Licence Appeal Tribunal
Licence Appeal Tribunal File Number: 23-015438/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:
Stacy Dimitropoulos
Applicant
and
Unifund Assurance Company
Respondent
DECISION
ADJUDICATOR:
Melanie Malach
APPEARANCES:
For the Applicant:
Lisa Bishop, Counsel
For the Respondent:
Ken Yip, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Stacy Dimitropoulos, the applicant, was involved in an automobile accident on July 27, 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, Unifund Assurance Company, 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 interest on any overdue payment of benefits?
ii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
3The Case Conference Report and Order (“CCRO”) dated May 2, 2024, lists eight treatment plans in dispute. The applicant in her submissions stated that all of the treatment plans were withdrawn except for the treatment plan submitted December 5, 2023. The actual date of this treatment plan is October 31, 2023, and is the date that will be referenced throughout this decision. The respondent in its submissions states that the treatment plan dated October 31, 2023 was paid on December 18, 2024 and is no longer in dispute. In reply, the applicant confirms that the October 31, 2023 treatment plan was approved and that the only remaining issues in dispute for the purposes of this hearing are interest and an award under s. 10 of Reg. 664. The respondent agrees that the only issues in dispute are interest and an award. Therefore, I have amended the issues in dispute for the purposes of this hearing.
RESULT
4I find that the applicant is entitled to interest on the balance of the treatment plan dated October 31, 2023, in the amount of $2,080.22, from December 19, 2023, the date of her application to the Tribunal, to December 18, 2024, the date of settlement of the issue, calculated at the prejudgment interest rate described in subsection 128(3) of the Courts of Justice Act.
5I find that the respondent is required to pay an award of 15% of the disputed treatment plan.
ANALYSIS
Background
6The applicant submitted a treatment plan dated October 31, 2023 recommending occupational therapy and assistive devices to the respondent on December 5, 2023.
7By letter dated December 18, 2023, the respondent partially approved the treatment plan in the amount of $1,297.16, leaving a balance of $2,080.22. The respondent advised the following to support its denial of the balance:
As per Section 15 and 16 of the SABS, an insurer shall pay for reasonable and necessary medical expenses. Any goods and services must be invoiced in accordance with Superintendent’s Guideline No. 02/16 – Costs of Goods Guideline. This Guideline indicates that goods are payable based on the lowest retail price. This includes delivery charges, duties and taxes. Based on this, we are lowering the cost of medical goods. Please find attached the advertisement(s) from https://www.amazon.ca, https://agtahomecare.com & https://costco.ca that shows a lower retail price.
8On December 19, 2023, the applicant filed her application to the Tribunal claiming entitlement to eight treatment plans, one of which is the treatment plan dated October 31, 2023.
9By correspondence dated December 18, 2024, the respondent approved the balance of the treatment plan dated October 31, 2023.
10The applicant claims that she is entitled to interest on the balance of the treatment plan that was denied for the period from December 18, 2023 to December 18, 2024, pursuant to s. 51(4) of the Schedule.
11The respondent claims that no interest is payable because the applicant has not provided any evidence that the amounts have been incurred pursuant to s. 38(11) of the Schedule.
Interest
12I find that the applicant is entitled to interest with respect to the balance of the treatment plan dated October 31, 2023, in accordance with s. 51(4) of the Schedule.
13Section 51(2) of the Schedule provides that the respondent shall pay interest on overdue payments of benefits. Section 51(4) sets out how interest is calculated when an application before the Tribunal is settled. It provides that interest on the benefits in dispute is calculated at the prejudgment interest rate described in subsection 128(3) of the Courts of Justice Act and is payable for the period that begins from the date of the application to the Tribunal and ends on the date a settlement is reached or a decision is issued that finally disposes of the dispute.
14I find that in agreeing to pay the unapproved amount of the treatment plan dated October 31, 2023, which was an issue in the application before the Tribunal, the respondent settled this issue on December 18, 2024, within the meaning of s. 51(4), and must therefore pay interest pursuant to that subsection.
15I do not agree with the respondent’s submissions that s. 38(11) of the Schedule applies to this matter. I find that the interest provisions in s. 51 of the Schedule are applicable to this matter because it addresses interest as it applies to benefits in dispute that are settled.
16For the reasons set out above and pursuant to s. 51(4) of the Schedule, I find that the applicant is entitled to interest on the balance of the treatment plan dated October 31, 2023 in the amount of $2,080.22, from December 19, 2023, the date of her application to the Tribunal, to December 18, 2024, the date of settlement of the issue, calculated at the prejudgment interest rate described in subsection 128(3) of the Courts of Justice Act.
Award
17The applicant is entitled to an award under s. 10 of Reg. 664.
18Pursuant to s.10 of Reg. 664, the Tribunal may grant an award of up to 50 percent of the total benefits payable, if it finds that an insurer unreasonably withheld or delayed the payment of benefits. An award may be granted where an insurer’s behaviour is excessive, imprudent, stubborn, inflexible, unyielding, or immoderate. The onus is on the applicant to prove entitlement to the benefits claimed.
19The applicant submits that she is entitled to an award in the amount of 50% of the value of the balance of the treatment plan in dispute. The applicant argues that the respondent unreasonably withheld payment to her when it denied the balance of the treatment plan dated October 31, 2023. She submits that the respondent failed to meet its obligation per the Superintendent’s Guideline No. 2/16. She argues that the respondent failed to meet its onus to provide reasons and proof of a lower retail price for the items proposed in the treatment plan, and in doing so, deprived her of access to the assistive devices which were required for her safety and convenience in getting back to her regular daily activities. She further submits that the respondent claimed to have attached advertisements from retailers showing a lower price for these items, however they did not do so. The applicant submits that the respondent provided nothing more than basic references to websites.
20The respondent submits that the applicant is not entitled to an award. It submits that it provided a well-reasoned and compliant denial notice. It argues that there is no evidence that its conduct was “excessive, imprudent, stubborn, inflexible, unyielding or immoderate”.
21In reply, the applicant submits that the fact the respondent denied entitlement to the balance of the treatment plan and only approved it after receipt of the applicant’s submissions is evidence that it unreasonably withheld payment of the balance of the treatment plan in dispute.
22I find that the applicant has proven that the respondent unreasonably withheld or delayed payment of the balance of the treatment plan dated October 31, 2023.
23I find that Superintendent’s Guideline No. 2/16 establishes the maximum expenses payable by insurers for goods delivered under sections 15 and 16 of the Schedule. It sets out that in the event of a dispute over the retail price for an item, the onus is on the insurer to provide reasonable evidence of the retail price of the item. Reasonable evidence includes but is not limited to: an advertisement; written confirmation from a vendor; or any other reliable form of proof of the retail price.
24I find that the respondent’s letter to the applicant indicated that it was “lowering the cost of medical goods proposed in the treatment plan.” It stated that it was “attaching advertisement(s)” from the following websites: https://www.amazon.ca, https://agtahomecare.com & https://costco.ca that purportedly showed a lower retail price. However, upon review of the letter provided in the parties’ submissions, there are no attachments, and the website links provided direct to the landing page for each company and not a specific advertisement or cost for each good in dispute. I find that the respondent has not met its onus of providing reasonable evidence of the alternative retail price of the item. I find that simply listing retail websites in its letter does not satisfy the respondent’s obligations in Superintendent’s Guideline No. 2/16.
25I agree with the applicant’s submission, that the respondent has not provided any explanation as to why it waited until December 18, 2024 to approve the balance of the treatment plan in dispute. The respondent did not provide any submissions as to why it decided on December 18, 2024 to approve the balance of the treatment plan, or on what basis it made this decision at that time.
26I find that on a balance of probabilities that the applicant has proved that the respondent acted unreasonably in maintaining the denial of the balance of the treatment plan by failing to comply with its obligations under Superintendent’s Guideline No. 2/16 to provide reasonable evidence of the retail price of the items recommended in the treatment plan.
27The applicant seeks an award of 50 percent of the balance of the treatment plan. A 50 percent award is reserved for the most egregious conduct on the part of the insurer and is not warranted in this case. I find that the respondent’s conduct should not attract the maximum award, however, in keeping with the fact that the applicant waited 12 months for the treatment plan to be approved, I find that 15% is sufficient. In addition, as a result of the respondent’s delay in approving the treatment plan, the applicant was forced to seek relief from the Tribunal, which resulted in additional costs to her.
28For the reasons set out above, I find that the applicant is entitled to an award of 15% of the amount of the disputed treatment plan.
Costs
29In her reply submissions, after providing submissions about her entitlement to an award, the applicant states that: “In the alternative, the applicant requests that the Tribunal award the applicant costs of this hearing in the amount of $1,000.00, pursuant to the Tribunal’s authority to do so from s. 17.1 of the Statutory Powers Procedure Act, R.S.O. 1990, c. S. 22.”
30I find that as I have ordered that an award is payable, it is not necessary for me to address the issue of costs, which was raised as an alternative to an award in the applicant’s submissions.
ORDER
31For the reasons set out above, I find that:
i. The applicant is entitled to interest on the balance of the treatment plan dated October 31, 2023 in the amount of $2,080.22, from December 19, 2023, the date of her application to the Tribunal, to December 18, 2024, the date of settlement of the issue, calculated at the prejudgment interest rate described in subsection 128(3) of the Courts of Justice Act.
ii. The respondent is required to pay an award of 15% of the disputed treatment plan.
Released: September 11, 2025
Melanie Malach
Adjudicator