Licence Appeal Tribunal File Number: 23-015078/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:
Jonathan Mazerolle
Applicant
and
Motor Vehicle Accident Claims Fund (MVACF)
Respondent
DECISION
ADJUDICATOR:
Jeff Chatterton
APPEARANCES:
For the Applicant:
Roger R Foisy, Counsel
For the Respondent:
Daniel Fenwick, Counsel
HEARD:
In Writing
OVERVIEW
1Jonathan Mazerolle, the applicant, was involved in an automobile accident on January 13, 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, Motor Vehicle Claim Fund, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issues in dispute are:
Is the applicant entitled to $839.92 ($8,685.70 less $7,845.78 approved) for life skills training, proposed by Bartimaeus Rehabilitation Services Inc. in a treatment plan/OCF-18 (“plan”) dated December 6, 2021?
Is the applicant entitled to $839.92 ($8,685.70 less $7,845.78 approved) for life skills training, proposed by Bartimaeus Rehabilitation Services Inc. in a plan dated July 12, 2022?
Is the applicant entitled to $79.50 ($2,693.84 less $2,614.34 approved) for physiotherapy services, proposed by Advanced Physiotherapy Clinic in a plan dated February 24, 2022?
Is the applicant entitled to $79.50 ($2,693.84 less $2,614.34 approved) for physiotherapy services, proposed by Advanced Physiotherapy Clinic in a plan dated September 9, 2022?
Is the applicant entitled to $79.50 ($2,693.84 less $2,614.34 approved) for physiotherapy services, proposed by Advanced Physiotherapy Clinic in a plan dated November 29, 2022?
Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
Is the applicant entitled to interest on any overdue payment of benefits?
3Since the case conference on May 1, 2024, the applicant has been declared catastrophically impaired, and the insurer issued full or partial approvals for all the treatment plans in dispute.
4What remains in dispute are amounts related to transportation and administrative expenses as set out above.
RESULT
5The applicant is not entitled to the disputed amounts for transportation expenses.
6The applicant is not entitled to $200 per treatment plan (less approved amounts) for paperwork and administrative expenses.
7No interest is payable, and the respondent is not liable to pay an award.
8The application is dismissed.
ANALYSIS
Is the applicant entitled to $1,440.00 in transportation expenses?
9I find that the applicant is not entitled to the unapproved amount of $720.00 ($1,440 total) for provider mileage proposed by Bartimaeus Rehabilitation Services in treatment plans 1 and 2, dated December 6, 2021 and July 12, 2022. (Treatment plans 1 & 2 also have unapproved amounts for administrative expenses, which I will address separately.) The applicant has not demonstrated that the transportation expenses are reasonable and necessary.
10To 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.
11The applicant submits that he should be entitled to transportation expenses for treatment providers to travel to the applicant. In paragraph 80 of his submissions, he states “The only reasons for denying parts of the treatment plans relate to statutory interpretation, specifically of section 16 and the Transportation Expense Guideline (‘TEG’), to determine whether “provider mileage” is covered and whether the insurer must fund costs for JM’s cost to participate in paid community activities.”
12Regarding ‘paid community activities,’ the applicant submits that transportation during a treatment session within the treatment provider’s vehicle should be covered since that includes transportation of the applicant and an aide. Specifically, he argues that the clinical notes and records from Bartimaeus Rehab “shows travel during RSW sessions were incurred for activities such as visiting coffee shops, going to a local shopping centre for an outing, driving to a nearby park for a walk, or accompanying JM to physical therapy. From May 2023, the RSW also accompanied JM to hydrotherapy sessions at a local facility every other session, following the recommendation of the treating physiotherapists”.
13The respondent maintains that s. 3(1) of the Schedule restricts coverage for authorized transportation expenses to those incurred by an insured or by the insured’s aide/attendant. In other words – the insurer is only liable to provide coverage for transportation expenses related to the insured traveling to the treatment provider, and that there is no coverage for transportation expenses incurred by treatment providers traveling to the insured’s home.
14The respondent also submits that the Financial Services Commission (now the Financial Services Regulatory Authority) clarified this when they issued a bulletin, which said “mileage and other expenses related to the transportation of anyone other than the insured person (and aide or attendant, if any) are not “authorized transportation expenses” under the SABS, and auto insurers are not required to pay for such expenses if claimed by a health care provider, even in circumstances where the insurer is paying for the provider’s travel time.”
15I agree with the respondent. There is no provision in the legislation to provide mileage related expenses when a service provider is traveling to a client. The Transportation Expense Guideline states “The insurer is liable to pay a mileage expense for transportation of the insured person and his/her aide or attendant, to and from treatment sessions, counselling sessions, training sessions, assessments and examinations, using the insured person’s automobile, excluding the first 50 kilometres of each round-trip.”
16Regarding mileage expenses on trips throughout the community, the applicant argues that since he is in the vehicle, mileage should be payable. While the applicant may be in the vehicle during rehabilitation trips throughout the community, I refer to the statement in paragraph 14 that insurers are not required to pay for mileage expenses “even in circumstances where the insurer is paying for the provider’s travel time.” The service provider is being paid during the rehabilitation session, and therefore the insurer is paying for the provider’s travel time.
17I find that the applicant has not established how these expenses for provider mileage are payable and/or not excluded from the guidelines.
18For these reasons, I find that the applicant has not demonstrated, on a balance of probabilities, that he is entitled to the unapproved amount of $1,440 proposed by Bartimaeus Rehabilitation Services
Is the applicant entitled to $200 (less approved amounts) for administrative expenses on each treatment plan?
19The applicant is not entitled to $200 (less approved amounts) for administrative expenses for each treatment plan in dispute.
20The respondent has approved one hour of time at their Professional Services Guideline maximum rate, for the purpose of filling out OCF-18 paperwork for the treatment plans numbered one through five. The respondent has indicated in the Explanation of Benefits letter dated July 15, 2024 that: “Should it be the case that more than one hour was required to complete the form, please have your provider submit an explanation to our office and we may revise our position. However, in review of the information provided on the Treatment Plan, we have determined that an hour is sufficient time to complete same.”
21The applicant submits that $200 is the standard rate for any service provider to complete an OCF-18.
22To support his claim, the applicant relies on H.R. v Intact, 2023 CanLII 56030 (ON LAT) where the Tribunal found that where an insured’s condition is seriously affected by their injuries, it is reasonable to approve additional time for the completion of the OCF-18 beyond one hour.
23The respondent submits that $200 is the maximum amount payable, but it is not automatic. Furthermore, the insurer submits that these forms are similar in nature to forms which were previously submitted, and should not require more than one hour to complete due to their duplicate format.
24I agree with the respondent that $200 for form completion is the standard amount but is not automatically payable.
25While I am alive to the applicant’s submission that he is catastrophically impaired and filling out forms would traditionally require additional time, in this particular case I have carefully reviewed the OCF-18 forms submitted into evidence. I note that the treatment plans appear to be substantially duplicative in nature. Therefore, since they are largely duplicative, I find one hour is a reasonable amount of time to complete a form.
26For these reasons, I find the applicant has not, on the balance of probabilities, met the onus to establish that he is entitled to the unapproved amounts for completing the OCF-18s for the treatment plans in dispute.
Interest
27Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no benefits are overdue, no interest is payable.
Award
28The 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.
29The applicant has detailed what he submits are repeated examples of the insurer mishandling the file, and situations where the insurer has changed their internal practices without warning. The applicant submits that such ongoing practices amount to punishable behaviour. He outlines a time period in early 2022 when there appeared to be confusion between how much medical rehabilitation was approved versus what was available, as per the Standard Benefit Statements.
30The applicant further submits that an award is created based on the handling of the file as a whole, versus merely the issues in dispute in front of the Tribunal.
31The respondent defends their business practices as normal handling of a client file, and that it has maintained a ‘good faith’ relationship with their client. I agree with the applicant that the confusion over policy limits is avoidable and should have been avoided. I also agree with the respondent’s submission that an insurer “cannot be held to a standard of perfection.”
32While an insurer’s behaviour may be frustrating, such frustration does not mean the insurer’s behaviour rises to the level of an award.
33For these reasons, I find that as no benefits were unreasonably withheld or delayed, no award is payable.
ORDER
34For all the foregoing reasons, I order:
i. The applicant is not entitled to the denied amounts on the treatment plans in dispute.
ii. The applicant is not entitled to an award or interest.
iii. The application is dismissed.
Released: August 26, 2025
Jeff Chatterton
Adjudicator