Licence Appeal Tribunal
RECONSIDERATION DECISION
Before: Robert Rock, Adjudicator
Licence Appeal Tribunal File Number: 23-008078/AABS
Case Name: Lobsang Tsetan v. Intact Insurance Company
Written Submissions by:
For the Applicant: Rajiv Kapoor, Paralegal
For the Respondent: Carman Lee, Counsel
OVERVIEW
1On July 2, 2025, the applicant requested reconsideration of the Tribunal’s decision dated June 19, 2025 (“decision”).
2In the decision, I found that the applicant was not entitled to two treatment plans in dispute, one for a psychological assessment, and one for a catastrophic impairment assessment. Additionally, I found that the applicant was not entitled to an award or interest.
3The grounds for a request for reconsideration are found in Rule 18.2 of the Licence Appeal Tribunal Rules, 2023 (“Rules”). To grant a request for reconsideration, the Tribunal must be satisfied that one or more of the following criteria are met:
a) The Tribunal acted outside its jurisdiction or committed a material breach of procedural fairness;
b) The Tribunal made an error of law or fact such that the Tribunal would likely have reached a different result had the error not been made; or
c) There is evidence that was not before the Tribunal when rendering its decision, could not have been obtained previously by the party now seeking to introduce it, and would likely have affected the result.
4The applicant is seeking a reconsideration pursuant to Rule 18.2(b). The applicant requested the decision be varied to have him receive payment, with interest, for the two treatment plans that were in dispute.
5The respondent requests the reconsideration be denied.
RESULT
6The applicant’s request for reconsideration is dismissed.
ANALYSIS
7I find that the applicant has not established grounds for the reconsideration under Rule 18.2(b).
8The test for reconsideration under Rule 18.2 involves a high threshold. The reconsideration process is not an opportunity for a party to re-litigate its position where it disagrees with the Tribunal’s decision, or with the weight assigned to the evidence. The requestor must show how or why the decision falls into one of the categories in Rule 18.2.
9The applicant submits I made four errors of law or fact in the decision as follows:
a. The use of the term “qualifications” regarding Mr. Walsh.
b. Review of the cases provided regarding session notes.
c. Additional time for form completion.
d. Decision regarding 38(8) of the Schedule.
Use of the term “qualifications”
10The applicant submits that I made a factual error in using the term “qualifications” in reference to Mr. Walsh at para 11, when referring to Adjudicator Setton’s decision in Tsetan v Intact Insurance Company, 2023 CanLII 116467 (ON LAT). The applicant asserts that this factual inaccuracy formed the key premise in my reasoning and deprived him of a fair assessment regarding the new treatment plan. The applicant submits this as it is his contention that Adjudicator Setton, did not review Mr. Walsh’s resume.
11I disagree with the applicant. While I agree that Adjudicator Setton did not use the term “qualifications” in this earlier decision, my use of the term was not in reference to specific qualifications found in a curriculum vitae, but in the broader sense of the term, not specific to qualifications that Mr. Walsh possessed that would warrant a higher rate of pay than outlined in the Professional Services Guideline. The Professional Services Guideline specifically outline the maximum hourly rate that healthcare professionals are able to charge. If a specific healthcare professional is not listed in the Guideline, they are deemed an unregulated provider. Mr. Walsh is identified as a psychotherapist which according to the Guideline is not recognized as a specified profession, so is seen as an unregulated provider that could be paid at a maximum rate of $58.19 per the Guideline.
12Also, while I did reference this previous case in my decision, this was not the only part of my analysis. In paragraph 12, I discussed the Professional Services Guideline that governs hourly rates of service providers. In paragraph 14, I provide analysis on one of the two cases that the applicant provided, Pauvif v Aviva General Insurance, 2020 CanLII 122614 (ON LAT). That analysis provided that I did not find that this case was analogous with the applicant’s case, and thus it did not convince me that the higher rate for Mr. Walsh was warranted.
13Irrespective of the misuse of the word “qualifications”, the applicant has still not met their onus of proving, on a balance of probabilities, that my use of the term qualifications would likely have impacted my finding about Mr. Walsh’s hourly rate in my original decision. Review of the previous decision by Adjudicator Setton and my reference to it were not the only reasons for my decision. It does not remove the applicant’s onus to prove that Mr. Walsh deserved a higher rate of pay than is outlined in the Professional Services Guideline, which the applicant did not meet.
14I find that the applicant has not established grounds for reconsideration with respect to Rule 18.2(b) regarding my use of the term “qualifications”.
Session notes
15The applicant submits that the respondent specifically requested psychotherapy treatment session notes in the Case Conference Report and Order (“CCRO”) but denied funding these same notes. The applicant has made no direct submission as to what the error in law I made in denying the session notes, beyond restating that it is the applicant’s position that the respondent requested these session notes.
16I disagree. In review of the CCRO, there is no mention of session notes. The CCRO states that the respondent requested the clinical notes and records (“CNRs”) from the applicant’s psychotherapy sessions. CNRs are made by clinicians or practitioner is a clinical setting and they typically encompass session notes or progress notes. The applicant has not directly engaged with the question of why an additional line item in the OCF-18 for session notes were reasonable and necessary in OCF-18 for psychotherapy services.
17While the applicant has raised this point in their reconsideration request, he did not argue what the error in law or fact was in my decision, beyond restating his original argument that they were requested in the CCRO. The applicant has not met his onus to prove on a balance of probabilities that my decision regarding session notes is an error of law or fact.
18I find that the applicant has not established grounds for reconsideration with respect to Rule 18.2(b) regarding the session notes in dispute.
Additional time for form completion
19The applicant submits that additional time was necessary to complete the forms due to his hearing loss. The applicant believes it was an error for me to say in the decision at para 14 that “the applicant has not made a direct argument…beyond the previous cited decision”.
20I again disagree with the applicant. The quote that the applicant refers to in my decision was speaking to the issues on session notes, and not to the issues on additional time for document preparation.
21My analysis of the question on additional required time happens at para 15. In it I outlined, the submission that the applicant suffers from hearing loss is not the same as proving that this hearing loss necessitated addition time to complete the form to justify additional payment. The CNRs of Dr. Edo outline that the applicant suffered decreased hearing in the right ear, as well as a perforation in the left ear. It also notes that the applicant declined any hearing aids to address this. The CNRs do not outline how long this hearing loss would persist, if it was permanent, or how the hearing loss affected the applicant’s ongoing functioning. As such, I reiterate that the applicant has not met his onus to the question of how the hearing loss necessitated additional time to complete the OCF-18, beyond stating he suffered from hearing loss and referring to another case.
22I find that the applicant has not established grounds for reconsideration with respect to Rule 18.2(b) regarding additional required time for the completion of the OCF-18 in dispute.
Section 38(8)
23The applicant submits that the totals included in the Explanation of Benefits (“EOB”) from July 19, 2025, do not match those submitted on the OCF-18. The applicant takes issue with my decision, which states: “the denial provided by the respondent… as well as why they agree to pay for from each element of the plan”. The applicant contends that this statement is factually incorrect.
24I again disagree with the applicant. In review of the EOB, the totals for each line item correspond exactly to the line items in the OCF-18. The totals that the applicant refers to in his submissions are with the addition of GST. This is not what I found in my decision. I stated that they correspond to the line items in the OCF-18, which they do. Those line items do not include GST.
25The applicant similarly submits that the totals on the EOB from November 18, 2025 do not match the submitted OCF-18, and he takes issue with my analysis at para 35 that they do.
26I again disagree. As above, the line-by-line breakdown of the denials correspond to the OCF-18 totals on a line-by-line basis, as, again, the line items do not include GST. Thus this does not invalidate the denial by the respondent and trigger the consequences of s. 38(11) of the Schedule.
27I find that the applicant has not established grounds for reconsideration with respect to Rule 18.2(b) regarding s. 38(8).
CONCLUSION & ORDER
28For the reasons noted above, the applicant’s request for reconsideration is dismissed.
Robert Rock Adjudicator Tribunals Ontario – Licence Appeal Tribunal
Released: September 12, 2025