Licence Appeal Tribunal File Number: 24-009572/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:
Christine De Angelis
Applicant
and
Aviva Insurance Company of Canada
Respondent
DECISION
ADJUDICATOR:
Jim Zotalis
APPEARANCES:
For the Applicant:
Charles Jung, Counsel
For the Respondent:
Hilary Doyle, Counsel
HEARD:
In Writing
OVERVIEW
1Christine De Angelis, the applicant, was involved in an automobile accident on May 12, 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 Insurance Company of Canada, 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 $1,014.00 ($3,814.00 less $2,800.00 approved) for social work services, proposed by Social Work Consulting Group in a treatment plan/OCF-18 (“plan”) dated July 25, 2022?
ii. Is the applicant entitled to $1,348.00 ($4,648.00 less $3,300.00 approved) for social work services, proposed by Social Work Consulting Group in a treatment plan dated November 30, 2022?
iii. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant is entitled to $1,014.00 for social work services, proposed by Social Work Consulting Group in a treatment plan dated July 25, 2022, plus interest.
4The applicant is entitled to $1,348.00 for social work services, proposed by Social Work Consulting Group in a treatment plan dated November 30, 2022, plus interest.
ANALYSIS
The applicant is entitled to the unapproved portion for social work services in the treatment and assessment plans dated July 25, 2022, and November 30, 2022.
5I find that the applicant has demonstrated, on a balance of probabilities, that the unapproved balances of the treatment plans for social work services are payable.
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 submitted a treatment plan for $3,814.00 proposed by Elizabeth Waisberg (“the provider”), social worker and psychotherapist, at Social Work Consulting Group, dated July 25, 2022. Of the submitted amount, $2,800 was approved by the respondent, leaving an unfunded balance of $1,014.00. The treatment plan consisted of completion of claims forms, assessment of mental health and counselling as well as documentation and planning services.
8The applicant also submitted another treatment plan for $4,648.00 proposed by the same provider, for social work services. In this treatment plan, the respondent approved $3,300.00, leaving an unfunded balance of $1,348.00. This treatment plan also consisted of an assessment of mental health, counselling, documentation and planning services.
9In both treatment plans, the respondent refused to pay the provider her hourly rate of $139.00 and instead agreed to fund the rate of $100.00 per hour.
10The hourly rates for the services of specified health care providers are found in the Financial Services Commission of Ontario Professional Services Guideline (“Guideline”). The Guideline is silent on the maximum hourly rate for a psychotherapist or social worker. The Guideline provides that the rate for services not covered are to be determined by the parties. If the parties are unable to reach an acceptable rate, then the Tribunal must decide. The onus is on the applicant to demonstrate that the proposed rate is appropriate based on the provider’s education, training and experience.
11The applicant submits that the respondent has not considered the provider’s qualifications or education. The applicant argues that the provider is entitled to an hourly rate commensurate with her educational background, which includes accreditation from the Adler Graduate Professional School in Cognitive Behavior Therapy with Mental Health and Addictions and Cognitive Behavior Therapy Foundations. The applicant also submits that the Tribunal has acknowledged that social workers registered with the Ontario College of Social Workers (“OCSW”) may provide psychotherapy services.
12The respondent submits that it only disputes the unapproved portion of the two treatment plans, that being the hourly rate for social work services provided by the provider. The respondent contends that it has agreed to pay her services at the reasonable rate of $100.00 per hour, and argues that where the Tribunal has found social worker services to be paid at a higher rate, it has done so on the basis that the provider has some specialized training, and that specialized treatment, such as psychotherapy or the provision of Cognitive Behavior Therapy (“CBT”) has been proposed in the relevant plan.
13There is evidence before me that the provider was in fact utilizing CBT as shown in the progress reports documenting the treatment sessions, dated November 28, 2022, August 14, 2023, and February 13, 2024. This is the case even though both treatment plans do not specifically refer to the use of CBT as a treatment method; however, I do not find that fact to be solely determinative of this issue in dispute. Of significance in this case, the provider’s progress reports indicate why CBT has been utilized in this case and how those skills have been imparted to the applicant for her benefit. Given that the provider here was providing psychotherapy, I do not find it an unreasonable expectation for the respondent to review the progress reports for evidence of the provision of CBT to the applicant. In this respect, I find the respondent has a duty to continuously adjust the file and this includes recognition of the fact the service provider in this case was in fact providing services comparable to other providers for a fee rate prescribed by the Guideline, namely that of a psychologist and/or psychological associate, paid at the rate of $149.61 per hour.
14Further, I find that the provider does posses the qualifications and licensure to provide CBT owing to her accreditation from the Adler Graduate Professional School and given that she is a social worker registered with the Ontario College of Social Workers (“OCSW”). The applicant has directed me to a previous LAT decision in which the adjudicator acknowledged that social workers registered with the OCSW may provide psychotherapy services. I agree with the reasoning in D.J. v Aviva Insurance Company of Canada, 2020 CanLII 40340 as it relies on the Regulated Health Professions Act, 1991, which notes that psychotherapy is within the scope of a social worker registered with the OCSW.
15When I examine the totality of the evidence, I find that the provider is entitled to be paid at her hourly rate of $139.00 for the provision of her psychotherapy services in this case on account of the following factors. First, her qualifications and licensure, in addition to her education and experience including over two decades of work experience in various clinical settings demonstrate that she is entitled to the rate of pay as indicated on the treatment plans. In addition, the provider has furnished documented progress reports submitted to the applicant and the respondent indicating her use of CBT during the counselling sessions. These factors all demonstrate that the provider is qualified to conduct the controlled act of psychotherapy.
16The provision of CBT by the provider in this case is the provision of services that is comparable to services provided by a psychologist and/or psychological associate, being $149.61 per hour. Given that the provider in this case has the skills, credentials and delivery of services that are commensurate with a regulated professional (i.e. psychologist), I find the amount proposed by the provider is payable.
17For the reasons stated above, I find the applicant is entitled to the unfunded disputed amounts in both treatment plans dated July 25, 2022, and November 30, 2022.
Interest
18Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. I find that the applicant is owed interest on the unfunded disputed amounts for both treatment plans as these are past due.
ORDER
19The Tribunal Order is as follows:
i. The applicant is entitled to $1,014.00 for social work services, proposed by Social Work Consulting Group in a treatment plan dated July 25, 2022, plus interest.
ii. The applicant is entitled to $1,348.00 for social work services, proposed by Social Work Consulting Group in a treatment plan dated November 30, 2022, plus interest.
Released: February 23, 2026
Jim Zotalis
Adjudicator