Licence Appeal Tribunal File Number: 24-000506/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:
Lian Tian Wang
Applicant
and
Aviva General Insurance
Respondent
DECISION
ADJUDICATOR:
Jeff Chatterton
APPEARANCES:
For the Applicant:
Maka Metreveli, Counsel
For the Respondent:
Heena Kapoor, Counsel
HEARD: In Writing
OVERVIEW
1Lian Wang, the applicant, was involved in an automobile accident on September 3, 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, 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 $2,822.90 for chiropractic services proposed by Dr. Georgia Palantzas, in a treatment plan / OCF-18 (‘plan’) submitted May 24, 2023?
ii. Is the applicant entitled to $3,445.33 for chiropractic services, proposed by Dr. Georgia Palantzas in a plan submitted October 26, 2023?
iii. Is the applicant entitled to $1,854.24 ($3,804.24 less $1,950.00 approved) for psychological services, proposed by Dr. Rick Lindal, in a plan submitted October 16, 2023?
iv. Is the respondent liable to pay an award under s.10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
v. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The application is dismissed. The applicant is not entitled to the treatment plans or amounts in dispute. No award or interest is payable.
ANALYSIS
Chiropractic Treatment Plans
4The applicant has not met the onus to prove that the chiropractic treatment plans are reasonable and necessary.
5The applicant seeks entitlement for two treatment plans for chiropractic services, the first for five weeks and the second for ten weeks of treatment. Both plans have a stated goal of pain reduction, increased strength and range of motion, with a plan to return to the activities of normal living and promote soft-tissue healing.
6To 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.
7The applicant states that the two disputed chiropractic treatment plans are reasonable and necessary for the treatment of chronic pain. The applicant has been removed from the Minor Injury Guideline. Neither party indicated why the applicant has been removed from the MIG.
8To support this claim, the applicant has included the Clinical Notes and Records (CNR’s) from his family physician, Dr. Annie Qu. He also relies upon the CNRs from Chiropractor Dr. Georgia Palantzas, at Point Grey Physio. As set out above, Dr. Palantzas is the recommending treatment provider for the treatment plans in dispute.
9The respondent argues that the applicant’s physical injuries are minor sprain and strain injuries. To support this claim, the respondent is relying upon the expert report from a s.44 assessment conducted by GP Dr. Seung-Jun Lee, which determined the applicant has already achieved maximal medical recovery. In light of having achieved maximal recovery, the respondent argues that further medical services are not reasonable or necessary.
10Despite having the onus, I was not led to medical evidence from the applicant that establishes the treatment plans are being met. The provided CNR’s from Dr. Qu relate to a single visit and do not contain a recommendation for chiropractic services. The CNR’s from Dr. Palantzas indicate that the applicant had been regularly receiving treatment, and outlined the injuries sustained, but I was not led to evidence stating that progress has been made. This lends support to the respondent’s claim that maximal medical recovery has already been achieved.
11While there is no doubt that the applicant has sustained injuries, I have not been led to supporting medical evidence to indicate that prior treatment plans have been successful in reducing pain or improving range of movement, nor any of the other stated goals. I was not led to a progress report or other indication of successful healing.
12I find, on the balance of probabilities, that the applicant has not met the onus to establish that the treatment plans for chiropractic services are reasonable and necessary.
Psychological Treatment Plan – Professional Rates
13The applicant has not met the onus to establish entitlement to the unapproved amount in the psychological treatment plan.
14The applicant is claiming $224.42 per hour for psychological services, with a proposal for 15 sessions of 1.5 hours each. Meanwhile, the respondent is claiming that the services are being conducted by a Social Worker, not a Psychologist, and therefore, it will not pay the Psychologist’s hourly rate. Instead, the respondent has agreed to pay $100 per hour for all 15 sessions.
15To support its position, the respondent refers to the Professional Services Guideline No.03/14 (“Guideline”) from the Financial Services Commission of Ontario, submitting that unregulated psychological providers are entitled to $58.19 per hour, but that it has agreed to pay a higher rate of $100 per hour.
16The applicant submits that the work is being conducted by Social Worker Sissie He, under the close supervision of Psychologist Dr. Rick Lindal. Aside from the supervision argument, the applicant has not made arguments as to why the insurer should pay a Social Worker a Psychologist’s rate or why the higher Guideline rate is reasonable and necessary.
17The Guideline establishes the maximum hourly rate payable by automobile insurers under the Schedule related to services provided by health care professions, or health care providers listed within the Guideline. Insurers are not prohibited from paying above any maximum amount or hourly rate established in the Guideline. It is also noted within the Guideline that services provided by health care professionals/providers, unregulated providers and other occupations not listed within the Guideline are not covered by the Guideline. For services not covered by the Guideline, the amounts payable by an insurer are to be determined by the parties involved. The Guideline further notes that automobile insurers are not liable to pay expenses for services rendered to an insured person which exceed the maximum hourly rates set out in the Guideline’s Appendix.
18In this case, the respondent has approved $100.00 an hour for Ms. He. While the applicant argues the respondent should approve the Psychologist’s rate, I have not been directed to any evidence that the work being done by Ms. He was essentially the same as a psychologist, or any other reason why Ms. He should be entitled to a psychologist’s hourly rate based on her credentials, education or experience. In my view, the $100.00 rate approved by the respondent is reasonable.
19For these reasons, I find the applicant has not, on a balance of probabilities, met the onus to establish that the disputed amounts related to professional rates in the psychological treatment plan are reasonable and necessary.
Psychological Treatment Plan – Progress Report
20The second area of dispute for the psychological plan in dispute involves $360 for the creation of a progress report. The respondent submits it does not require a progress report and will request one, if necessary, at a later date.
21To support their claim that a progress report is necessary, the applicant relies on 17-001523/AABS v Allstate Insurance Company of Canada, 2018 CanLII 8084 (ON LAT) where the adjudicator determined that a progress report was reasonable and necessary. In that case, the adjudicator states that the progress report “was also essential in determining the progress of the applicant’s psychological treatments thus far. I find it unreasonable for the respondent to deny payment for the progress report. The fact that the respondent ultimately approved treatment is also telling.”
22It is unclear from reading the respondent’s submissions what tools, in the absence of a progress report, it will use to adjust the file on a good-faith basis moving forward.
23For this reason, I find a progress report is reasonable and necessary because it serves as the primary tool to justify further treatments, and/or for the ongoing adjustment of the file. I find the applicant has met the onus to establish that they are entitled to $360 for the creation of a progress report.
Interest
24Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Interest applies on the disputed amount for the progress report, $360, as per the Schedule.
Award
25The 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. While the parties disagreed on some issues, I do not find the respondent’s conduct unreasonable nor does it rise to the level of an award.
ORDER
26The application is granted in part:
i. The applicant is not entitled to the treatment plans for physiotherapy.
ii. The applicant is entitled to $360 for a progress report, but the applicant is not entitled to the balance of the disputed amounts for psychological services.
iii. Interest is payable as per the Schedule. An award is not granted.
Released: September 29, 2025
__________________________
Jeff Chatterton
Adjudicator