Citation: Huang v. Pembridge Insurance Company, 2025 ONLAT 23-010382/AABS

Licence Appeal Tribunal File Number: 23-010382/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:

Zhi Neng Huang

Applicant

and

Pembridge Insurance Company

Respondent

DECISION

ADJUDICATOR:

Robert Rock

APPEARANCES:

For the Applicant:

Ryan Olson, Paralegal

For the Respondent:

Simran Walia, Counsel

HEARD:

By way of written submissions

OVERVIEW

1Zhi Neng Huang, the applicant, was involved in an automobile accident on October 20, 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, Pembridge 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 $1,395.48 for Physiotherapy Services, proposed by Total Recovery Rehab Centre in a treatment plan/OCF-18 (“treatment plan”) dated January 24, 2022?

ii. Is the applicant entitled to $4,303.90 for Physiotherapy Services, proposed by Total Recovery Rehab Centre in a treatment plan dated May 23, 2023?

iii. Is the applicant entitled to $1,047.34 for Psychological Services, proposed by Somatic Assessments and Treatment Clinic in a treatment plan dated September 26, 2022?

iv. Is the applicant entitled to $748.10 ($2,804.20 less $2,056.10 approved) for Psychological Services, proposed by Somatic Assessments and Treatment Clinic in a treatment plan dated May 4, 2023?

v. Is the applicant entitled to $748.10 ($2,804.20 less $2,056.10 approved) for Occupational Therapy Services, proposed by Somatic Assessments and Treatment Clinic in a treatment plan dated November 21, 2023?

vi. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?

vii. Is the applicant entitled to interest on any overdue payment of benefits?

Procedural Issue

3Issue i, as listed in the Case Conference Report and Order, does not note that this issue is regarding a partially approved physiotherapy services treatment plan. The OCF-18 was for $3,989.56, and the respondent has partially approved this treatment plan for $2,594.08, leaving an unapproved balance of $1,395.56.

4Issue v is listed as an occupational therapy services treatment plan in the Case Conference Report and Order, but it should have been identified as a treatment plan for psychological services.

RESULT

5The applicant is not entitled to the two physiotherapy services treatment plans.

6As no benefit payments have been withheld, no interest is owning.

7As no benefit payments have been withheld or delayed, no award in owing.

ANALYSIS

8To receive payment for a treatment and assessment plan under s. 15 and s. 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.

Physiotherapy Services Treatment Plans

9I find that the applicant has not proven, on a balance of probabilities, that the two physiotherapy services treatment plans are reasonable and necessary. The applicant has also not demonstrated that the outstanding balance from the January 24, 2022 plan is payable, pursuant to s. 38 of the Schedule.

10The goals of both treatment plans are pain reduction, increased range of motion, increase in strength, return to activities of normal living, and return to modified work activities. Both treatment plans include 16 sessions of therapy multiple body sites, travel time, documentation, and an assessment. The May 23, 2023 treatment plan also includes 16 sessions of acupuncture and 16 sessions of exercise.

11The applicant argues that the physiotherapy treatment plans are reasonable and necessary due to ongoing pain and the need for pain relief. The applicant relies on the clinical notes and records (“CNRs”) of Dr. Melina Hong and Dr. Benjamin Lee, the applicant’s family doctors. In addition, the applicant argues that the outstanding balance of the January 24, 2022 plan is payable due to non-compliance with s. 38(8) of the Schedule.

Reasonable and Necessary

12I find that the CNRs of Dr. Hong do not support the applicant’s claim that the physiotherapy treatment plans are reasonable and necessary. The CNRs note that the applicant is showing improvement post-accident in both a physical and psychological perspective. The pain complaints are listed as aching/soreness that the doctor rates as a 2-3/10. Dr. Hong’s CNRs do not reflect that he scheduled or suggested any ongoing testing of the pain reporting.

13I also find that the CNRs of Dr. Lee do not support the applicant’s claim that the physiotherapy treatment plans are reasonable and necessary. Similar to Dr. Hong, Dr. Lee did not schedule or suggest any ongoing testing for the applicant’s pain reporting.

14The respondent argues that the physiotherapy services treatment plans are not reasonable and necessary. The respondent relies on a physiatry report by Dr. Jennifer Gordon, physiatrist, completed on June 23, 2022.

15I find that the physiatry report completed by Dr. Gordon does not support the applicant’s claim that physiotherapy services are reasonable and necessary. Dr. Gordon concluded that the applicant suffered from minor injuries as defined by MIG. Dr. Gordon also stated that, based on her physical examination and document review, she found no compelling evidence to support the applicant that the physical treatment plan is reasonable and necessary.

16Taken together, I find that the applicant has not proven that the treatment plans for physiotherapy services are reasonable and necessary. The CNRs of both Dr. Hong and Dr. Lee do not demonstrate that the treatment plans are reasonable and necessary based on their findings. I place significant weight on the physiatry report of Dr. Gordon, as the conclusions she presents in her report are corroborated by the reporting in the two doctors’ CNRs.

Section 38 of the Schedule

17Turning to the argument about s. 38 non-compliance, the applicant has not proven, on a balance of probabilities, that he is entitled to the outstanding balance for the January 24, 2022 plan based on this argument.

18The applicant argues, based on s. 38(8) of the Schedule, that the respondent did not provide adequate reasons for its partial approval of this plan. The respondent argues that it has conformed with the requirements of s. 38(8).

19Section 38(8) of the Schedule states:

Within 10 business days after it receives the treatment and assessment plan, the insurer shall give the insured person a notice that identifies the goods, services, assessments and examinations described in the treatment and assessment plan that the insurer agrees to pay for any the insurer does not agree to pay for and, the medical reasons and all of the other reasons why the insurer considers any goods, services, assessments and examinations, or the proposed costs of them, not to be reasonable and necessary.

20The denial provided by the respondent identified the goods and services in the treatment plan, as well as what they agreed to pay for from each element of the plan. The applicant had originally denied this treatment plan on the basis of their physiatry report from Dr. Gordon. Once the applicant was removed from MIG on the basis of a psychological condition, the respondent stated, in a further review of the request that, while they maintain that the treatment plan is not reasonable and necessary, they would pay for the portion of the treatment plan that was incurred by the applicant and requested that the applicant, pursuant to s. 47(2) of the Schedule, provide it with invoices.

21I disagree with the applicant that the respondent failed to comply with the requirements of s. 38(8). In my review of their denial, it adhered to the identified elements of s. 38(8).

22I find that the applicant has not proven, on a balance of probabilities, that the respondent failed to comply with the s. 38(8) requirements.

Psychological Services Treatment Plans

23The respondent has supplied Explanations of Benefits for the three psychological services treatment plans to show they have been paid in full, not partially paid as listed in the Case Conference Report and Order.

24I find that I do not need to review if any of these three plans are reasonable and necessary, as they have been paid in full and therefore are not in dispute before me.

Interest

25Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As there are no overdue benefit payments, no interest is owning.

Award

26The 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. As no benefit payments have been withheld or delayed, no award is owing.

ORDER

27I find that:

i. The applicant is not entitled to the two physiotherapy treatment plans.

ii. As no benefit payments have been withheld, no interest is owning.

iii. As no benefit payments have been withheld or delayed, no award in owing.

iv. The application is dismissed.