Licence Appeal Tribunal File Number: 23-009209/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:
Yi Jie Dong
Applicant
and
Certas Home and Auto Insurance Company
Respondent
DECISION
ADJUDICATOR: Brian Norris
APPEARANCES:
For the Applicant: Sareena Samra, Counsel
For the Respondent: Kevin H. Griffiths, Counsel
HEARD: By way of written submissions
OVERVIEW
1Yi Jie Dong (“the Applicant”) was involved in an automobile accident on December 15, 2018, and sought benefits from Certas Home and Auto insurance Company (“the Respondent”) 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 to be decided in the hearing are:
i. Is the Applicant entitled to a medical benefit in the amount of $16,712.81, less $11,000.00 approved by the Respondent, for a multidisciplinary catastrophic assessment, proposed by Somatic Assessments & Treatment Clinic in a treatment plan dated June 24, 2021?
ii. Is the Respondent liable to pay an award under section 10 of Regulation 664 because it unreasonably withheld or delayed payments to the Applicant?
iii. Is the Applicant entitled to interest on any overdue payment of benefits?
RESULT
3The Applicant is not entitled to the unapproved balance of the catastrophic impairment assessments.
4No award or interest is payable.
BACKGROUND
5The Applicant was the driver of a vehicle which was involved in a three-car collision. She sustained injuries including but not limited to a spleen laceration, sternal and rib fractures, a disc herniation, compression fracture in her back, and a broken collarbone. She was hospitalized for five days following the accident before being discharged with instructions to engage in rehabilitative therapy.
6At issue is whether the Applicant is entitled to the unapproved balance of the catastrophic impairment assessments. For the following reasons, I find that she is not entitled to the unapproved balance of the catastrophic impairment assessments. Likewise, she is not entitled to interest or an award as it relates to the denial of services.
ANALYSIS
7Pursuant to section 25(5) of the Schedule, the Applicant is entitled to funding for reasonable and necessary assessments performed in connection with a determination of whether she suffered a catastrophic impairment. Section 25(5)(a) of the Schedule caps the cost of an assessment at $2,000.00.
8Section 25(1)(5) of the Schedule provides the respondent shall pay for the reasonable fees charged for preparing an application under section 45 for a determination of whether the insured person has sustained a catastrophic impairment, including any assessment necessary for that purpose. Section 25(5)(a) provides the respondent is not liable to pay more than $2,000.00 plus HST for fees and expenses for conducting any one assessment or examination and the preparation of the related report.
9As it relates to the catastrophic impairment assessments, the Respondent approved funding in full for each of the following services proposed: a neurological assessment, an in-home occupational therapy (“OT”) assessment, psychological assessment, the overall assessment summary and final rating, and a chiropractic assessment. Each of these assessments were approved in full, at $2,000.00 per modality. The plan also includes a request for $600.00 for interpretation services, $200.00 for the completion of the OCF-19, and $200.00 for the completion of the treatment plan, which the Respondent also funded.
10The Respondent denied funding for the following: $600.00 for transportation for the Applicant to the assessments, $112.81 for transportation for the OT to the Applicant’s home, $2,000.00 for a file review by a neurosurgeon, and three other file reviews at $1,000.00 each.
11The Applicant submits that the Respondent is ignoring the Schedule and caselaw with respect to the approval of assessments. It notes that catastrophic impairment assessments are not to be considered a medical benefit and are not subject to the funding limits outlined in section 18(3)(a) of the Schedule. The Applicant also submits that the Respondent is required to pay reasonable fees for preparing an application for determination of catastrophic impairment. She relies on Hassani v. Guarantee Company of North America, 2018 ONFSCDRS 5 (“Hassani”) to support her position that the unapproved fees are payable.
12The Respondent first highlights that the Applicant has not incurred the full amount claimed in the assessment. It submits that the Applicant incurred $14,712.81 of the $16,712.81, according to the invoices submitted to it. On this note, the Respondent submits that a third assessment, or the third service fee of $2,000.00, completed by the neurosurgeon was proven to be unnecessary given that it was not incurred.
13The Respondent further submits that file review fees, like the three proposed in this plan at a rate of $1,000.00 each, are part of an assessment and cannot be billed separately to circumvent the $2,000.00 funding limit for each assessment.
14Lastly, the Respondent submits that the Applicant is not entitled to transportation expenses because she is subject to a 50 km deductible. It submits that, according to online maps, the Applicant’s residence is 15.2 km from the assessment centre, thus she is not entitled to any transportation expenses.
15The Applicant was provided an opportunity to reply to the Respondent’s submissions but chose not to.
File review is an essential component of an assessment
16I find the Applicant is not entitled to any unapproved amounts for the various file reviews because a file review is included in the $2,000.00 funding limit for any one assessment. Reviewing documents in advance of an assessment is a necessary part of the process and is contemplated in section 25(5)(a) of the Schedule. I agree with the reasoning in 17-007215 v Aviva General Insurance, 2018 CanLII 141011 (ON LAT) which found the fees associated with file review are captured in the $2,000.00 funding limit for fees and expenses for conducting any one assessment or examination.
17The Applicant has provided no other reason why she may be entitled to the file review fees, other than to suggest that the Schedule and caselaw support it. The Schedule does not provide any further guidance on the issue other than the sections I previously outlined. Moreover, the caselaw provided by the Applicant does not address whether a file review should or should not be included in the $2,000.00 fee for any one assessment. Instead, I find that Hassani stands for the proposition that each modality in a catastrophic impairment assessment is subject to the $2,000.00 funding limit – there is no discussion in Hassani regarding what the goods and services are included in the funding cap for each assessment.
18Thus, I conclude that the Applicant is not entitled to the three $1,000.00 file review fees, as well as the $2,000.00 file review fee. These fees are not reasonable and necessary because a file review is an essential component of an assessment and is included in the $2,000.00 funding limit.
No transportation expenses are payable
19I find that the Applicant has not demonstrated that she is entitled to transportation fees claimed. I agree with the Respondent that transportation is subjected to a 50km deductible, as outlined in the definition of “authorized transportation expenses” found in section 3(1) of the Schedule, unless the insured person has sustained a catastrophic impairment.
20The evidence indicates that the Applicant lives approximately 15 km away from the assessment centre. The Respondent submitted an online map depicting the Applicant’s residence, the location of the assessment centre, and the route between the two. The map shows a distance of 15.2 km between the Applicant’s residence and the assessment centre. This distance falls within the 50 km deductible. Thus, the Applicant has not demonstrated entitlement to transportation based on the distance from her residence.
21The Applicant has not demonstrated that she is entitled to transportation fees on account of having sustained a catastrophic impairment. The Applicant may not be subject to the 50 km deductible if she can demonstrate that she sustained a catastrophic impairment. According to a motion order, dated August 26, 2024, the Applicant withdrew her claim for a determination that she sustained a catastrophic impairment. Further, according to the Respondent’s submissions, there has been no determination that the Applicant sustained a catastrophic impairment. While the Applicant’s evidence includes a report that finds she sustained a catastrophic impairment, I give that conclusion no weight in this hearing considering the Applicant withdrew her claim for a catastrophic impairment determination, that the Respondent denies that she sustained a catastrophic impairment, and because the Applicant never issued reply submissions to address whether she sustained a catastrophic impairment as a result of the accident.
22Accordingly, I find that the Applicant has not demonstrated that she is entitled to transportation fees in relation to the catastrophic impairment assessments.
Award
23I find no award payable.
24Pursuant to section 10 of Regulation 664, the Applicant may be entitled to an award if it is deemed that the Respondent unreasonably withheld or delayed payment of a benefit.
25The Applicant claims that the Respondent unreasonably denied portions of the catastrophic impairment assessments, prolonging her injuries and road to recovery. She highlights various injuries documented in her medical record to support her claim that she is to the unapproved balance of the catastrophic impairment assessments. The Respondent submits that the Applicant had not put forth an argument as to what it did that amounts to unreasonable conduct. It submits that the manner in which it adjusted the Applicant’s claim cannot be described as unreasonable and does not warrant an award.
26Having found no benefits or interest payable, it follows that no benefits or payments have been unreasonably delayed or withheld. Accordingly, no award is payable.
Interest
27Interest applies on the payment of any overdue benefits pursuant to section 51 of the Schedule. Having found no benefits payable, it follows that no interest is payable.
CONCLUSION AND ORDER
28The Applicant has not met her onus to demonstrate entitlement to the unapproved balance of the catastrophic impairment assessments.
29No award or interest is payable.
30The application is dismissed.
Released: July 30, 2025
Brian Norris
Adjudicator