr. Nikneshan’s July 26, 2023 reports, which would have provided corroboration of her objective results, as well as insight into the applicant’s reporting of the mechanics of the accident.

23I prefer the assessment report of Dr. Nikneshan, who relied on the diagnostic imaging, mechanics of the accident, and objective findings to conclude that the applicant has persistent headaches secondary to Whiplash II, with a component of medication overuse headaches. He opined that the predominant symptoms are musculoskeletal in nature, which can be managed by the family physician. I find Dr. Nikneshan’s opinions are corroborated by Dr. Mohammed, who concurred that the applicant’s injuries are soft tissue injuries in various musculoskeletal systems.

24For the reasons above, I find the applicant has not proven, on a balance of probabilities, that the neurological assessment is reasonable and necessary.

Issues 4 & 5: Concussion Assessment and Concussion Treatment Plans

25For the reasons that follow, I find the applicant is not entitled to the concussion assessment plan, dated May 14, 2023, nor is she entitled to the concussion treatment plan, dated July 27, 2023.

26I have reviewed the concussion assessment plan completed by Dr. James Fung, chiropractor, on May 14, 2023. The goal of the plan is a concussion assessment to confirm the traumatic head injury and evaluate the extent of her concussion injury. The evaluation methods are identified as balance tests, processing speed tasks, visual screening examination (near point convergence test, saccades, smooth pursuit, vestibular ocular reflex, reaction time tests), Standard Assessments of concussions, grades symptoms checklists and neuropsychological screening tests, autonomic nervous system testing, cerebellum, dual tasks and sensory testing. The services proposed include a total body examination and the completion of the OCF-18. The cost of the proposal is $2,200.00, plus HST.

27Further, I have reviewed the plan for concussion treatment completed by Dr. Fung on July 27, 2023. The goals of the plan are to improve balance, decrease other concussion symptoms, such as headache and dizziness, and to improve daily functions and symptoms. The evaluation methods are subjective and objective measures and a mini-evaluation on each visit. The services proposed include: 24 – 1.25 hour sessions of therapy for motor and living skills; 6 sessions of facilitation, cognition and learning; 4 sessions of training, cognition and learning skills; as well as 1 – 2.5 hour total body assessment; 2 hours for documentation, and preparation and documentation time and expenses for educational materials, at a total cost of $5,629.43, plus HST.

28The applicant submits that she was diagnosed with a concussion at Credit Valley Hospital on May 16, 2023. She attended iScope Concussion & Pain Clinic on June 7, 2023, and, during an initial assessment, her diagnosis was confirmed. Dr. Fung’s concussion evaluation report, dated July 19, 2023, confirms the applicant is suffering from post-concussion symptoms as a direct result of the accident, and that the treatment plans are reasonable and necessary.

29The respondent submits that there is no documentation of a head injury, loss of consciousness, concussion, headache, or nausea. Also, Credit Valley Hospital ER records from May 16, 2023, document the applicant’s complaint of worsening headache, however the CT Scan of her head and cervical spine were negative. The respondent relies on the Independent General Practitioner’s Paper Review report of Dr. Mohammed, dated October 19, 2023, who opined the concussion assessment is not reasonable or necessary. Further, the respondent submits that Dr. Fung is a chiropractor, and therefore he is not qualified to provide a medical diagnosis.

30Although the ambulance report and ER admittance records do not support the applicant struck her head during the accident, or that she lost consciousness, I find that the applicant did complain of a headache when assessed by the ER physician on May 12, 2023. I also find that the medical records of the ER physicians, Dr. Jessica Cheung and Dr. Indraneel Ghosh at Credit Valley Hospital prove the applicant received a diagnosis of a concussion, and she was prescribed Flexeril 5mg 3x/d for 10 days on May 16, 2023. The ER physicians also recommended for the applicant to contact iScope Concussion & Pain Clinic. I note that in making this diagnosis, the ER records mention a “recent trauma” and a car accident on May 12, 2023, but do not mention the applicant’s history of headaches. Further, the May 16, 2023 ER records indicate the CT and MRI were negative.

31I find that the applicant has already been diagnosed with a concussion, and she has attended iScope Concussion & Pain Clinic on June 7, 2023, for an assessment, which confirmed the diagnosis and made several recommendations for treatment. Therefore, I find the applicant has not demonstrated how an assessment to confirm the diagnosis is reasonable and necessary.

32Further, I find that the methodology for assessment in the concussion treatment plan is vague, as is the description of the proposed treatment modalities. In my view, there is little correlation between the recommended treatment listed in either the iScope Concussion & Pain Clinic’s report or Dr. Fung’s assessment report and the concussion treatment plan. Therefore, I find the applicant has not demonstrated how the proposed plan for concussion treatment is not reasonable and necessary.

33I find the applicant has not proven, on a balance of probabilities, that the plans for a concussion assessment and treatment are reasonable and necessary.

Issues 6 & 7: Chiropractic Treatment Plans

34For the reasons that follow, I find the applicant is not entitled to the chiropractic treatment plans, dated June 6, 2023, and August 17, 2023.

35I have reviewed the treatment plan completed by Dr. Jennifer Violante, chiropractor, on May 26, 2023. The goals of the plan are to reduce pain, increase range of motion, increase strength, return to activities of normal living and return to modified work activities. The methods of evaluation are identified as range of motion, visual analog scale or pain rating scale, and orthopaedic testing. The proposal includes physical manipulation, stimulation of muscles, acupuncture, exercise, assessment and personal protective equipment. The total number of sessions is 21, over a period of six weeks, at a cost of $3,680.33.

36I have also reviewed the treatment plan completed by Dr. Na Ryung Kim, chiropractor, on August 17, 2023. The goals of the plan are consistent with the May 26, 2023 plan. The evaluation indicates the applicant reports ongoing pain and limited range of motion. The proposal includes 8 sessions of physical manipulation, over six weeks, at a cost of $1,300.00. The plan was partially approved for $1,015.29, leaving $284.71 in dispute.

37The applicant submits that the medical records are evidence of her overall body pain, shoulder pain, pain in her left arm and hip, as well as her ongoing headaches due to her concussion. On May 24, 2023, the family doctor’s records indicate the applicant was referred to physiotherapy, occupational therapy and psychological services. The applicant submits the abundance of medical evidence justifies these treatment plans.

38The respondent relies on Dr. Mohammed’s Independent General Practitioner’s Assessment Report, dated July 26, 2023, which opines that, in the absence of definitive evidence from imaging studies or specialist reports that conclusively establish the applicant's significant impairment or validate the necessity for the proposed treatment plan, it is not reasonable or necessary.

39I note that the family doctor’s notes and records do not recommend or mention chiropractic treatment. The records do support the need for physiotherapy, occupational therapy and psychological treatment. It is well established that a treatment plan must be supported by medical recommendation or documentation, in addition to that of the provider of the treatment. I have not been directed to any medical records or other documentation that support the chiropractic treatment plan dated May 26, 2023, is reasonable and necessary. In the absence of supporting evidence, I find the applicant has not proven this plan is reasonable and necessary.

40The August 17, 2023, treatment plan was partially approved in the amount of $1,015.29. Neither party has made submissions or led evidence as to why the partial approval was granted, or why the $284.71 was denied. It is the applicant’s burden to prove the treatment plan is reasonable and necessary, and, in the absence of evidence to explain and justify the outstanding cost of this plan, I find the applicant has not met her burden.

41For the reasons above, I find the applicant has not proven, on a balance of probabilities, that the June 6, 2023 plan or the outstanding amount from the August 17, 2023 plan for chiropractic treatment are reasonable and necessary.

Issue 8: Chiropractic Treatment Plan

42For the reasons that follow, I find the applicant is not entitled to the chiropractic treatment plan dated November 16, 2023.

43I have reviewed the treatment plan completed by Dr. Kim on November 16, 2023. The goals are consistent with the two previous OCF-18s for chiropractic treatment. The evaluation is consistent with the May 17, 2023 OCF-18. The proposal includes 9 sessions of physical manipulation by Dr. Kim, and 9 sessions of physical therapy by Marco Bianchi, massage therapist, over six weeks at a cost of $1,691.57.

44The applicant submits the abundance of medical evidence justifies the treatment plan.

45The respondent submits that the applicant has not complied with a request for an Insurer’s Examination, pursuant to s. 44 of the Schedule. Letters and notices of examination, dated December 1, 2023, December 11, 2023 and January 22, 2024, are compliant with the requirements set out in s. 44(5) and s. 44(6) of the Schedule. Section 44(9) requires the insured person to cooperate with the examination and to submit to all reasonable examinations requested by the examiner. The applicant has not explained her non-attendance. Therefore, the respondent takes the position that it is not liable for the benefit.

46I note that the applicant did not make submissions to address the respondent’s position.

47It is the applicant’s burden to prove the treatment plan is reasonable and necessary. I have not been directed to medical records or other documentation that support the chiropractic treatment plan, dated November 16, 2023. I find that due to a lack of supporting evidence, the applicant has not met her burden of proof.

48For the reasons above, I find the applicant has not proven, on a balance of probabilities, that the chiropractic treatment plan is reasonable and necessary.

Issue 9: Physiotherapy Treatment Plan

49For the reasons that follow, the applicant is not entitled to the physiotherapy treatment plan.

50I have reviewed the treatment plan completed by Dr. Sanjeet Singh, chiropractor, on September 22, 2023. The goals of the plan are consistent with the OCF-18s for chiropractic treatment. The evaluation indicates complaints of a lack of sensation in her feet bilaterally, back pain, and right shoulder tendinosis. The proposal includes 11 sessions of physical manipulation by Dr. Singh, and 11 sessions of physical therapy by Marco Bianchi, massage therapist, over six weeks at a cost of $2,023.03.

51The applicant submits that the records of the family doctor, Mackenzie Medical Rehabilitation and Trillium Health Partners support that this treatment plan is reasonable and necessary.

52The respondent relies on the Independent General Practitioner’s Paper Review reports of Dr. Mohammed, dated October 19, 2023 and February 9, 2024. It is Dr. Mohammed’s opinion that the physiotherapy treatment plan is not reasonable and necessary, because there is an absence of definitive evidence, from imaging studies or specialist reports, that conclusively establish the applicant has a significant impairment or validate the necessity for the treatment.

53I find that the references to the applicant’s symptoms found in the family doctor’s notes are not the opinion of the family doctor, but rather, they are the content of a letter received by the family doctor on May 26, 2023 from Mackenzie Medical Rehabilitation. The letter lists the applicant’s reported symptoms. The family doctor does not comment on the correspondence, nor does there appear to be any action taken in response. It is well established that a treatment plan must be supported by medical recommendation or documentation, other than the provider of the treatment. I have not been directed to medical records or other documentation that support the physiotherapy treatment plan is reasonable and necessary.

54For the reasons above, I find the applicant has not proven, on a balance of probabilities, that the physiotherapy treatment plan is reasonable and necessary.

Issue 10: Psychological Treatment Plan

55For the reasons that follow the applicant is not entitled to the denied amount of $2,768.77 ($4,215.13 less $1,446.36 approved) for the psychological treatment plan.

56I have reviewed the treatment plan completed by Dr. Leon Steiner, psychologist, on September 11, 2023. The plan provides for services from Laiba Imran, psychotherapist. The goals of the plan are pain reduction, return to pre-accident level of psychological functioning, and return to activities of normal living. The evaluation methods are indicated as the administration of psychological tests. The proposed services include: 12 - 1.5 hour sessions of therapy with Laiba Imran, at a cost of $2,693.04; 1 - 1.5 hour session of testing at a cost of $224.42; 1.5 hours of preparation, 1 documentation support activity by Dr. Steiner at a cost of $673.25; educational material at a cost of $200.00; and document completion by Dr. Steiner at a cost of $200.00. The total cost of the submitted plan is $4,215.13.

57The amount approved includes 12 - 1.5 hour sessions of therapy and 1 - 1.5 hour session of testing with Laiba Imran at the Guideline’s hourly rate of $99.75 and 1 documentation support activity by Dr. Steiner at the Guideline’s hourly rate of $149.61. The total cost approved is $1,446.36.

58The applicant submits that the medical records support the treatment plan is reasonable and necessary.

59The respondent submits that it is not liable for expenses related to professional services that exceed the maximum rate established under the Professional Services Guideline No. 03/14 (“Guideline”). According to the respondent, the claim for $224.42 per hour by Laiba Imran, and $673.25 per hour by Dr. Steiner, exceed the Guideline’s hourly rates of $99.75 and $149.61, respectively.

60I do not have before me any submissions from the applicant as to what hourly rates apply for Laiba Imran or Dr. Steiner. It is the applicant’s burden to prove that the treatment plan, including the cost, is reasonable and necessary. In the absence of evidence to support that the Guideline rates do not apply; I agree with the respondent. Pursuant to the Guideline, the maximum payable rate for a psychotherapist is $99.75 per hour, while the maximum payable rate for a psychologist is $149.61 per hour. Therefore, I find the denied amount of $2,768.77 is not payable.

61The applicant has not proven, on a balance of probabilities, that the denied amount of $2,768.77 is payable.

Issues 11 and 12: Medications and Parking Expenses

62For the reasons that follow, I find the applicant is entitled to the expense for the prescription medication Zopiclone. However, she is not entitled to the expenses for parking, nor is she entitled to the expense for the prescription medication Cambia.

63I have reviewed the OCF-6, dated May 18, 2023, which itemizes a parking receipt for $11.25 from Credit Valley Hospital, as well as a prescription medication that is not in dispute.

64Further, I have reviewed the OCF-6, dated June 15, 2023, which itemizes a parking receipt for $15.00 from Credit Valley Hospital, as well as the following prescription medications from Shopper’s Drug Mart: Zopiclone 7.5mg, $44.80, and Cambia 50mg/SAC, $27.77.

65Section 15(1)(c) of the Schedule states medical benefits shall pay for all reasonable and necessary expenses incurred by or on behalf of the insured person as a result of the accident, including medication.

66Section 15(2)(c) of the Schedule states the insurer is not liable to pay medical benefits for certain expenses, including for transportation expenses other than authorized transportation expenses.

67The applicant submits that Zopiclone has been prescribed for insomnia. The applicant submits it was prescribed by Dr. Nasirzadeh on June 6, 2023. The applicant further submits that she requires Cambia for her migraines. The applicant also submits that the parking expenses were incurred when visiting Credit Valley Hospital.

68The respondent does not make submissions regarding the medications. The respondent submits it is not liable for parking expenses.

69I note the applicant has not directed me to records that support who prescribed her Cambia or why. Also, the applicant has not directed me to records in support of the parking expenses being part of authorized transportation expenses. Therefore, in the absence of supporting evidence, I find the applicant is not entitled to the expenses for Cambia or parking.

70However, I find the clinical notes of Dr. Nasirzadeh on June 6, 2023 support that Zopiclone is for sequelae related to her accident injuries. I again note that the respondent has not addressed this expense in its submissions.

71For the reasons above, I find the applicant has proven, on a balance of probabilities, that she is entitled to the expense of $44.80 for Zopiclone. I also find the applicant has not proven, on a balance of probabilities, that she is entitled to the expenses for parking or Cambia.

Issue 13: Interest

72Pursuant to s. 51 of the Schedule, the applicant is entitled to interest on any overdue payment of benefits.

Issue 14: Award

73The 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.

74The applicant submits that respondent unreasonably withheld or delayed payments. The respondent submits the applicant has not led evidence to support a s. 10 claim.

75I find the applicant has not led evidence to support the respondent has acted in a manner worthy of an award. It is well established that the respondent is not held to a standard of perfection. No award is payable.

CONCLUSION and ORDER

76For the reasons stated above:

i. The applicant is not entitled to the treatment plans in dispute. ii. The applicant is entitled to $44.80 for the prescription medication Zopiclone. iii. The applicant is not entitled to $27.77 for the prescription medication Cambia. iv. The applicant is not entitled to parking expenses. v. The applicant is entitled to interest on any overdue payment of benefits. vi. The applicant is not entitled to an award under s. 10 of Reg. 664.