Licence Appeal Tribunal
Citation: Harrison v. CAA Insurance Company, 2026 CanLII 10329 Licence Appeal Tribunal File Number: 25-003007/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:
Carol Harrison
Applicant
and
CAA Insurance Company
Respondent
DECISION
ADJUDICATORS:
Melissa Shea
Tami Cogan
APPEARANCES:
For the Applicant:
Daniel Rabinovitch, Counsel
For the Respondent:
Mai Nguyen, Counsel
Court Reporter:
Hanya Palumbo (Network)
HEARD by Videoconference:
November 4, 2025
OVERVIEW
1Carol Harrison, the applicant, was involved in an automobile accident on August 5, 2023, 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, CAA Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
2The parties participated in a case conference on June 12, 2025, however, were unable to resolve the issues in dispute. The matter proceeded to a 1-day videoconference hearing. The applicant testified on her own behalf.
ISSUES
3The issues in dispute are:
i. Is the applicant entitled to attendant care benefits in the amount of $5,284.12 per month from September 10, 2024 to present? ($6,000.00 less $715.88 approved)
ii. Is the applicant entitled to $2,394.00 for physio/vestibular services proposed by McKelvie Physiotherapy & Vestibular Rehabilitation, in a treatment plan/OCF-18 (“plan”) dated December 2, 2024?
iii. Is the applicant entitled to the denied amounts in the treatment plans proposed by Rehab First Inc., as follows:
a) $1,031.25 ($4,281.25 less $3,250.00 partially approved) for occupational therapy assessment, in a plan dated September 29, 2023;
b) $66.00 ($3,824.46 less $3,758.46 partially approved) for physiotherapy services, in a plan submitted on March 19, 2023;
c) $198.00 ($4,723.84 less $4,525.84 partially approved) for physiotherapy services in a plan, dated October 26, 2023;
d) $16.50 ($2,510.77 less $2,494.27 partially approved) for occupational therapy services in a plan dated November 10, 2023;
e) $16.50 ($2,510.77 less $2,494.27 partially approved) for occupational therapy services, in a plan submitted on April 5, 2024;
f) $186.44 ($4,202.56 less $4,016.12 partially approved) for physiotherapy services, in a plan submitted on June 3, 2024; and
g) $709.50 ($5,291.01 less $4,581.51partially approved) for social work services, in a plan submitted on June 13, 2024?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
4The applicant is entitled to receive:
i. Attendant care benefits that are incurred but not exceeding $1,879.82 per month from September 10, 2024, to date, less amounts already paid by CAA Insurance Company.
ii. Interest in accordance with the Schedule for any overdue benefits listed above.
5The applicant is not entitled to receive:
a) $2,394.00 for physio/vestibular services proposed by McKelvie Physiotherapy & Vestibular Rehabilitation, in a plan dated December 2, 2024;
b) $1,031.25 ($4,281.25 less $3,250.00 approved) proposed by Rehab First Inc., for occupational therapy assessment, in a plan dated September 29, 2023;
c) $66.00 for milage proposed by Rehab First Inc., submitted on March 19, 2023;
d) $198.00 for milage proposed by Rehab First Inc., submitted on October 31, 2023;
e) $16.50 for milage proposed by Rehab First Inc., submitted on November 13, 2023;
f) $16.50 for milage proposed by Rehab First Inc., submitted on April 5, 2024;
g) $186.44 for milage proposed by Rehab First Inc., submitted on June 3, 2024; and
h) $709.50 for milage proposed by Rehab First Inc., submitted on June 13, 2024.
PROCEDURAL ISSUE
6At the start of the hearing the applicant withdrew her claim for an award under s.10 of Reg. 664.
ANALYSIS
Background
7As a result of the accident, the applicant has suffered an injury which includes functional neurological and gait disorder, tremors and balance issues.
The applicant is entitled to an Attendant Care Benefit (ACB) in the amount of $1,879.82 per month, from September 10, 2024 to present.
8Section 19 of the Schedule states that an insurer shall pay for all reasonable and necessary expenses incurred by or on behalf of an insured person as a result of an accident for ACBs provided by an aide or attendant. Section 42(1) of the Schedule provides that an application for ACBs must be in the form of, and contain the information required to be provided in, the version of the document entitled Assessment of Attendant Care Needs (“Form-1”).
9The applicant submits that she is entitled to ACB, which is not contested by the respondent. The dispute is regarding quantum of the benefit owed. The applicant submits she was injured as a result of the accident, which is not contested by the respondent, and relies on clinical notes and records from Lakeridge Health and Integrated Movement Disorder Clinic, Neurovision Clinic, Quinte Health Care, McKelvie Physiotherapy and Vestibular Rehabilitation, and clinical notes of Dr. Nantheeswarar, MD, and Dr. Varade, Neurologist, in support of injuries including functional neurological and gait disorder, tremors, and balance issues.
10The applicant submits she is entitled to $6,000.00 per month in ACBs because she has optional benefits. The amount in dispute is $5,284.12 which represents the difference between $6,000.00 and the $715.88 per month approved by the respondent. The applicant relies on the Form-1, dated September 10, 2024, completed 13 months post-accident, by Occupational Therapist Katie Hickling. The applicant submits her Form-1 must be preferred as it is a more detailed understanding of her needs and functional limitations, identifies specific challenges, and because the Form-1 was completed in collaboration with her Personal Support Worker (PSW) Shannon Gibson, who works with the applicant and is familiar with the applicant’s inability, for example, to handle hot items and sharp objects. The applicant further submits that the Form-1 prepared by Occupational Therapist Famida Kanji on behalf of the respondent, does not provide sufficient detail and minimizes the impact of the tremors and balance issues in meals, bathing, transfers and mobility, and therefore provides an inadequate amount of attendant care. The applicant argues ACBs should be deemed incurred at $6,000.00 per month, from September 10, 2024 to present, and submits evidence in the form of OCF-6 expense claim forms for attendant care expenses dated from August 2024 to August 2025, in support of her argument.
11The respondent agrees the applicant is entitled to ACBs, but disputes the quantum, and submits that its Form-1 dated November 1, 2024, 15 months post-accident, and completed by Occupational Therapist Famida Kanji in the amount of $715.88 per month is to be preferred. The respondent submits that s. 42 caps the limit on ACBs for persons with non-catastrophic (“CAT”) impairment. The respondent submits that no OCF-6s for a personal support worker were submitted past April 2025.
12Based on the applicant’s testimony and uncontested medical evidence submitted by the applicant we are persuaded that the applicant suffers from the following injuries as a result of the accident: functional movement and gait disorder, tremors, and balance issues.
13The chart below summarizes the attendant care benefit that we find the applicant is entitled to, retroactive to September 10, 2024, with reasons to follow.
| Total Minutes per week | Total Weekly Hours | Total Monthly Hours | Hourly Rate | Monthly Care Benefit | |
|---|---|---|---|---|---|
| Part 1 | 636 | 10.6 | 45.58 | $14.90 | $679.14 |
| Part 2 | 105 | 1.75 | 7.525 | $14.00 | $105.35 |
| Part 3 | 724 | 12.06666 | 51.88663 | $21.11 | $1,095.33 |
| Total Monthly Attendant Care Benefit | $1,879.82 |
14We find the applicant’s Form-1 excessive and the respondent’s Form-1 insufficient because neither aligns with the applicant’s testimony and medical records. The applicant and the respondent agree only on the reasonable and necessary time assigned for the following:
i. Level 1 –
a) Dressing: upper body, 21 minutes per week;
b) Grooming: toenails, 10 minutes per week;
c) Feeding: 420 minutes per week;
ii. Level 3 –
a) Maintenance of Supplies and Equipment 35 minutes per week.
15Based on the evidence before us, we agree with the parties and find no reason to interfere with these attendant care allotments. The time for upper body dressing and toenail grooming will be repeated below as they are included in their respective subcategories. The time for feeding and maintenance will not be repeated in the analysis below but is included in the final calculation for the attendant care benefit.
16Based on the evidence before us, we find the following attendant care is reasonable and necessary for the following reasons:
17Part 1, Level 1:
a) Dress: The applicant and respondent disagree, with 42 and 27 minutes proposed respectively. The respondent assigned less time to the lower body. We find the evidence does not support that dressing the lower body requires less time; We find the applicant’s proposed 42 minutes per week is reasonable and necessary because the applicant testified that she requires assistance dressing after bathing when she is damp.
| Number of Minutes | Times per week | Total Minutes per week | |
|---|---|---|---|
| Upper Body | 3 | 7 | 21 |
| Lower Body | 3 | 7 | 21 |
| Subtotal: | 42 |
b) Undress: The applicant proposed 70 minutes per week, and the respondent proposed 12 minutes per week. We do not accept the Form-1 of either party for the time allotted because the applicant testified, she is currently able to undress herself without assistance. We find 0 minutes is reasonable and necessary.
| Number of Minutes | Times per week | Total Minutes per week | |
|---|---|---|---|
| Upper Body | 0 | 0 | 0 |
| Lower Body | 0 | 0 | 0 |
| Subtotal: | 0 |
c) Grooming: The applicant and respondent agree that this is required, but disagree as to the amount of time required, with 174 and 83 minutes proposed respectively. We find the applicant’s Form-1 reasonable and necessary based on her testimony that she is unable to lift her arms for the time required to shampoo, blow-dry or style her hair. The blow-drying stand paid for by insurance has not worked, and she requires assistance combing her hair. Due to her tremors she is unable to manipulate the clippers to trim her nails.
Hair:
| Number of Minutes | Times per week | Total minutes per week | |
|---|---|---|---|
| Brushes/combs | 2 | 7 | 14 |
| Shampoo/blow dry | 15 | 7 | 105 |
| Styling | 5 | 7 | 35 |
| Fingernails | 10 | 1 | 10 |
| Toenails | 10 | 1 | 10 |
| Subtotal: | 174 |
d) Mobility: The applicant has proposed 60 minutes, 7 days a week for supervision and assistance with walking. The respondent has indicated 0 minutes are required. We prefer the respondent’s Form-1. The applicant testified that she is able to stand from a chair unassisted and does not require assistance with transfers. She does not use mobility aids in her home and does not walk when shopping but does use a scooter. Further, in Part 3 we provide time for exercise, which includes supervision with exercising outdoors. We find that it would be duplicative to assign time for mobility.
| Number of Minutes | Times per week | Total Minutes per week | |
|---|---|---|---|
| Assistance from seated position | 0 | 0 | 0 |
| Supervise/assist walking | 0 | 0 | 0 |
| Performs transfers | 0 | 0 | 0 |
| Subtotal: | 0 |
18Level 1 Summary:
| Total Minutes per week | |
|---|---|
| Dressing | 42 |
| Grooming | 174 |
| Feeding | 420 |
| Subtotal: | 636 |
19Part 2, Level 2:
a) Hygiene:
i. Bathroom: The respondent proposes 0 minutes, and the applicant proposes 5 minutes per day. We prefer the applicant’s Form-1 because the applicant testified that pre-accident, she normally cleaned the tub after each use and cleaned the toilet every couple of days but now is not able to do so.
ii. Bedroom: 1) Changes bedding, makes bed, cleans bedroom: The respondent proposes 10 minutes, 1 time per week. The applicant proposes 5 minutes, 7 times per week. We prefer the applicant’s Form-1. The applicant testified she needs help making the bed, changing bedding and cleaning the bedroom, and find the applicant’s Form-1 reasonable for the completion of these tasks;
- Ensures comfort, safety and security in this environment: The respondent proposes 0 minutes, and the applicant proposes 60 minutes per day. We prefer the respondent’s Form-1. We find that based on the testimony of the applicant and documentary evidence that there are no safety or security concerns for the applicant and therefore 0 minutes is reasonable and necessary.
iii. Clothing care: 1) assists in preparing daily wearing apparel; and 2) hangs clothes and sorts clothing to be laundered: The applicant proposes a combined 10 minutes per day, the respondent proposes 0 minutes per day arguing that the applicant testified that the PSW assists the applicant with the laundry, including helping to launder clothing for other family members, which is not covered by ACB. We find that the applicant testified she needs assistance with retrieving her clothes from the closet and hanging them after laundering, and therefore find that 5 minutes is reasonable for this task each day.
Hygiene:
| Number of Minutes | Times per week | Total minutes per week | |
|---|---|---|---|
| Bathroom | 5 | 7 | 35 |
| Bedroom 1) | 5 | 7 | 35 |
| Bedroom 2) | 0 | 0 | 0 |
| Clothing Care | 5 | 7 | 35 |
| Subtotal: | 105 |
b) Basic Supervisory Care: We prefer the respondent’s Form-1. We find that the applicant has not demonstrated why 7670 minutes (as opposed to the respondent’s proposal for 0 minutes per week) from the applicant’s Form-1 is required for the following: “applicant lacks the ability to independently get in and out of a wheelchair in to be self-sufficient in an emergency.” The applicant submits that this is necessary. The respondent submits that this is not necessary and excessive, as the applicant is mobile within the home. We find from the applicant’s testimony, as well as medical reports in evidence, that she is not currently using a wheelchair, and is able to transfer in and out of bed, to stand from a seated position, and uses the stairs albeit carefully. Further, the applicant testified, and the parties do not dispute her ability to understand what constitutes an emergency and to respond appropriately, therefore we find sufficient evidence that the applicant is currently able to be self-sufficient in an emergency and find that the proposed amount is not reasonable and necessary as a result.
| Number of Minutes | Times per week | Total Minutes per week | |
|---|---|---|---|
| Basic Supervisory Car | 0 | 0 | 0 |
| Subtotal: | 0 |
20Level 2 Summary:
| Total Minutes per week | |
|---|---|
| Hygiene | 105 |
| Subtotal: | 105 |
21Part 3, Level 3:
a) Exercise, assistance with prescribed exercise/stretching program: The applicant submits that 75 minutes per day is required. The respondent submits that no time is required. We prefer the applicant’s Form-1. We accept the applicant’s testimony that she requires assistance with the exercise that her therapist prescribed, including reminding her of exercises, and for 60 minutes of walking per day outside of the house due to her safety issues related to balance. We therefore find that 75 minutes per day is reasonable and necessary.
| Number of Minutes | Times per week | Total Minutes per week | |
|---|---|---|---|
| Exercise | 75 | 7 | 525 |
| Subtotal: | 525 |
b) Medication:
i. Monitors medication intake and effect: The applicant submits that 2 minutes every day is required. The respondent submits that no assistance is required. We prefer the Form-1 of the applicant because the applicant has testified to cognition issues and that she does require reminders to take her medication. We therefore find this is reasonable and necessary.
ii. Maintains and controls medication supply: The applicant submits that 10 minutes once per week is required. The respondent submits that no assistance is required. We prefer the Form-1 of the applicant. The applicant testified that she requires assistance obtaining her medication from the pharmacy. We are satisfied that the applicant is no longer able to drive or use transit to obtain this herself and therefore maintaining her medication supply requires assistance and is reasonable and necessary.
| Number of Minutes | Times per week | Total Minutes per week | |
|---|---|---|---|
| Monitors | 2 | 7 | 14 |
| Maintains | 10 | 1 | 10 |
| Subtotal: | 24 |
c) Bathing:
i. Transfers to bathtub or shower: We prefer the Form-1 of the applicant. The applicant submits that 5 minutes each day is required. The respondent submits that no assistance is required. We accept the applicant’s testimony that she requires help with transfers into the shower because she is unsteady on her feet, especially in a wet/slippery environment. Therefore, we find this is reasonable and necessary.
ii. Bathes and dries client: We prefer the Form-1 of the applicant. The applicant and respondent agree that this is required, but disagree as to the amount of time required, with 10 and 7 minutes each day, proposed respectively. The applicant testified that she requires assistance with scrubbing her back and washing her feet in the shower, as well as drying herself off. We find that 10 minutes is a reasonable and necessary amount of time for bathing and drying.
iii. Applies creams, lotions as required: We prefer the Form-1 of the applicant. The applicant submits that 5 minutes is required per day. The respondent submits that assistance is not required. We accept the applicant’s testimony that she requires assistance with this after bathing because she cannot reach her back. Therefore, we find 5 minutes per day is reasonable and necessary.
| Number of Minutes | Times per week | Total minutes per week | |
|---|---|---|---|
| Transfers | 5 | 7 | 35 |
| Bathes and Dries | 10 | 7 | 70 |
| Applies creams | 5 | 7 | 35 |
| Subtotal: | 140 |
22Level 3 Summary:
| Total Minutes per week | |
|---|---|
| Exercise | 525 |
| Medication | 24 |
| Bathing | 140 |
| Maintenance | 35 |
| Subtotal: | 724 |
23We find for the reasons above the applicant is entitled to $1,879.82 per month in attendant care benefits.
24The respondent does not dispute that the attendant care has been incurred for the amounts invoiced.
25We find the applicant has proven, on a balance of probabilities, that she has incurred and submitted monthly expenses for attendant care from September 2024 to August 2025, based on OCF-6s with attached receipts for those dates. The monthly ACBs submitted on OCF-6 forms are as follows:
i. September 2024, $895.00
ii. October 2024, $2,017.00
iii. November 2024, $1,470.00
iv. December 2024, $1,395.00
v. January 2025, $1,410.00
vi. February 2025, $935.50
vii. March 2025, $622.35
viii. April 2025, $697.50
ix. May 2025, $840.00
x. June 2025, $675.00
xi. July 2025, $1,605.00
xii. August 2025, $1,290.00
26The applicant submits Tribunal case 17-001681 v Motor Vehicle Accident Claims Fund, 2018 CanLII 112134 (ON LAT) (“17-001681”), arguing that the amount incurred in the invoices should not limit her entitlement to ACB, and seeks the Tribunal to deem her entitlement to be the limit of her policy’s optional benefits of $6,000.00.
27In the case of 17-001681 the applicant was unable to afford to incur the ACB without the approval of the benefit, and therefore, no services were received. Having found the respondent had unreasonably withheld or delayed payment of benefits, the adjudicator deemed the expenses to have been incurred, pursuant to s. 3(8) of the Schedule. In that case, the adjudicator confirmed the applicant’s attendant care needs to be reasonable and necessary in excess of the maximum allowable $6,000.00. It followed that the deemed incurred and ongoing ACB was to the limit of the Schedule.
28We find that the respondent has not acted unreasonably in relying on its reports and medical evidence, and therefore will not deem the ACBs to have been incurred, pursuant to s. 3(8) of the Schedule.
29We are satisfied, on a balance of probabilities, that the applicant is entitled to the incurred ACBs up to $1,879.82 per month from September 10, 2024 to date, less amounts paid.
30To 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.
The applicant is not entitled to $2,394.00 for physio/vestibular services proposed by McKelvie Physiotherapy & Vestibular Rehabilitation, in a plan dated December 2, 2024.
31The applicant does not contest that this was not submitted through the Health Claims for Auto Insurance (HCAI) system but submits that the Schedule does not require submission through HCAI, and that this plan was properly submitted and is therefore payable. The applicant relies on the OCF-18, and the denial letter from the respondent dated December 19, 2024.
32The respondent submits that this was not submitted through HCAI and is therefore not payable.
33We find that this OCF-18 form was submitted by fax. On the treatment plan provided, there is no HCAI Facility Registry Number listed. We find that it is a requirement that plans be submitted through HCAI if they are a Participating Facility, as required by FSCO Health Claims for Auto Insurance Guideline of October 2018, Superintendent’s Guideline No. 02/18 referred to in s. 64(7) of the Schedule. However, there is no evidence before us as to whether McKelvie is a Participating Facility, or not.
34The applicant has not met her onus to prove that the treatment provider was not required to submit this form through HCAI.
35The applicant has not proven on a balance of probabilities that this plan is payable.
The applicant is not entitled to $1,031.24 ($4,281.25 less $3,250.00 approved) proposed by Rehab First Inc., for an occupational therapy assessment, in a plan dated September 29, 2023.
36The applicant submits that the partial denial was based on the rate of pay for the social worker and milage expenses. The applicant is seeking a rate of $140.00 per hour for social worker services on the grounds that the nature of the services being provided to a person with significant care needs increases the payable rate. The applicant relies on the plan as above, and the respondent’s denial letter dated October 13, 2023. Further, the applicant submits that the mileage expenses submitted by the applicant are for the applicant’s treatment providers to attend her home as she is unable to drive or take transit due to her accident-related impairment, thus the transportation is reasonable and necessary.
37The respondent submits that this plan was partially payable up to $3,250.00, and submits two reasons for denial, the first of which is that the maximum hourly rate the respondent is willing to pay for a social worker is $100.00 per hour. The respondent submits that at no time has the applicant contacted the respondent to reach an agreement on the payable rate for the social worker, outside of the Professional Services Guideline amount, therefore the $100.00 per hour should stand. The respondent further submits the second reason for partial denial is that mileage is payable only for authorized transportation expenses, and therefore $0 is payable for mileage in this plan.
38We find the FSCO Professional Services Guideline (“PSG”) dated September 2014 does not list an hourly rate for social workers. Since the PSG is silent on the maximum hourly rate for a social worker, it is left to the parties to determine what the acceptable hourly rate would be, and if they are unable to do so, the Tribunal must decide. The onus is on the applicant to demonstrate that the proposed rate is appropriate on the basis of the provider’s education, training, and experience.
39We find the applicant’s submitted case law, of Breault v. CAA Insurance Company, 2025 CanLII 72418 (ON LAT) (“Breault”) was not helpful. In the case of Breault the Tribunal determined the social worker was payable at a rate of $134.17/hr. However, the determination was not made based on the level of care the applicant requires. The higher rate of pay was determined based on the qualifications of the individual social worker.
40We find the applicant has not led evidence to support the social worker’s education, training, and experience attract a higher rate of pay. The respondent is willing to pay $100.00 for the social worker and has partially approved the plan on that basis. We find no reason to interfere with the rate of pay.
41Under s. 15 of the Schedule, transportation for the insured person to and from treatment sessions, including transportation for an aide or attendant, is payable. Under s. 3, authorized transportation expense is defined as expenses authorized by, and calculated by applying the rates set out in the most recent transportation expense guideline published by the Financial Services Regulatory Authority of Ontario. Further, unless the insured person sustained a catastrophic impairment as a result of the accident, a transportation expense only applies after the first 50 kilometres of a trip.
42We find that the applicant has not argued catastrophic impairment, and has not provided evidence that these expenses are for travel over 50 kms. Further, the applicant has not led evidence that the amount listed for milage has been calculated by applying the rates set out in the most recent transportation expense guideline published by the Financial Services Regulatory Authority of Ontario. We find that mileage for the treatment provider to travel to the applicant, is not an authorized transportation expense in the Schedule, and therefore mileage in this plan is not payable.
43We find the applicant has not proven on a balance of probabilities that the denied amount of $1,031.24 is payable.
The applicant is not entitled to mileage proposed in plans by Rehab First: $66.00 submitted March 19, 2023; $198.00 submitted October 31, 2023; $16.50 submitted November 13, 2023; $16.50 submitted April 5, 2024; $186.44 submitted June 3, 2024; $709.50 submitted June 13, 2024.
44The applicant submits that the mileage expense contained in the treatment plans is reasonable because she is unable to drive to treatment and the treatment providers travel to her home. Further, that the Schedule should be broadly interpreted, and in this case denying mileage denies access to necessary care.
45The applicant relies on an OCF-18 completed by Rehab First dated November 10, 2023, with the partial denial letter from the respondent dated November 29, 2023; the OCF-18 completed by Rehab First dated March 19, 2024, with the partial denial letter from the Insurer dated April 10, 2024; the OCF-18 proposed by Rehab First dated November 10, 2023, with the partial denial letter from the respondent dated November 29, 2023; the OCF-18 proposed by Rehab First submitted June 13, 2024, with the partial denial letter from the Insurer dated June 26, 2024; the OCF-18 submitted June 3, 2024, with the partial denial letter from the respondent dated June 21, 2024. Each of these treatment plans contains milage expenses for the treatment providers, all of which were denied by the respondent.
46The respondent submits as per partial denial letters that these amounts are not payable under the Schedule, as they were not authorized transportation expenses. Further, that Statutory Accident Benefits are not intended to cover 100 per cent of the cost of treatment, but rather are an offset of the cost.
47We note that the OCF-18 submitted June 13, 2024, is in dispute for $709.50, which is the difference of the submitted amount of $5,291.01 less $4,581.51 partially approved. This was incorrectly identified in the Case Conference Report and Order as being submitted in the amount of $4,202.56 less $4,016.12 partially approved.
48As stated above, under s. 15 of the Schedule, transportation for the insured person to and from treatment sessions, including transportation for an aide or attendant, is payable. Under s. 3, authorized transportation expense is defined as expenses authorized by, and calculated by applying the rates set out in the most recent transportation expense guideline published by the Financial Services Regulatory Authority of Ontario. Further, unless the insured person sustained a catastrophic impairment as a result of the accident, a transportation expense only applies after the first 50 kilometres of a trip.
49We find that the applicant has not argued catastrophic impairment, and has not provided evidence that these expenses are for travel over 50 kms. Further, the applicant has not led evidence that the amounts listed for milage have been calculated by applying the rates set out in the most recent transportation expense guideline published by the Financial Services Regulatory Authority of Ontario. We find that mileage for the treatment provider to travel to the applicant, is not an authorized transportation expense in the Schedule, and therefore mileage in this plan is not payable.
50We find that the applicant has not proven on a balance of probabilities that the milage amounts submitted in the treatment plans is payable.
Interest
51Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. The respondent shall pay interest on the benefits that we have found to be owing and that are overdue.
ORDER
52The applicant is entitled to receive:
i. Attendant care benefits that are incurred but not exceeding $1,879.82 per month from September 10, 2024, to date, less amounts already paid by CAA Insurance Company.
ii. Interest in accordance with the Schedule for any overdue benefits listed above.
53The applicant is not entitled to the remaining benefits in dispute.
Released: February 6, 2026
Melissa Shea Adjudicator
Tami Cogan Adjudicator