Citation: Guan v. Co-operators General Insurance Company, 2026 ONLAT 25-003550/AABS

Licence Appeal Tribunal File Number: 25-003550/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:

Feng Tong Guan

Applicant

and

Co-operators General Insurance Company

Respondent

DECISION

ADJUDICATOR:

Harry Adamidis, Member Aric Bhargava, Member

APPEARANCES:

For the Applicant:

Vanessa Liang, Counsel

For the Respondent:

Julianne Brimfield, Counsel

Brittany Tambroro, Adjuster

HEARD by Videoconference:

December 16, 2025

OVERVIEW

1Feng Tong Guan, the applicant, was involved in an automobile accident on February 10, 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, Co-operators General Insurance Company, and applied to the Licence Appeal Tribunal — Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

PRELIMINARY ISSUES

2The Case Conference Report and Order (“CCRO”), dated June 20, 2025, lists res judicata as a preliminary issue. The respondent withdrew this issue at the start of the hearing.

ISSUES

3The issues in dispute are:

1. Is the applicant entitled to $6,441.00 for an endocrinology and CAT assessment, proposed by Omega Medical Associates in a treatment plan submitted February 14, 2025?

2. Is the applicant entitled to $11,370.37 ($17,570.37 less $6,200.00 approved) for CAT assessments, proposed by Connections Physiotherapy in a treatment plan submitted February 4, 2025?

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

4. Is the respondent liable to pay an award under section 10 of Regulation 664 because it unreasonably withheld or delayed payments to the applicant?

4The applicant withdrew the following issues listed in the CCRO: income replacement benefit in the amount of $400.00 per week from February 18, 2025, to date and ongoing; attendant care benefits in the amount of $6,000.00 per month from April 12, 2023, to date and ongoing; and a treatment plan in the amount of $5,538.28 for case manager services.

RESULT

5The applicant is not entitled to the treatment plan for an endocrinology and CAT assessment.

6The applicant is not entitled to the treatment plan for CAT assessments dated February 4, 2025.

7No interest or award is payable.

PROCEDURAL ISSUES

The applicant did not attend the hearing

8On July 11, 2025, the Tribunal issued a Notice of Videoconference Hearing for a hearing to take place on December 16, 2025 at 9:30 AM.

9The applicant did not appear at the start of the hearing. The applicant’s counsel stated that the applicant was unable to attend because she is currently hospitalized. The applicant’s counsel argued that the matter should proceed in the absence of the applicant and the applicant is not providing testimony at the hearing. The respondent did not object to proceeding.

10If a party has been given notice of a hearing in accordance with the Statutory Powers Procedure Act (“SPPA”), Rule 3.7.1(a) of the Licence Appeal Tribunal Rules, 2023 (“LAT Rules”) requires the Tribunal to consider the reasons for non-attendance, if any, and may proceed with the hearing in the absence of a party. In this case, the applicant was provided with notice in accordance with the SPPA on July 11, 2025 and this is not disputed by the parties.

11We determined that the hearing would proceed in the applicant’s absence because there is reasonable notice of the hearing, she is dealing with a serious medical issue, she will not be providing testimony, both parties agreed to proceed in her absence, and there is no prejudice to the applicant in proceeding with an oral hearing.

The applicant brought a motion to convert the format of the hearing

12At the outset of the hearing, the applicant brought a motion for the videoconference to be converted to a written hearing because there would be time limits on the oral submissions and the applicant states she would not be provided time to reply. The respondent did not consent to convert the format to a written hearing because the applicant did not provide advance notice, and the respondent had also arranged for a court reporter. The respondent was prepared to proceed, did not want to increase costs unnecessarily. The respondent indicated that if the matter proceeded as a written hearing, then the respondent would be seeking costs.

13The applicant submitted she was merely pursuing the possibility of converting to a written hearing and also prepared to proceed with the videoconference hearing but was pursuing her request to convert to a written hearing.

14We declined to grant the applicant’s motion for a written hearing. We agree that the respondent did not have notice of the request, and the applicant is prepared to proceed with the videoconference hearing. Accordingly, we were satisfied that the matter could proceed and both parties submitted they were prepared to proceed, as scheduled.

15Accordingly, the motion to convert the matter to a written hearing was denied.

ANALYSIS

CAT assessments

Is the applicant entitled to an endocrinology and CAT assessment?

16We find the applicant is not entitled to an endocrinology and CAT assessment.

17To receive payment for a treatment and assessment plan under section 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 the treatment, how the goals would be met to a reasonable degree and that the overall costs of achieving them are reasonable.

18The applicant bears the onus of demonstrating, on a balance of probabilities, that there are grounds on which to believe that a condition exists that would warrant further investigation by way of an assessment.

19When the Tribunal is considering whether an assessment is payable, the test is guided, in part, by section 25 of the Schedule, which provides limits on how much an insurer will be expected to pay for an assessment. Sections 25(1) and (5) of the Schedule sets out that the insurer shall pay reasonable fees charged to prepare any assessment that is necessary for a determination of whether an insured person is catastrophically impaired. Specifically, section 25(5)(a) states that an insurer shall not pay:

“more than a total of $2,000.00 plus the amount of any applicable harmonized sales tax payable under Part IX of the Excise Tax Act (Canada) for accidents that occur on or after June 3, 2019 in respect of fees and expenses for conducting any one assessment or examination and for preparing reports in connection with it …”

20The plan was proposed by Dr. Lisa Becker, physician. The plan proposes an endocrinology file review, endocrinology catastrophic impairment evaluation, endocrinology medical legal assessment, and completion of the OCF-18. The injuries listed are sprain and strain of cervical and lumbar spine, injury of other muscles and tendons at shoulder and upper arm level, Type 2 diabetes mellitus, dizziness, headache, concussion, recurrent depressive disorder, somatoform disorders, post-traumatic stress disorder. The goals of the plan are “N/A OCF-19 CAT Assessment”. The total cost includes $1,000.00 for endocrinology file review, $2,000.00 for endocrinology catastrophic impairment evaluation, $2,500.00 for endocrinology medical legal assessment, and $200.00 for OCF-18 submission, plus tax of $741.00. The applicant seeks the full cost of the treatment and assessment plan dated February 14, 2025, totalling $6,441.00.

21The applicant submits she has a history of diabetes and relies on the treatment plan dated February 18, 2025 and the Notice of Examination dated September 23, 2025, portions of the section 44 assessment of attendant care needs, the section 25 physiatry evaluation, and the section 25 internal medicine evaluation report.

22The respondent denied the treatment and assessment plan in a letter dated February 19, 2025 because the assessments are not reasonable and there is no evidence that the applicant’s pancreatitis diabetes and degenerative lumbar issues were caused by the accident.

23We find that the applicant has not established there are grounds to believe she has an accident-related condition that warrants further investigation by way of an endocrinology CAT assessment. In reaching this conclusion, we note that the September 23, 2025 Notice of Examination states “The s. 25 CAT internal medicine report completed by Dr. Dina Reiss, [endocrinologist], provides there is evidence that you likely had diabetes before the MVA …”. Accordingly, we find that the preponderance of the evidence indicates that the applicant had diabetes and pancreatitis before the accident, and although she received treatment for her conditions following the accident, the medical evidence does not causally connect these conditions to the accident.

24The section 25 physiatry evaluation dated March 27, 2025 prepared by Dr. Eugene Chang, physiatrist, makes no casual connection with the accident. Dr. Chang’s report combined with the note of Dr. F. Yao, family physician, dated March 7, 2023, that states the applicant’s pancreatitis is “clinically resolved” further undermines a link between the pancreatitis or Type 2 diabetes being caused by the accident.

25In our view, the applicant has not provided medical evidence that establishes grounds for pursuing an endocrinology assessment to assess accident-related impairments.

26We find the applicant has not demonstrated, on a balance of probabilities, that the treatment plan and assessment are reasonable or necessary. Accordingly, the applicant is not entitled to the treatment plan in dispute.

Is the applicant entitled to $11,370.37 ($17,570.37 less $6,200.00 approved) for CAT assessments?

27We find the applicant is not entitled to $2,000.00 for the psychiatric evaluation part 2: Criterion 8 for CAT determination, and not entitled to $2,000.00 for the occupational therapy situational assessment for CAT determination.

28The plan proposed by Justin Moy, occupational therapist, proposes catastrophic assessments consisting of;

1. Documentation, support activity for claim form (e.g. for insurance third party payor, worker’s compensation)

2. Catastrophic determination assessment

3. Catastrophic determination assessment

4. Attendant care benefits determination – completion of Form 1

5. Catastrophic determination assessment

6. Catastrophic determination assessment

7. Catastrophic determination assessment

8. Provider travel time, provider to treatment

9. “Documentation support activity”

10. “Interpretation, service”

29The injuries listed are other chronic pain, sprain and strain of cervical spine, thoracic spine, shoulder joint, rotator cuff, hip, sacroiliac, postconcussional disorder, other symptoms involving cognitive functions, headache, dizziness, nausea, muscle strain, abnormalities of gait, stress, sleep disorders, disorder of vestibular function, fracture of lumbar vertebrae. The goals of the plan are to examine if the client meets the criteria of catastrophic impairment.

30In a letter dated February 6, 2025, the respondent partially approved the plan in the amount of $6,200.00 that included the following items numbered in the plan as follows:

1. Documentation, support activity for claim form (e.g. for insurance third party payor, worker’s compensation)

2. Catastrophic determination assessment

3. Catastrophic determination assessment

4. Catastrophic determination assessment

31The applicant seeks entitlement to the remaining balance of the treatment plan, in the amount of $9,349.00 plus $2,021.37 tax, totaling $11,370.37, for items numbered in the plan as follows:

3. Catastrophic determination assessment (also referred to as psychiatric evaluation part 2: Criterion 8)

4. Attendant care benefit determination – completion of Form 1 (also referred to as psychiatric evaluation part 3)

5. Catastrophic determination assessment (also referred to as occupational therapy situational assessment)

6. Provider travel time, provider to treatment

7. “Documentation support activity” (also referred to as OCF-19 completion)

8. “Interpretation, service”

Is the psychiatric evaluation part 2: Criterion 8 reasonable and necessary?

Is the occupational therapy situational assessment reasonable and necessary?

32We find that the psychiatric evaluation part 2 and the occupational assessment situational assessment are not reasonable and necessary.

33The applicant submits the psychiatric assessment part 2 and the occupational therapy situational assessment are reasonable and necessary because of the complexity of her accident-related injuries require additional time to properly assess the extent and impact of her injuries. The applicant further submits different tools are required for Criterion 7 and Criterion 8 psychiatric assessments, and a different setting/location is required for the occupational therapy situational assessment.

34The applicant relies on the treatment plan dated February 4, 2025. The applicant also relies on Monks v. ING Insurance Company of Canada, 2008 ONCA 269 (“Monks”), Tomec v. Economical Mutual Insurance Company, 2019 ONCA 882 (“Tomec”), Surju v. The Personal Insurance Company, 2025 CanLII 524 (“Surju”).

35According to the applicant the respondent has not met the standard of broad interpretation of the Schedule, maximizing benefits for victims due to their accident-related injuries and catastrophic assessments are complex, multi-step evaluations requiring assessments to utilize distinct approaches for the different criterion and two-part occupational therapy assessment inside and outside of the home.

36Citing Monks, Tomec, and Surju, the applicant states her accident-related injuries have left her with lasting and serious impacts and this requires a different approach and assessment tools to evaluate, assess, and consider the severity of her impairments. However, the applicant did not direct us to evidence of how her accident-related impairments were different. Citing Monks at paragraph 51, she argues that insurance coverage principles are to be interpreted broadly, while coverage exclusions or restrictions are to be construed narrowly. Citing Tomec at paragraph 43, she argues the purpose of the Schedule is to maximize benefits for that class of accident victims who suffer from lasting and very serious health impacts as a result of a motor vehicle accident. Citing Surju at paragraph 25, she argues two reports were completed, one for Criterion 7 and another for Criterion 8, and each report was separately payable.

37The respondent submits the applicant has not met her onus to demonstrate the assessments are reasonable and necessary. The respondent approved one psychiatric evaluation and denied the psychiatric assessment part 2 in a letter dated February 6, 2025, stating that the approved executive assessment can encompass the ratings for Criterion 7 and Criterion 8. In the same letter, the respondent denied the occupational therapy situational assessment because the applicant provided insufficient information to demonstrate two days are required for a second assessment. The respondent argues that it has approved the assessments within the allowable cap, per section 25(5)(a).

38In the applicant’s case, the Criterion 8 reports included the same psychometric testing, and the analysis is the main difference between the reports. Criterion 7 is assessed using the 6th edition of the American Medical Association’s Guides to Evaluation of Permanent Impairment, and Criterion 8 is evaluated using the 4th edition. We find the Criterion 8 report involves distinct considerations, however, we find that while two different criterion are being assessed, the applicant has not directed us to evidence that these cannot be dealt with in a single assessment. We find that no explanation has been provided for why multiple assessments are required. When viewed in the context of the applicant’s claimed physical and psychological accident-related impairments, we find that the psychiatric assessment part 2 is not reasonable and necessary.

39We also find the occupational therapy situational assessment is not reasonable and necessary.

40In this case, the applicant has not led evidence to demonstrate the occupational therapy situational assessment is distinguished from the occupational therapy in-home assessment in terms of the time required. It is well-established by this Tribunal that OCF-18s on their own are not sufficient to demonstrate entitlement. We find the occupational therapy situational assessment is not reasonable and necessary because the applicant provided no evidence to support the reasonableness of the cost of the second occupational therapy assessment, and she did not direct us to medical evidence in support of this assessment.

41For these reasons, and on a balance of probabilities, the applicant is not entitled to the psychiatric evaluation part 2, and the occupational therapy situational assessment.

Is the psychiatric evaluation part 3 reasonable and necessary?

42We find the psychiatric evaluation part 3 is not reasonable and necessary.

43The applicant submits that catastrophic assessments are complex, multistep evaluations utilizing distinct approaches, such as the three-part psychiatric assessment for different Criterion.

44The respondent denied the psychiatric evaluation part 3 in a letter dated February 6, 2025, stating that the approved psychiatric executive assessment can encompass the psychiatric evaluation part 3 and therefore is duplicative in nature. The respondent argues that it has approved the assessments within the allowable cap, per section 25(5)(a).

45We find the applicant has not directed us to persuasive evidence that the psychiatric evaluation part 3 is reasonable and necessary because in Part 12 of the OCF-18 dated February 4, 2025 it states “4. Attendant care benefit determination – completion of Form 1”. However, the Additional Comments section state:

Line 4: Psychiatric Evaluation part 3

Report preparation Communication with team members

For this psychiatric evaluation to be complete […]

We note the applicant is seeking entitlement for a psychiatric evaluation part 3, however, the OCF-18 states that it is for attendant care benefit determination. This may be a typographical error, however, this description in the Additional Comments is inconsistent and does not have a clear nexus with the treatment plan in dispute and there is not medical evidence supporting the need for the treatment plan.

46The applicant has not met her onus to demonstrate that the “Attendant care benefit – completion of Form 1” (or psychiatric evaluation part 3) is reasonable and necessary. In our view it is not clear what the expense is for because the applicant’s submissions did not clarify what the purpose of the “Attendant care benefit determination – completion of Form 1” assessment is, and she did not direct us to corroborating objective medical evidence to support that it was reasonable and necessary.

47For these reasons, we find on a balance of probabilities that the applicant is not entitled to the attendant care benefit, also listed as the psychiatric evaluation part 3.

Travel time

48We find the applicant has not met her burden to demonstrate that the travel time in dispute is reasonable and necessary.

49Section 25(1)5 of the Schedule provides that an insurer shall pay for reasonable fees for the determination of whether the insured person has sustained a catastrophic impairment, including any assessment or examination necessary for that purpose. This is to be read in conjunction with s. 25(5)(a) which limits the cost of any one assessment or examination to $2,000.00 plus tax. The applicant bears the onus of proving on a balance of probabilities that each of the disputed components of the treatment plan are reasonable and necessary.

50The applicant submits that the total travel expenses incurred were $399.00 for the occupational therapist to attend for the occupational therapy in-home assessment and the occupational therapy situational assessment that was conducted over a two-day period. The applicant submits that she spoke with the adjuster regarding the travel expense, and this expense relates to the two visits for the occupational therapy assessments.

51The respondent denied the travel fees in a letter dated February 6, 2025. The respondent submits travel time is included in $2,000.00 cap in accordance with the Financial Services Regulatory Authority of Ontario Cost of Assessments and Examinations Guideline.

52While we agree that it is reasonable for the applicant to undergo the occupational therapy catastrophic assessments generally, the applicant has not persuaded us that the cost of the travel time in dispute is necessary or that it should be paid outside of the section 25(5)(a) cap for each assessment.

53We find the applicant has not met her burden to establish, on a balance of probabilities, her entitlement to the travel expense and that the transportation costs for the provider are not included in the section 25(5)(a) cap of $2,000.00 for fees and expenses relating to any one assessment.

Documentation support - OCF-19 completion

54We find the applicant did not meet her burden to demonstrate, on a balance of probabilities, that the OCF-19 is reasonable and necessary.

55The applicant made no submissions on the issue of the documentation support - OCF-19 completion.

56The respondent denied the OCF-19 documentation request in a letter dated February 6, 2025 because the CAT assessments are not completed and that it is yet to be determined if the OCF-19 is required.

57We find that the applicant has not met her burden, on a balance of probabilities, of proving that the denied OCF-19 is reasonable and necessary.

Is the applicant entitled to interpretation fees?

58We find the applicant has not demonstrated, on a balance of probabilities, that the interpretation fee is reasonable and necessary.

59The applicant submits that interpretation services are reasonable and necessary because she does not speak English, and an interpreter is required in order to engage in the completion of assessments and access treatment. The applicant argues the interpretation fees are not included in the $2,000.00 cap in section 25(a) and relies on the email exchange dated December 12, 2025 with the insurer and the rates listed in the Professional Services Guideline.

60In the email dated December 12, 2025, the applicant notes the hourly fee for interpretation is comprised of $68.00 per hour for interpreter time plus $45.00 per hour for service fees, totalling $113.00 per hour for 18 hours of interpretation services.

61The respondent submits the interpretation fee is included in the FSRA Guideline. The FSRA Guideline states the insurer is not required to pay interpreter fees and “Health care providers and other persons acting on their behalf should not arrange for interpreters without the prior approval of both the insured person and the insurer.” The respondent argues the interpretation receipts were late filed and relies on section 15 and 16 of Schedule. The respondent states that it denied this expense in a letter dated February 6, 2025 stating that “this is not a covered expense within the SABS.”

62In this case, the parties do not dispute whether the interpretation service is necessary, however, the dispute is whether the incurred interpretation fee is reasonable. The interpretation fee is guided by the Cost of Assessments and Examinations Guideline (“FSRA Guideline”). The FSRA Guideline is not legislation, rather guidance to be weighed when making a finding of entitlement.

63While we acknowledge the interpretation service is necessary because the applicant requires this service to access the benefit process, the applicant has not met her onus of establishing the rate is reasonable. The applicant failed to direct us to evidence that the interpretation fee should be paid outside of the section 25(5)(a) cap, or that the interpretation rates are a reasonable fee. As a result, there is no basis to find the cost is reasonable.

64We find the applicant has not demonstrated, on a balance of probabilities, that the interpretation fee is reasonable and necessary.

Interest

65Interest applies on the payment of any overdue benefits pursuant to section 51 of the Schedule. Having concluded that no benefits are payable, it follows that no payments went overdue and that no interest is payable.

Award

66The applicant sought an award under section 10 of Regulation 664. Under section 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. The Tribunal has determined that an award is justified where the delay or withholding of benefits by the insurer is unreasonable conduct, meaning “behaviour which is excessive, imprudent, stubborn, inflexible, unyielding or immoderate.” The onus is on the applicant to prove, on a balance of probabilities, that the respondent’s conduct meets this threshold.

67The applicant submits the respondent behaviour was unreasonable because it unreasonably withheld or delayed payments.

68The respondent states the award particulars were not provided and this is procedurally unfair.

69The CCRO dated June 20, 2025 notes the applicant shall provide particulars of the award claim within 30 days after receipt of the adjusters’ log notes. We were not directed to particulars of the applicant’s award claim. In our view, this creates an unfair situation where the respondent is being asked to reply to submissions on the award without out being provided the particulars in advance in accordance with the CCRO. As a result, the respondent does not have the opportunity to prepare and respond to the applicant’s award particulars.

70We find an award is not appropriate and the respondent’s actions do not constitute unreasonable withholding or delayed payment of benefits. As a result, no award is payable.

71In the alternative, the applicant submits the respondent should reconsider the denial of the Criterion 8 CAT assessment and the occupational therapy situational assessment and relies on the email exchange dated February 6, 2025. The email argues the situational assessment because it is completed on two separate dates, and the Criterion 8 CAT assessment is more complex, requires different skill sets, and requires more time and it is unreasonable to deny the assessments.

72We find the applicant’s disagreement with the respondent’s decision does not mean the respondent has conduct itself in a manner that is excessive, imprudent, stubborn, inflexible, unyielding or immoderate.

73For the reasons outlined above, we find no award is warranted.

ORDER

74The applicant is not entitled to an endocrinology and CAT assessment in the treatment plan dated February 14, 2025.

75The applicant is not entitled to the treatment plan for CAT assessments dated February 4, 2025.

76No interest or award is payable.

77The application is dismissed.