Licence Appeal Tribunal File Number: 24-009998/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:
Huimin Yao
Applicant
and
SGI Canada Insurance Services Ltd.
Respondent
DECISION
ADJUDICATOR:
Lisa Holland
APPEARANCES:
For the Applicant:
Rakesh Sharma, Counsel
For the Respondent:
Jonathan Heeney, Counsel
HEARD:
By Way of Written Submissions
OVERVIEW
1Huimin Yao, the applicant, was involved in an automobile accident on September 1, 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, SGI Canada Insurance Services Ltd., 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 $3,394.46 ($4,348.56 less $954.10 approved) for chiropractic services, proposed by UHeal Rehab Centre, in a treatment plan/OCF-18 (“plan”) dated December 12, 2023?
ii. Is the applicant entitled to $4,028.56 for chiropractic services, proposed by UHeal Rehab Centre, in a plan dated April 30, 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?
RESULT
3The applicant has not demonstrated that the denial notices for the treatment plans in dispute contravene s.38(8) of the Schedule. She is not entitled to these treatment plans on this basis and she has made no submissions on the reasonableness and necessity of the plans. Therefore, the treatment plans, interest and an award are not payable.
PROCEDURAL ISSUES
Page Limits Exceeded
4The respondent submits that the applicant has failed to abide by the submission page limits set out in the Case Conference Report and Order dated December 16, 2024 (“CCRO”). The CCRO indicates the applicant’s and respondent’s written submission will be limited to 7 pages in length.
5The respondent argues that the applicant’s 7 pages of submissions are single spaced, which exceeds the page limits set out in the CCRO, and therefore should not be considered by the Tribunal.
6In her reply, the applicant submits that although the page limits were exceeded in error, the respondent has not suffered any prejudice, and the applicant would suffer prejudice by the exclusion of her submissions.
7I find that the applicant exceeded the 7-page limit as set out in the CCRO, since the submissions are single-spaced. However, I agree that the respondent did not provide any reasons that it would suffer prejudice by the submissions, and the applicant would suffer prejudice if her submissions are not considered due to a technical error.
8The CCRO specified that the hearing adjudicator may not consider submissions which exceed page limits. The discretion lies with the hearing adjudicator. I note that pursuant to ss. 23(1) and 25.0.1 of the Statutory Powers Procedure Act, it falls directly within my discretion to admit or strike any submissions in excess of the 7-page limits set out in the CCRO. However, in this case, I will admit non-compliant submissions.
ANALYSIS
9The applicant makes no submissions as to the reasonableness or necessity of the treatment plans in dispute. The applicant’s focus is on alleged procedural errors made by the respondent. The applicant submits that these procedural errors should result in finding the disputed benefits payable.
10Section 38(8) of the Schedule provides that an insurer shall respond to a treatment and assessment plan within 10 business days of receiving it by identifying the goods, services, assessments and examinations described in the plan that the insurer does and does not agree to pay for. The insurer must also provide medical and all other reasons why it has determined that the treatment and assessment plan is not reasonable and necessary.
11If an insurer fails to comply with s. 38(8), the Schedule sets out two consequences under s. 38(11). First, an insurer who fails to provide the insured with adequate notice of the reasons for its denial is prohibited by s. 38(11) 1 from taking the position that the insured person has an impairment to which the MIG applies. Second, s. 38(11)2 provides that is an insurer fails to provide proper notice of the reasons for its denial it must pay for all goods, services, assessments and examinations described in the treatment and assessment plan that relate to the period starting on the 11th business day after the day the insurer received the application and ending on the day the insurer gives notice as described in s. 38(8).
12The Tribunal has recognized medical reasons for denial as specific details about the insured’s condition forming the basis for the insurer’s decision or identifying information about the insured’s condition that the insurer still requires. In addition, the insurer should refer to the specific benefit or determination at issue with the relevant section of the Schedule.
Plan dated December 12, 2023 for the outstanding amount of $3,394.46
13I find that the applicant is not entitled to the unapproved portion of the December 12, 2023 plan.
14The applicant submitted a plan dated December 12, 2023, for chiropractic services in the amount of $4,348.56, proposed by UHeal Rehab Centre. The plan included the following treatment:
a) 16 one-hour sessions manipulation therapy at a rate of $112.81 per hour, totaling $1,804.96;
b) 16 half-hour sessions exercise therapy at a rate of $112.81 per hour, totaling $902.56;
c) 16 one-hour sessions acupuncture therapy at a rate of $58.19 per hour, totaling $931.04;
d) 16 one-hour trips travel time at a rate of $20.00 per hour, totaling $320.00;
e) Assessment for $200.00; and,
f) Documentation support activity for $190.00.
15The respondent denied the plan for chiropractic services by way of letter dated December 21, 2023, within 10 business days after the plan was submitted through HCAI on December 14, 2023. The respondent stated in their denial letter dated December 21, 2023, that it required documentation under section 33 for the clinical notes and records (“CNRs”) of Dr. Tat Hang Wong, family physician, UHeal Rehab Centre and an OHIP summary. The respondent also requested a s. 44 assessment to determine whether the proposed plan is reasonable and necessary.
16In a subsequent letter dated March 19, 2024, the respondent provided a copy of an Insurer’s Examination (“IE”) report dated March 7, 2024, by Dr. Mohammed Abdul Wahab Khan, physiatrist. Based on the report of Dr. Khan, the respondent removed the applicant from the Minor Injury Guideline (“MIG”) and partially approved the treatment plan in the amount of $954.10, which included 10 half-hour sessions exercise therapy, totaling $564.10, plus the cost of an assessment and documentation support activity. The respondent denied the proposed 16 one-hour sessions manipulation therapy; 16 one-hour sessions acupuncture therapy; 6 half-hour sessions exercise therapy; and 16 one-hour trips travel time, for a difference of $3,394.46.
17The applicant argues that the treatment plan is certified by a duly qualified medical professional to contain accurate information in proposing reasonable and necessary treatment. The applicant argues that the certification creates a rebuttable presumption that the plan is reasonable and necessary, which the respondent must rebut on the basis of fair and principled reasons in the denial notice.
18The applicant made no submissions regarding whether the outstanding amount for manipulation therapy, acupuncture therapy, exercise therapy, and travel time is reasonable and necessary and, instead, relied solely on her argument that the respondent’s denial was non-compliant under s.38(8) of the Schedule such that the remaining amount of the treatment plan is payable.
19The applicant submits that the March 19, 2024 letter was an improper denial with limited, non-specific explanations, and the respondent cannot rely on the IE report of Dr. Khan since its based on insufficient medical reasons. The applicant submits that the denial notice for the plan dated March 19, 2024, for the unapproved portion of the plan for manipulation therapy, acupuncture therapy, 6 sessions exercise therapy and travel time was based on the applicant’s self-reports to Dr. Khan that she has no long-term benefit from treatment and she has returned to driving. The applicant further submits that Dr. Khan mentions that the applicant has not reached maximum medical recovery, and she has anxiety and pain while driving. What the applicant has not done is provide submissions despite having the onus to do so to explain why the unapproved portion of the plan is reasonable and necessary.
20In the December 21, 2023 letter, the respondent states that the documentation supports that the applicant has a minor injury with soft tissue injuries which fall within the MIG. The respondent also requested information about the insured’s medical condition that the insurer does not have but requires to determine whether the treatment plan is reasonable and necessary. In addition, the respondent stated that it required an Insurer’s Examination (“IE”) to determine whether the recommended treatment is reasonable and necessary for the injuries the applicant sustained as a result of the accident.
21I find that the denial dated December 21, 2023, provides reasons specific to the applicant and indicated that the respondent requires additional medical information and an IE to determine whether the proposed plan is reasonable and necessary. I find this was a clear and unequivocal denial. Although the applicant may disagree with the respondent’s stated reasons or its assessment of medical documentation, it does not render the notice invalid. Accordingly, I find that the denial complies with s.38(8) of the Schedule.
22Since I have found that the respondent’s denial notice dated December 21, 2023 was a valid notice, it is not necessary to determine whether further notice dated March 19, 2024 was also a valid notice regarding the same issue.
23Since the respondent’s denial was compliant with the Schedule and the applicant made no submissions as to why the unapproved portion of the proposed manipulation therapy, acupuncture therapy, travel time and 6 exercise sessions are reasonable and necessary, I find that the applicant has not met her burden to establish entitlement to the unapproved portion of this plan.
24I find that the applicant has not demonstrated on a balance of probabilities, that she is entitled to the unapproved portion of $3,394.46 of the December 12, 2023 plan, and the plan is not payable under section 38.
Is the plan dated April 30, 2024 for chiropractic services payable?
25I find that the applicant has not established that the April 30, 2024 plan is payable because the respondent’s denial notices were complaint with the Schedule.
26The plan dated April 30, 2024 for chiropractic services by Dr. Richard Tavares, chiropractor at UHeal Rehab Centre was submitted on May 2, 2024. The plan includes: 16 one-hour sessions manipulation therapy; 16 half-hour sessions exercise therapy; 16 one-hour sessions acupuncture therapy; assessment; and documentation support activity.
27The respondent wrote to the applicant on May 16, 2024, which is within 10 business days of receiving the plan as required by the Schedule. In the denial letter, the respondent provided medical reasons in a summary from Dr. Khan’s report including: no referrals to specialists; no new medical conditions; independent in all activities of daily living, including housekeeping, walking and playing with children; returned to driving; no missed time from work; 70% improvement in symptoms; and recommended a self-directed exercise program.
28The applicant submits that the May 16, 2024 letter was an improper denial because it has not provided medical and other reasons why it is not reasonable and necessary, and the plan is deemed reasonable and necessary. The applicant submits that the respondent may not rely on Dr. Khan’s report since it was obtained before the plan was submitted.
29The respondent submits that it provided medical and other reasons in its denial letter dated May 16, 2024, and the applicant has not provided any medical evidence in support that the disputed plan is reasonable and necessary. The respondent denied the benefits on May 16, 2024 on the basis that they are unreasonable and unnecessary.
30I find that the May 16, 2024 notice letter was complaint with s.38(8) of the Schedule. The respondent’s letter provides reasons for the denial by summarizing the IE report by Dr. Khan, which mentions that the applicant has not been referred to any specialists; there are no new medical conditions; she is independent in all her activities of daily living, including housekeeping, walking and playing with her children; she has returned to driving; she has not missed any time from work; there is a 70% improvement in her symptoms; and Dr. Khan recommended a self-directed exercise program. The respondent provided clear medical and other reasons in its notice to allow the applicant to make an informed decision as to whether to accept or dispute the decision.
31Given that the respondent provided proper notice and no submissions as to why this plan is reasonable and necessary, I find that the applicant has not met her burden to establish entitlement to this plan.
Interest
32Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since no benefits are owing, interest does not apply.
Award
33The 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. I find an award is not appropriate because the respondent did not unreasonably withhold payment as the denials were based on reasonable, objective assessments of the applicant.
ORDER
34For the reasons set out above, I find that:
i. The treatment plans in dispute for an outstanding amount for chiropractic services dated December 12, 2023, and for chiropractic services dated April 30, 2024 are not payable;
ii. The applicant is not entitled to interest or an award; and,
iii. The application is dismissed.
Released: March 9, 2026
Lisa Holland
Adjudicator