Ahmed v. Aviva General Insurance Company, 2025 CanLII 99890

Citation: Ahmed v. Aviva General Insurance Company, 2025 ONLAT 24-001991/AABS

Licence Appeal Tribunal File Number: 24-001991/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:

Shakeel Ahmed

Applicant

and

Aviva General Insurance Company

Respondent

DECISION

ADJUDICATOR: Melanie Malach

APPEARANCES:

For the Applicant: Daniela Algieri-Boileau, Counsel

For the Respondent: Melanie Sousa, Counsel

HEARD: By way of written submissions

OVERVIEW

1Shakeel Ahmed, the applicant, was involved in an automobile accident on July 19, 2019, 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 General Insurance 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 $1,125.30 ($3,719.06 less $2,593.76 approved) for psychological services, proposed by Medex Assessments Inc. in a treatment plan submitted February 22, 2022?

ii. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

3I find that the applicant is not entitled to the balance of the treatment plan for psychological services submitted February 22, 2022 or interest.

ANALYSIS

Entitlement to the balance of the treatment plan for psychological services

4I find that the applicant is not entitled to the balance of the treatment plan for psychological services.

5The applicant claims entitlement to the balance of the treatment plan for psychological services submitted on February 22, 2022 by Medex Assessments Inc. By correspondence dated March 10, 2022, the respondent partially approved the treatment plan in the amount of $2,593.76, leaving a balance of $1,125.30 denied.

6The applicant submits that the respondent’s denial is deficient under s. 38(8) of the Schedule as the respondent failed to provide a principled and meaningful denial of the treatment plan and failed to properly outline its medical and other reasons or refer to his specific condition. The applicant relies upon the Tribunal decisions in T.F. v. Peel Insurance Company, 2018 CanLII 39373 (ON LAT) (“T.F. v. Peel”), McPherson v. Aviva General Insurance Company, 2024 CanLII 67360 (ON LAT) (“McPherson”); and M.B. v. Aviva Insurance Canada, 2017 CanLII 87160 (ON LAT) (“M.B. v. Aviva”).

7The applicant submits that the respondent denied the balance of the treatment plan, stating that “The OCF-18 noted above is listing Allan P. Shapiro as your direct treatment health care provider under Part 12 of the OCF-18; however, it may be the case that a different health care provider will be providing services to you under supervision of the provider listed on the OCF-18” and indicating that different rates apply depending on which health care provider is providing services. The applicant submits that the respondent failed to identify any other reason for declining to fund the full cost of the treatment plan and therefore the denial does not comply with s. 38(8) of the Schedule.

8The respondent submits that by letter dated March 10, 2022, it partially approved the treatment plan in dispute. It submits that it fully approved the 16 psychological treatment sessions to be provided by Dr. Shapiro, at the rate recommended, but denied the items in the amount of $1,125.30 as follows:

Line 2 – review of external material: $149.61 Line 4 – preparation of progress report: $299.22 Line 5 – scoring and interpretation: $149.61 Line 6 – brokerage, service: $99.00 Tax: $427.86

9The respondent submits that with respect to the applicant’s argument that the denial letter did not comply with s. 38(8) of the Schedule because it did not provide a medical reason for the denial, an insurer is not required to provide a medical reason for a denial if there was no such medical basis for the denial. The respondent relies upon the Ontario Court of Appeal decision in Varriano v. Allstate Insurance Company of Canada, 2023 ONCA 78 (“Varriano”) where the Court held that an insurer does not always need to provide a medical reason when denying a benefit. The reasons need to be sufficient but can be either medical, non-medical or both. The respondent further relies upon the Tribunal decision in Phillip v. Aviva Insurance Company, 2023 CanLII 17703 (ON LAT) (“Phillip”), where Adjudicator Pahuta found that medical reasons for the denial were not required, as the psychotherapy sessions were approved, and only the rate of specific fees were in dispute.

10The respondent submits that its reasons for the denial are clear and sufficient enough to allow an unsophisticated person to make an informed decision to either accept or dispute its decision. Specifically, it advised that psychological treatment is not taxable on top of the maximum hourly rate and that the amount for tax was denied. It advised that review of external material, scoring, interpretation and brokerage services were denied as the expenses are considered to be part of the treatment and assessment expenses, and the maximum amount for completing a treatment plan is $200.00 pursuant to the Professional Services Guideline – Superintendent’s Guideline No. 03/14 (“the Guideline”). Finally, it advised that the progress report was denied and stated that if progress information was required, it would request it and fund it accordingly.

11With respect to the sufficiency of the respondent’s denial, I find that the respondent’s denial letter complied with its obligations under s. 38(8) of the Schedule. The only portions of the treatment plan that were denied were the costs of reviewing external material; scoring and interpretation; brokerage services and the amount for tax. While the applicant submits that the respondent failed to provide a medical reason for its denial, I find that a medical reason was not required, as the psychological sessions were approved in full, and only the costs of the specific fees were in dispute. I find that the respondent is permitted to rely on non-medical reasons where a medical reason is not available as set out by the Ontario Court of Appeal in Varriano. Therefore the “other reasons” specified by the respondent were sufficient to meet the requirements under s. 38(8) of the Schedule.

12I find that the respondent clearly set out the reasons why it would not pay for the costs of the specific fees of reviewing external material; scoring and interpretation; brokerage services and the amount for tax. I find that the reasons were clear and sufficient enough to allow an unsophisticated person to make an informed decision to either accept or dispute the decision at issue in accordance with the principles set out in T.F. v. Peel.

13I find that with respect to payment of the disputed items in the treatment plan, the applicant did not provide any arguments or evidence as to the reasonableness and necessity of these items or why the treatment provider required fees beyond the $200.00 prescribed by the Guideline.

14In my view, the hourly rate for professional services includes things like reviewing external material, scoring and interpretation and brokerage services. Without submissions from the applicant on this issue, I am bound by s. 15(2)(b) of the Schedule which states that the respondent is not liable to pay for medical goods or services that exceed the maximum rate prescribed by the Guideline. In addition, with respect to the progress report, I agree with the respondent that charging for a future mental health assessment when one may not be required is premature and is not a reasonable expense. With respect to the tax charged, I find that the applicant did not make submissions or point me to any evidence in support of his entitlement to tax.

15For the reasons outlined above, I find that the applicant has not proven on a balance of probabilities that the balance of the treatment plan for psychological services is reasonable and necessary.

Interest

16Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As there are no benefits owing, the applicant is not entitled to interest.

ORDER

17For the reasons set out above, I find that the applicant is not entitled to the balance of the treatment plan for psychological services submitted February 22, 2022 or interest. The Application is dismissed.

Released: October 2, 2025

__________________________

Melanie Malach Adjudicator