Licence Appeal Tribunal File Number: 23-014346/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:
Yu Qian
Applicant
and
Aviva Insurance Company of Canada
Respondent
DECISION
ADJUDICATOR: Estella Muyinda
APPEARANCES:
For the Applicant: Sareena Samra, Counsel
For the Respondent: Kevin Griffiths, Counsel
HEARD: By way of written submissions
OVERVIEW
1Yu Qian, the applicant, was involved in an automobile accident on May 13, 2020, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”).
2The 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
3The issues in dispute are:
Is the applicant entitled to the services and assessments proposed by Somatic Assessments and Treatment Clinic, as follows: i. $1,047.06 ($3,701.88 less $2,654.82 approved) for psychological services in a treatment plan/OCF-18 (“OCF-18”) submitted on June 12, 2023; ii. $1,047.06 ($3,701.88 less $2,654.82 approved) for psychological services in an OCF-18 submitted on November 10, 2023; and iii. $130.00 ($2,200.00 less $2,070.00 approved) for an in-home occupational therapy assessment in an OCF-18 submitted on July 10, 2023?
Is the respondent liable to pay an award under section 10 of Regulation 664 because it unreasonably withheld or delayed payments to the applicant?
Is the applicant intitled to interest on any overdue payment of benefits.
RESULT
4The applicant is not entitled to $1,047.06 the unapproved balance of the June 12, 2023, OCF-18.
5The applicant is not entitled to $1,07.06 the unapproved balance of the November 10, 2023, OCF-18.
6The applicant is not entitled to the unapproved balance of $130.00 for the July 10, 2023, OCF-18 for an in-home occupational therapy assessment.
7The applicant is not entitled to interest.
8The applicant is not entitled to an award under Regulation 664.
ANALYSIS
The applicant is not entitled to the unapproved portion of the June 12, 2023, and November 10, 2023, treatment plans for psychological services.
9I find that the applicant has not demonstrated, on a balance of probabilities that the unapproved balances of the treatment plans for psychological services are payable.
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 because 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 submitted a treatment plan for $3,701.88 proposed by Somatic Assessments on June 12, 2023. Similarly, a subsequent treatment plan was submitted on November 10, 2023. The proposed services for each plan are 14 - 1.5-hour sessions at the rate of $149.61 per hour, $360.00 for document support and $200.00 for the document support for the form, for a total of $3,701.88. The respondent partially approved the treatment plans, in the amount of $2,654.82.
12The hourly rates for the services of specified health care providers and maximum fees for completing forms paid to health care providers is found in the Financial Services Commission of Ontario Professional Services Guideline (Guideline). The respondent approved and paid a rate of $99.75, rather than the proposed $149.61. The unapproved amount relates to the hourly rate for services by Ms. Joyce Zhou, psychotherapist.
13The applicant submits that Ms. Zhou under the supervision of Dr. Bruce Cook (psychologist) performed the same services as a psychologist, and as such she is entitled to the same rate as a psychologist. Therefore, the $1,047.06 unapproved balance on each treatment plan should be paid.
14The applicant further asserts that the rate is justifiable because Dr. Cook ensured that Ms. Zhou provided effective service. Further, as the applicant did not speak proficient English, Ms. Zhou provided interpretation services for the applicant and Dr. Cook. The applicant submits that without the interpretive services, she would not have been able to receive the necessary treatment needed in the time approved for the treatment plans.
15The respondent submits that it indicated that it would pay for the benefit based on the qualifications of the treatment provider. The respondent stated that if a psychologist provided the therapy, it would pay $149.61 per hour. If the treatment was provided by a psychotherapist, it would pay $99.75 per hour.
16Further, the respondent submits that the applicant did not adduce evidence indicating that Ms. Zhou has a specialized expertise that warrant her receiving the same rate as a qualified psychologist.
17The Guideline is silent on the maximum hourly rate for a psychotherapist. The Guideline provides that the rate payable for services not covered are to be determined by the parties. If the parties are unable to reach an acceptable rate, then the Tribunal must decide. The onus is on the applicant to demonstrate that the proposed rate is appropriate based on the provider’s education, training, and experience.
18The applicant has not submitted evidence of Ms. Zhou’s education, training, and experience. As a result, I find that the applicant has not met the onus establishing that the proposed rate of $149.61 is appropriate. Further, as much as the applicant benefited from Ms. Zhou interpretive service, as did Dr. Cook, this does not justify an increased rate for psychotherapy services.
19In sum, the applicant has not met her burden of demonstrating that the $149.61 per hour rate for Ms. Zhou’s services is reasonable and necessary. The applicant did not submit any evidence showing that Ms. Zhou has specialized training and experience. Psychotherapists are not listed in the Guideline and therefore they are not subject to the same rate as a psychologist. I find that the rate of $99.75 per hour is reasonable in the circumstances.
20Therefore, I find on a balance of probabilities that the applicant is not entitled to the unapproved amounts in the OCF-18s submitted June 12, 2023, and November 10, 2023.
The applicant is not entitled to the unapproved portion of the July 10, 2023, for an in-home occupational therapy assessment.
21I find that the applicant is not entitled to the unapproved portion of $130.00 with respect to this treatment plan.
22The applicant submits that in the occupational therapy report dated July 25, 2023, Mr. Raymond Wong, (occupational therapist) recommended monthly attendant care for feeding and hygiene in the amount of $2,200.00. The treatment plan proposed 840 minutes per week for feeding, 210 minutes per week for hygiene, 9 hours per week for housekeeping tasks. He suggested a re-assessment in eight weeks to help determine if the applicant needed the service.
23The respondent approved the in-home occupational therapy in the amount of $2,070.00 only. The respondent stated that it would not pay $130.00 for the planning service on the basis that the applicant had not indicated how the service would directly contribute to recovery.
24The applicant has not pointed to any evidence in support of the unapproved amount. I find that the applicant has not met her burden of proof showing that the unapproved portion of the treatment plan is reasonable and necessary at the time it was submitted.
Interest
25Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no payments are overdue, there is no interest payable.
Award
26The 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. As no benefits were unreasonably withheld or delayed by the respondent, the applicant is not entitled to an award.
ORDER
27The applicant is not entitled to the unapproved balance of the June 12, 2023, OCF-18.
28The applicant is not entitled to the unapproved balance of the November 10, 2023, OCF-18.
29The applicant is not entitled to $130.00, the unapproved balance of the July 10, 2023, OCF-18.
30The applicant is not entitled to interest pursuant to s. 51 of the Schedule.
31The applicant is not entitled to an award under Regulation 664.
Released: September 10, 2025
Estella Muyinda
Adjudicator