Licence Appeal Tribunal File Number: 23-013919/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:
Xiu Ying Chen
Applicant
and
Aviva Insurance Company of Canada
Respondent
DECISION
ADJUDICATOR:
Jeff Chatterton
APPEARANCES:
For the Applicant:
Sareena Samra, Counsel
For the Respondent:
Aimee Draper, Counsel
HEARD:
In Writing
OVERVIEW
1Xiu Ying Chen, the applicant, was involved in an automobile accident on December 18, 2020, 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 Company of 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 $1,161.74 ($3,701.74 less $2,540.00 approved) for psychological services, proposed by Somatic Assessments in a treatment plan/OCF-18 (“plan”) dated May 15, 2023?
ii. Is the applicant entitled to $803.50 ($2,200.00 less $1,396.50 approved) for an attendant care assessment, proposed by Somatic Assessments in a treatment plan dated March 13, 2023?
iii. Is the applicant entitled to $5,084.81 ($14,750.81 less $9,666.00 approved) for catastrophic assessments, proposed by Somatic Assessments in a treatment plan dated October 3, 2022?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The application is dismissed. The applicant is not entitled to the denied amounts on the treatment plans in question, and no interest is payable.
ANALYSIS
Psychological Treatments
4I find the applicant is not entitled to the unapproved amounts for psychological treatments.
5To receive payment for a treatment and assessment plan under s. 15 and 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.
6The applicant submits that the entire amount for a treatment plan, submitted May 15, 2023 by Occupational Therapist Raymond Wong, is reasonable and necessary.
7The goals of the treatment plans are stated as alleviation of anxiety, depressive and post-traumatic symptoms in order for the applicant to return to activities of normal living.
8To support her claim, the applicant has submitted as evidence a copy of the OCF-18 in question. The Treatment plan recommends 14 sessions with a social worker Mandy Fang, payable at a psychologist rate of $149.61 per hour. It also calls for $523.60 for ‘Ongoing Evaluation,’ $523.60 for ‘Communication with Others,’ and $560.00 for a progress report and completing the OCF-18.
9The applicant submits that pain relief is a valid medical care goal that insurers are required to pay for.
10The respondent submits that they have approved all 14 sessions with Ms. Fang, at a Social Workers maximum hourly rate of $100 per hour, which is the maximum rate allowable under the Professional Services Guideline.
11The respondent also submits that the applicant has submitted no documentation to justify the paying Ms. Fang the same rate as a psychologist.
12I agree with the respondent. The applicant has not submitted evidence to support her claim that the Social Worker should be paid at the same amount as a psychologist. As it is the applicant’s onus to demonstrate that the unapproved amount is reasonable and necessary, I find the applicant has not met her onus with respect to the rate for Ms. Fang.
13Further, the applicant did not make a submission as to why $1,607.20 in non-therapy related overhead costs was reasonable or necessary.
14For these reasons, I find on the balance of probabilities that the applicant has not met the onus of establishing that the unapproved amounts are reasonable and necessary.
Attendant Care Assessment
15The applicant is not entitled to the unapproved amounts in the OCF-18 for an Attendant Care Assessment.
16Occupational Therapist Raymond Wong submitted an OCF-18 for an Attendant Care Assessment, outlining $2,000 in professional services and a further $200 to complete the OCF-18.
17The applicant chose not to make a submission regarding the Attendant Care Assessment.
18The respondent submits that they have calculated the amount of work proposed by the Occupational Therapist in the OCF-18 for the Attendant Care Assessment, and applied the proposed hours at the OT’s maximum hourly rate in question.
19For this reason, I find the applicant has not met her onus to establish that she is entitled to the unapproved amounts for the Attendant Care Assessment.
Catastrophic Assessment
20Now I will turn to the Catastrophic Assessments. Occupational Therapist Raymond Wong prepared a treatment plan / OCF-18 dated October 3, 2022 in the amount of $14,750.81 which included a physiatry assessment by Dr. Wong ($2,000), psychology assessment by Dr. Naisi ($2,000), OT in home assessment by Raymond Wong ($2,000), assessment summary by Raymond Wong ($2,000), file review by Dr. Wong ($2,000), file review by Dr. Naisi ($1,000), file review by Raymond Wong ($1,000) and applicant transportation ($512.81).
21The applicant submits that the CAT assessments have been incurred and should be paid. To support her claim that the fees are reasonable and necessary, the applicant submitted copies the OCF-18. She also relies upon R.B. v. RSA Insurance, 2020 CanLII 19589 (ON LAT) where “Adjudicator Kaur clearly states that CAT assessments are not to be considered a medical benefit and are not subject to medical and rehabilitation limits as set out in section 18(3)(a) of the Schedule.”
22The applicant has also submitted that Section 25(1) and 25(1)(5) of the Schedule state the Insurer must pay reasonable fees charged for preparing a catastrophic impairment application. (Of note, the applicant cites various sections of the Schedule three times, stating “(emphasis added)”, but there is no emphasis in her submission. It remains unclear what she wished to emphasize.)
23The applicant also states that 25(5)(a) of the Schedule only applies to any one assessment or examination and for preparing reports in connection” with that one assessment or examination.
24The respondent submits they have approved everything requested with two exceptions – a final summary and rating and a file review. They submit that the summary was not approved as it was to be prepared by the OT and was outside his area of expertise. The amounts for file reviews by the psychologist and OT were also denied they were included in the maximum fees approved for the assessment and report. I also note they have denied transportation costs for the Occupational Therapist to visit the client.
25I have not been led to convincing evidence which indicates the denied amounts are reasonable, necessary, and not a duplication of service. I also remain unconvinced by the applicant’s citation of R.B v RBC Insurance. In this particular application, unlike R.B., the CAT assessments were not denied due to policy limits.
26Although not binding on me, I note that my finding is consistent with other Tribunal decisions, including 17-007215 v. Aviva General Insurance, 2018 CanLII 141011 (ON LAT). In this decision, the Tribunal held that, in accordance with section 25(5) of the Schedule, the applicant was entitled to payment of $2,000.00 in fees and expenses, inclusive of file and medical document review, for each of a neurological, occupational therapy, psychiatry and orthopedic CAT assessment. The Adjudicator found that seeking file and medical document review as a separate fee for the assessments was a duplication of services, and was therefore unreasonable.
27For these reasons, I am convinced by the respondent’s argument.
28I find, on the balance of probabilities, that the applicant has failed to meet the onus to prove that the denied amounts are reasonable or necessary. Her application is denied.
Interest
29Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no overdue benefits are payable, no interest is due.
ORDER
30The application is denied.
i. The applicant is not entitled to the partially denied amounts for a psychological assessment.
ii. The applicant is not entitled to the partially denied amounts for Attendant Care or Catastrophic Impairment Assessments.
iii. No interest is payable.
Released: August 26, 2025
__________________________
Jeff Chatterton
Adjudicator