Licence Appeal Tribunal File Number: 24-008925/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:
Olivia Zhang
Applicant
and
CAA Insurance Company
Respondent
DECISION
ADJUDICATOR:
Lisa Holland
APPEARANCES:
For the Applicant:
Sareena Samra, Counsel
For the Respondent:
Mitchell Barber, Counsel
HEARD:
By Way of Written Submissions
OVERVIEW
1Olivia Zhang, the applicant, was involved in an automobile accident on September 20, 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, CAA Insurance Company, and applied to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
2The applicant was involved in a serious accident, where she was a passenger in a vehicle towing a trailer, when the trailer lost control causing an impact with their vehicle. Both parties agree that the applicant sustained a catastrophic impairment based on Criterion 8. She has also been diagnosed with major depressive disorder, post traumatic stress disorder, and somatic symptom disorder.
ISSUES
3The issues in dispute are:
i. Is the applicant entitled to psychological services, proposed by Somatic Assessments and Treatment Clinic as follows:
a) $2,468.10 ($5,611.22 less $3,143.12 approved) in a treatment plan/OCF-18 (“plan”) submitted February 14, 2024?
b) $2,468.10 ($5,611.22 less $3,143.12 approved) in a plan submitted March 19, 2024?
c) $2,468.10 ($5,611.22 less $3,143.12 approved) in a plan submitted May 13, 2024?
d) $2,468.10 ($5,611.22 less $3,143.12 approved) in a plan submitted July 22, 2024?
e) $2,468.10 ($5,611.22 less $3,143.12 approved) in a plan submitted August 12, 2024?
f) $2,468.10 ($5,611.22 less $3,143.12 approved) in a plan submitted September 25, 2024?
ii. Is the applicant entitled to $400.00 for housekeeping and home maintenance benefits, proposed by UHeal Rehab Centre in a plan submitted February 2, 2024?
iii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
4In its written hearing submissions, the respondent provided a copy of an email correspondence dated July 25, 2025, to the applicant’s representative with written approval of the OCF-6 dated February 23, 2024, for medication, in the amount of $32.80; and OCF-6 dated April 10, 2024 (submitted on April 12, 2024) for medication in the amounts of $32.67. The respondent submits that these issues are no longer in dispute. The applicant submits that the respondent did not respond to the OCF-6’s, and she chose not to file reply submissions, nor did she provide any evidence to refute the approval. Therefore, I have removed these items from the issues in dispute.
RESULT
5The applicant is not entitled to the outstanding amounts owing for the treatment plans for psychological services.
6The applicant is not entitled to payment of housekeeping and home maintenance benefits in the amount of $400.00.
7The applicant is not entitled to interest or an award.
ANALYSIS
8To receive payment for a treatment plan (OCF-18) 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. 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 same are reasonable.
The applicant is not entitled to the outstanding amount of $2,468.10 for each of the plans listed in issues 3 i. (a) through (f)
9I find that the applicant has not established on a balance of probabilities that the outstanding balance of $2,468.10 for each of the plans listed in issues 3 i. (a) through (f) are payable.
10Under s.25(3) of the Schedule, an insurer is not liable to pay for expenses for professional services that exceed the Professional Services Guideline, Superintendent’s Guideline No.03/14 (“Guideline”).
11The applicant is seeking the outstanding amount of 6 plans listed in issue 3 i. or the difference between the amount proposed of $5,611.22 and the approved amount of $3,143.12, totaling $2,468.10 for psychological services, completed by Svetlana Gabidulina, psychologist, and provided by Xiao Lan Yang, psychotherapist, of Somatic Assessments & Treatment Clinic. The dates of the plans listed under issue 3 i. are as follows:
(a) plan dated February 5, 2024;
(b) plan dated March 19, 2024;
(c) plan dated May 13, 2024 ;
(d) plan dated July 22, 2024;
(e) plan dated August 12, 2024; and,
(f) plan dated September 25, 2024.
12Each of the plans listed in issues 3 i. (a) through (f) sought 18 one and a half-hour sessions of mental health therapy, with progress report, 2 hours for communication with team and completion of the OCF-18 in the amount of $5,611.22. The respondent partially approved each of the proposed plans in the amount of $3,143.12, which includes mental health therapy, communication with team, plus completion of a progress report and the OCF-18. The respondent denied the proposed rate of $149.61 per hour for treatment provider, Xiao Lan Yang, who is a psychotherapist, and paid a rate of $89.07 per hour. The outstanding amount of $2,468.10 consisted of:
i. Psychotherapist – the difference between a rate of $149.61 per hour and $89.07 per hour for 18, one and a half-hour sessions, totaling $2,404.89;
ii. Psychotherapist – the difference between a rate of $149.61 per hour and $89.07 per hour for 2 hours of communication with team, totalling $178.23.
Psychotherapist rate
13I find that the applicant has not established how the hourly rate of the treatment provider, Xiao Lan Yang, who is a psychotherapist, should be equivalent to a psychologist, and therefore, payable at the maximum rate of $149.61 per hour.
14The applicant submits that the proposed treatment plans for psychological services are reasonable and necessary. However, the applicant makes no submissions to explain how the services of Xiao Lan Yang are the same or similar to a psychologist on the basis of his degree in Counselling Psychology, and his experience in cognitive behavioural therapy, and are therefore payable at the proposed rate of $149.61 per hour.
15The respondent submits that it paid a fair rate of $89.07 per hour for Xiao Lan Yang, as a psychotherapist, since the hourly rate of a psychotherapist is not payable at the same rate of a psychologist, which it argues is fair under the circumstances for the services of an unregulated health care professional.
16I find that the qualifications of Xiao Lan Yang as indicated on the plans is a psychotherapist, and there is no evidence that she has a degree in psychology or that she has expertise in providing cognitive behavioural therapy. I also find that there is no evidence that Xiao Lan Yang has the same expertise as a psychologist and therefore, payable at the maximum rate of $149.61 per hour.
17The applicant does not explain the reason that the plans indicates that Xiao Lan Yang is the treatment provider for the 18 individual counselling sessions, nor does she indicate whether Svetlana Gabidulina, or another psychologist, is present during each session. The applicant has not provided an explanation for the proposed amount of $149.61 per hour for Xiao Lan Yang, who is a psychotherapist. The Guideline states that an insurer is not liable to pay above the Guideline’s specified hourly rates. While the Guideline specifies certain rates for certain professions, a psychotherapist is not included and the amounts payable for services not covered by the Guideline are to be determined by the parties.
18Therefore, I find that the applicant has not demonstrated, on a balance of probabilities, that she is entitled to the unapproved portion of $2,468.10 for each of the plans listed in issue 3 i. (a) through (f).
The applicant is not entitled to housekeeping and home maintenance benefits in the amount of $400.00 per week submitted on February 2, 2024
19I find that the applicant has not established on a balance of probabilities that she is entitled to the housekeeping and home maintenance benefit, which were submitted on February 2, 2024, by UHeal Rehab Centre. I find the applicant is not entitled to payment of same because she has not submitted proof that the benefit has been incurred pursuant to s. 3(7)(e)(iii) of the Schedule.
20Section 23 of the Schedule requires an insurer to pay up to $100.00 per week for reasonable and necessary additional expenses incurred by or on behalf of an insured person as a result of an accident for housekeeping and home maintenance services if, as a result of the accident, the insured person sustains a catastrophic impairment that results in a substantial inability to perform the housekeeping and home maintenance services that he or she normally performed before the accident.
21In order for the insured person to receive payment for the housekeeping and home maintenance benefit, there must be evidence that the expense was incurred as per s. 3(7)(e)(iii) of the Schedule. To satisfy this requirement the insured person must have received the service to which the expense relates and paid or promise to pay the expense.
22The applicant makes no submissions, nor does she point or direct me to evidence in support of whether housekeeping and home maintenance benefits are reasonable and necessary for her accident-related injuries. In addition, although the applicant submits that the claimed expenses in the amount of $400.00 were incurred, she does not point or direct me to evidence in support of the incurred expenses.
23The respondent relies on an insurer examination (“IE”) report dated January 17, 2020, by Elana Korman, occupational therapist; and an IE report dated August 20, 2020, by Dr. Ian Smith, psychologist. The respondent submits that both OT Korman and Dr. Smith found that the applicant was able to perform housekeeping tasks. The respondent further submits that the housekeeping invoices submitted by UHeal Rehab Centre lack particulars of the type of service provided pursuant to s. 3(7)(e)(iii) of the Schedule.
24I find that the applicant has not met her onus to establish that she is entitled to housekeeping and home maintenance benefits in the amount of $400.00 because she does not direct or point me to any evidence in support of whether the expenses are reasonable and necessary or whether they have been incurred.
Interest
25Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since there are no benefits delayed or owing, interest is not 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.
27The applicant submits that she is entitled to an award because the respondent denied her entitlement to the benefits in dispute. I find the respondent’s denial of the benefits in dispute in and of itself does not prove entitlement to an award. For these reasons, I find the applicant has not met her onus in proving that she is entitled to an award.
ORDER
28For the reasons set out above, I find that:
i. The applicant is not entitled to the outstanding amounts of the treatment plans for psychological services in dispute.
ii. The applicant is not entitled to payment of housekeeping and home maintenance benefit in the amount of $400.00 submitted on February 2, 2024.
iii. The applicant is not entitled to interest or an award.
iv. The application is dismissed.
Released: February 20, 2026
__________________________
Lisa Holland
Adjudicator