Licence Appeal Tribunal File Number: 23-011971/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:
BoWen Xi
Applicant
and
Aviva Insurance Canada
Respondent
DECISION
ADJUDICATOR: Patrick Molloy
APPEARANCES:
For the Applicant: Aylina Dhanji, Counsel
For the Respondent: Branson Wong, Counsel
HEARD: In Writing
OVERVIEW
1BoWen Xi, the applicant, was involved in an automobile accident on January 25, 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, Aviva Insurance Canada, 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 the treatment plans / OCF-18 (“plans”) proposed by Somatic Assessments and Treatment Clinic, as follows:
a. $1,581.64 ($3,701.74 less $2,120.10 approved) for psychological services in a plan dated February 9, 2023?
b. $1,756.08 ($3,701.74 less $1,945.66 approved) for psychological services in a plan dated July 6, 2023?
c. $1,756.08 ($3,701.74 less $1,945.66 approved) for psychological services in a plan dated October 4, 2023?
d. $1,756.08 ($3,701.74 less $1,945.66 approved) for psychological services in a plan dated December 15, 2023?
ii. Is the applicant entitled to $253.82 for physiotherapy services proposed by Total Recovery Rehab Centre, in a plan dated June 4, 2022?
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
3The applicant is not entitled to the unapproved amounts for the treatment plans from Somatic Assessments and Treatment Clinic.
4The applicant is not entitled to the treatment plan for physiotherapy services.
5The applicant is not entitled to interest or an award.
ANALYSIS
The hourly rate of $149.61 for the psychotherapist services is not applicable in issues 1 – 4, based on the FSRA Professional Services Guidelines.
6The Professional Services Guideline (“Guideline”) establishes the maximum expenses payable by automobile insurers under the Schedule related to services provided by health care professions, or health care providers listed within the Guideline. Insurers are not prohibited from paying above any maximum amount or hourly rate established in the Guideline. It is also noted within the Guideline, that services provided by health care professionals/providers, unregulated providers and other occupations not listed within the Guideline are not covered by the Guideline. For services not covered by the Guideline, the amounts payable by an insurer are to be determined by the parties involved. The Guideline further notes that automobile insurers are not liable to pay expenses for services rendered to an insured person which exceed the maximum hourly rates set out in the Guideline’s Appendix.
7I have not been convinced by any evidence provided, the psychotherapist services warrant the rate of $149.61 because psychotherapists rates are prescribed in the professional services guideline established by the Financial Services Regulatory Authority.
8The burden of proof is the applicants, I am not satisfied by the evidence provided there is any reason for the hourly rate to be anything other than the prescribed minimum rate for a psychotherapist, in the professional services guidelines.
9The applicant refers to section 15.1 of the schedule which reads, “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 for, (b) chiropractic, psychological, occupational therapy, and physiotherapy services.” There is however legislation prescribing acceptable fee schedules in the Financial Services Regulatory Authority, which the respondent has complied with.
Progress reports
10The applicant has not provided evidence to support whether the progress reports are reasonable or necessary, in issues 1 through 5 of the application, only a brief reference was made in the submissions in Paragraph 17.
Brokerage service
11The applicant has not provided evidence to support whether the Brokerage services are reasonable or necessary, in issue 4 of the application. Dr. Woods determined in the December 15, 2023, plan that the Brokerage service was not reasonable.
Service planning.
12The applicant has not provided sufficient evidence to support the request for the service planning, there is little mention of the benefit with little reference to any prescribed services.
Interest
13The applicant is not entitled to interest as the amounts paid were as required by the respondent.
Award
14The applicant is not entitled to an award.
ORDER
15I find the applicant is not entitled to the unapproved amounts for the treatment plans from Somatic Treatments and is not entitled to the treatment plan for physiotherapy services from Total Recovery Rehab and the applicant is not entitled to interest or an award. The application is dismissed.
Released: August 18, 2025
Patrick Molloy
Adjudicator