Licence Appeal Tribunal File Number: 23-008066/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:
Dimple Kumari
Applicant
and
Wawanesa Insurance
Respondent
DECISION
ADJUDICATOR: Andrea Reid
APPEARANCES:
For the Applicant: Rohan Haté, Counsel
For the Respondent: Gabrielle Nigro, Counsel
HEARD: By way of written submissions
OVERVIEW
1Dimple Kumari, the applicant, was involved in an automobile accident on September 12, 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, Wawanesa Insurance, 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 for $139.86 ($4,379.68 less $4,239.82 approved) for massage therapy and assistive devices, proposed by Prime Health Care Inc. in an OCF-18/treatment plan (“plan”) dated September 20, 2021?
ii. Is the applicant entitled to $2,000.00 for an attendant care assessment, proposed by Prime Health Care Inc. in a plan dated September 20, 2021?
iii. Is the applicant entitled to $2,200.00 for psychological assessment, proposed by Prime Health Care Inc. in a plan dated January 25,2022?
iv. Is the respondent liable to pay an award under s.10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
v. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant is not entitled to the unapproved amount in a treatment plan for massage therapy and assistive devices.
4The applicant is not entitled to an attendant care assessment.
5The applicant is not entitled to a psychological assessment.
6The applicant is not entitled to interest or an award.
ANALYSIS
The applicant is not entitled to the outstanding balance of a treatment plan for massage therapy and assistive devices
7I find that the applicant has not met her onus, on a balance of probabilities, to establish that the unapproved balance for massage therapy and assistive devices is reasonable or necessary.
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.
9The outstanding amount is for personal protective equipment.
10The applicant submits that she has met her burden to demonstrate that she is entitled to the outstanding amount of $139.86 for personal protective equipment (“PPE”) submitted by chiropractor, Dr. Hefford. The applicant further submits that if this treatment plan had been submitted with a higher hourly rate, the outstanding amount would have been included and paid by the respondent.
11The respondent argues that the applicant is not entitled to the cost of PPE as it is not covered under the Schedule and is considered “administration costs, overhead, and related costs, fees, expenses, charges and surcharges” pursuant to the Professional Services Guideline (“Guideline”). The respondent further argues that allowing for an additional fee for PPE would increase Dr. Hefford’s hourly rate beyond the maximum listed in the Guideline. The respondent points to the Tribunal’s decisions in Vila v. Aviva General Insurance, 2023 CanLII 50532, Kireev v. Certas Home and Auto, 2024 CanLII 41003, Murray v. Aviva General Insurance, 2023 CanLII 87412 and Bowen v. Aviva Insurance Company, 2024 CanLII 23451 to support its argument that PPE is not a reasonable and necessary expense.
12The decision in Vila v. Aviva General Insurance, 2023 CanLII 50532 states, “I find that PPE is captured by administrative and overhead costs, and including the cost of the PPE would increase the provider’s hourly rate beyond the maximum listed in the Guideline. In the absence of any evidence or argument from the applicant on this issue, I agree with the respondent and find that the expense for PPE is not payable” (para 54).
13In the absence of any evidence from the applicant on this issue or an explanation as to why PPE is payable under the Schedule, I agree with the respondent and find that the costs of PPE is not payable.
14Accordingly, I find that the applicant has not proven on a balance of probabilities that the unapproved balance for this treatment plan is reasonable and necessary.
The applicant is not entitled to an attendant care assessment
15I find that the applicant has not established, on a balance of probabilities, that an attendant care assessment is reasonable and necessary.
16The applicant submits she is entitled to an attendant care assessment. The applicant further submits that her injuries, sequalae and required time off work necessitate the need for assessing her needs for attendant care. The applicant relies on Section 25(1)4 of the Schedule in support of her claim.
17The respondent argues that the applicant has not met her burden to establish that an attendant care assessment is reasonable and necessary. The respondent relies on medical records from Brampton Civic Hospital, where imaging revealed a hairline, nondisplaced fracture through the left eighth rib for which she was discharged the same day without any follow-up instructions. The respondent further relies on the fact that the applicant has not visited an OHIP-funded physician since January 27, 2023, never reported the subject accident to an OHIP-funded physician at any time and has failed to produce evidence that supports a need for an attendant care assessment.
18I agree with the respondent. I am unable to locate any clinical notes or medical records to substantiate that any further accident-related injuries have been diagnosed by a physician beyond the hairline rib fracture on the date of loss. Further, I cannot locate anything in the records which indicate limitations caused by the accident-related impairments which necessitate an attendant care assessment. I was unable to find any evidence from any medical physician recommending an attendant care assessment.
19Importantly, the applicant returned to work one month after the subject accident. Further, at the time of the chronic pain assessment conducted in April 2024, the applicant self-reported she had gradually resumed most of her household chores, indicative of a good recovery and contradictory towards a need for attendant care services.
20For these reasons, I find that the applicant has not met her onus to establish on a balance of probabilities that an attendant care assessment is reasonable and necessary.
The applicant is not entitled to a psychological assessment
21I find that the applicant has not met her onus to demonstrate that a psychological assessment is reasonable and necessary.
22The applicant submits she is entitled to a psychological assessment based on psychological impairments arising from the subject accident. The applicant relies on the psychological pre-screen report conducted by Psychologist by Dr. Jacqueline Brunshaw and the subsequent self-funded psychological assessment, completed by Psychotherapist Sandra Ramnaraine (overseen by Dr. Brunshaw).
23The respondent argues that the applicant is not entitled to the cost of a psychological assessment. The respondent submits that the applicant did not report any psychological concerns to an OHIP funded physician or her treating physical therapist at Prime Health Care around the time the treatment plan was submitted. The respondent further submits the applicant’s psychological symptoms are extremely mild in nature, supported by the lack of any psychological complaints in the evidentiary record.
24The applicant’s submissions included two copies of the psychological pre-screen interview report conducted by Dr. Brunshaw that include different accident dates. While both interview reports reflect being conducted on January 11, 2022, pages 62-64 note the subject accident occurred on November 3, 2021. Conversely, on pages 167-169 (Tab 10), the report notes that the subject accident took place on September 12, 2021, the correct date of loss.
25Further, pages 50-52 (Tab 4) of the applicant’s submissions include a psychological pre-screen interview report conducted by Dr. Brunshaw on December 13, 2021 for a completely different patient (initials A. H.) injured in a motor vehicle accident on September 23, 2021.
26While mistakes happen, these errors raise concerns regarding the reliability of the psychological pre-screening report. Further, as noted in Karimi v. Pembridge Insurance Company, 2023 CanLII 1467 and Wadood v. Economical Insurance, 2023 CanLII 9251, the Tribunal has repeatedly confirmed that pre-screening reports are not compelling evidence on their own and must be accompanied by corroborating evidence. In this case, the report did not include a review of any contemporaneous medical records and all conclusions, including the rationale for the proposed assessment, were based solely on self-reporting by the applicant. For these reasons, I assign no weight to either copy of the psychological pre-screening report.
27Further, I agree with the respondent’s position that the applicant did not report any psychological concerns to an OHIP funded physician or her treating physical therapist at Prime Health Care around the time the treatment plan was submitted. There was no reference to psychological issues in the clinical notes from Prime Health up until the date of the submitted assessment. There is no referral for a psychologist from an OHIP-funded physician.
28The psychological assessment report was conducted by Dr. Brunshaw in February of 2024, over two years after the treatment plan was submitted. At the time the report was prepared, the applicant had not attended for any treatment in over two years and had not need an OHIP-funded physician for over one year. Further, Dr. Brunshaw was not provided with any post-accident medical records post January 11, 2022. His conclusions were not corroborated by medical evidence and instead, based on the applicant’s self-reporting.
29The applicant has not produced any clinical notes and records contemporaneous with the time the treatment plan was submitted or any documents demonstrating a psychological assessment was reasonable and necessary.
30I find that the applicant has not met her onus, on a balance of probabilities, that the proposed psychological assessment is reasonable and necessary.
Interest
31Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As there are no overdue benefits owed to the applicant, no interest is payable.
Award
32The 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
33I find:
i. The applicant is not entitled to the unapproved amount in a treatment plan for massage therapy and assistive devices.
ii. The applicant is not entitled to an attendant care assessment.
iii. The applicant is not entitled to a psychological assessment.
iv. The applicant is not entitled to interest or an award.
v. The application is dismissed.
Released: July 30, 2025
Andrea Reid
Adjudicator