Licence Appeal Tribunal File Number: 23-013252/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:
Ying Qi Li
Applicant
and
Belair Insurance Company Inc.
Respondent
DECISION
ADJUDICATOR:
Robert Rock
APPEARANCES:
For the Applicant:
Aylina Dhanji, Counsel
For the Respondent:
Navjot Banipal, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Ying Qi Li, the applicant, was involved in an automobile accident on February 11, 2022, 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, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
PRELIMINARY ISSUE
2The preliminary issue to be decided is:
i. Is the applicant barred from proceeding to a hearing for all of the benefits claimed in this application because the applicant failed to attend an insurer’s examination under s. 44 of the Schedule?
SUBSTANTIVE ISSUES
3The substantive issues in dispute are:
i. Are the applicant’s injuries predominantly minor as defined in s. 3 of the Schedule and therefore subject to treatment within the $3,500.00 Minor Injury Guideline (MIG) limit?
ii. Is the applicant entitled to $2,200.00 for a psychological assessment, proposed by Somatic Assessments and Treatment Clinic in a treatment plan/OCF-18 submitted June 6, 2022 and denied on the same day?
iii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
2The applicant is barred from proceeding to a hearing for all of the benefits claimed in this application, pursuant to s. 55(1) of the Schedule.
ANALYSIS
3I find the applicant did not attend a reasonably necessary insurer’s examination (“IE”) that was scheduled in compliance with the Schedule. This breach of s. 44(1) means that the applicant is barred from proceeding to a hearing for all of the benefits claimed in this application, pursuant to s. 55(1) of the Schedule.
Sections 44 and 55 of the Schedule
4Section 44(1) of the Schedule provides that, for the purposes of assisting an insurer to determine if an insured person is or continues to be entitled to a benefit for which an application is made, but no more often than is reasonably necessary, an insurer may require an insured person to be examined by one or more persons chosen by the insurer who are regulated health professionals or who have expertise in vocational rehabilitation.
5Section 55(1)2 of the Schedule provides that an insured person shall not apply to the Tribunal if the insurer has provided the insured person with notice that it requires an examination under section 44, but the insured person has not complied.
6Section 55(2) states that the Tribunal may permit an insured person to apply to it, despite paragraphs 2 and 3 of section 55(1).
7The respondent bears the onus of establishing that the applicant is statute-barred for failing to comply with a reasonably necessary IE request. .
Non-attendance at s. 44 assessments
8The respondent submits that the applicant failed to attend two scheduled IEs for an in-person psychological assessment and cancelled four subsequent IEs meant to assess whether she is subject to the MIG and her entitlement to the treatment plan. The respondent submits that the applicant has not attended any IEs, and the respondent submits that the applicant is barred from proceeding to a hearing for failure to attend the IEs.
9The applicant submits she is not refusing to attend IEs, and there are reasonable explanations for the ones she missed. Specifically, the first examination was cancelled by the assessor, due to an emergency and was not her fault. The applicant references work schedule issues in relation to the other scheduled IEs, but has not directed me to any evidence in support of this submission.
10There is no dispute between the parties that the applicant has not attended any of the IEs described in the respondent’s submissions. While the first IE was cancelled by the insurer, the evidence before me indicates that the IEs were scheduled and rescheduled six times between July 2022 and October 2023. There may be a dispute between the parties over the applicant’s attempts to remedy this non-compliance (e.g., emails requesting the IEs to be rescheduled for a Friday or Saturday from October 13, 2023, February 22, 2024, July 15, 2024, October 15, 2024, and December 4, 2024). However, I do not find this dispute over the applicant’s efforts to remedy the breach establishes that she has a reasonable explanation for not attending. The respondent did reply to the applicant indicating that she had not appeared at 2 appointments and cancelled 4 appointments. In that reply, the respondent requested notice in writing with the reasons for non-attendance, and confirmation to attend future IEs, I have not been presented any evidence that the applicant has complied and provided a reasonable explanation for non-attendance.
11I find that there is a nexus between the request for the IE assessment and the injuries of the applicant that makes it “reasonably necessary” for a MIG determination and assessing entitlement to a psychological assessment funding for treatment outside the MIG. In a notification from the respondent on October 25, 2023, the IEs were meant to assist the respondent in determining the applicant’s MIG determination and whether the OCF-18 for a psychological assessment was reasonable and necessary.
12It was reasonably necessary for the respondent to seek its own assessment of the applicant’s condition.
13I now turn to the applicant’s explanation for the non- attendance. The applicant did not make any submissions or point me to evidence of the reasons why she did not attend the two scheduled appointments, or why she cancelled four additional appointments, other than general references to meetings and her work schedule.
14I have not been directed by applicant to any responses indicating a reasonable explanation for the cancelations and non-attendance beyond an email from the applicant noting an important meeting. However, that does not explain the four additional cancelled appointments.
15The respondent has satisfied me that the applicant failed to attend a reasonably necessary IE. For this reason, the applicant is barred from proceeding to a hearing for issues in dispute in this application, pursuant to s. 55(1) of the Schedule.
ORDER
16I find that:
i. Pursuant to s. 55(1) of the Schedule, the applicant is barred from proceeding to a hearing for all of the benefits claimed in this application.
Released: August 8, 2025
Robert Rock
Adjudicator