Licence Appeal Tribunal
Licence Appeal Tribunal File Number: 24-013352/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:
Huanyu Li
Applicant
and
Security National Insurance Company
Respondent
DECISION
VICE-CHAIR:
Julian DiBattista
APPEARANCES:
For the Applicant:
Rakesh Sharma, Counsel
For the Respondent:
Caleb Lee, Counsel
HEARD: In Writing
OVERVIEW
1Huanyu Li, the applicant, was involved in an automobile accident on December 20, 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, Security National Insurance Company, 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. Are the applicant's injuries predominantly minor as defined in s. 3 of the Schedule and therefore subject to treatment within the $3,500.00 Minor Injury Guideline limit ("MIG")?
ii. Is the applicant entitled to $399.50 for physiotherapy services, proposed by Atlas Physiotherapy & Health in a treatment plan/OCF-18 ("plan") dated October 14, 2023?
iii. Is the applicant entitled to $698.75 for physiotherapy services, proposed by Atlas Physiotherapy & Health in a plan dated October 14, 2023?
iv. Is the applicant entitled to $2,144.93 for a Psychological Assessment, proposed by Somatic Assessments & Treatment Clinic in a treatment plan dated December 23, 2024?
v. Is the applicant entitled to $45.00 for ambulance fee, submitted on a claim form (OCF-6) dated January 31, 2023?
vi. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
vii. Is the applicant entitled to interest on any overdue payment of benefits?
3Issues ii, iii and v above were withdrawn by the applicant in written submissions.
RESULT
4The applicant remains subject to the MIG.
5The applicant is not entitled to the treatment plan in dispute.
6The applicant is not entitled to interest or an award under s. 10 of Reg 664.
ANALYSIS
The applicant remains subject to the MIG
7I find the applicant remains within the MIG.
8The applicant submits that under s. 38(11) the respondent is precluded from taking the position that the applicant is within the MIG as they have failed to properly deny the treatment plan in dispute. However, I do not accept this submission because the Divisional Court's binding decision in Zheng, Cai v. Aviva Insurance Company of Canada, 2018 ONSC 5707 determined that the language in used in s. 38(11) refers to the specific treatment plan in question and does not impose a permanent prohibition with respect to whether the applicant is out of the MIG. In other words, an applicant is not removed from the MIG based on non-compliance with s. 38 of the Schedule.
9The applicant has not advanced any submissions which argue removal from the MIG on medical grounds.
10Therefore, I find that the applicant has not met their onus to prove they should be removed from the MIG.
Section 54 of the Schedule does not limit the respondent's ability to present its case
11The applicant in submissions refers to s. 54 of the Schedule. They submit that there is no onus to disprove the case made out by the respondent that is not based on the denial reasons served upon the applicant under s. 54 of the Schedule.
12Section 54 of the Schedule provides that if an insurer refuses to pay a benefit or reduces the amount of a benefit that a person is receiving, the insurer shall provide the person with a written notice advising the person of his or her right to dispute the refusal or reduction.
13I find that the applicant is attempting to assert that the respondent is not allowed to make new submissions in this hearing, that were not specifically noted in the respondent's denial letters of the benefits in dispute. The applicant has provided no authority to support this interpretation, nor do I find that it is remotely accurate based on a plain reading of the section. There is no indication in s. 54 of the Schedule that the respondent in a hearing before the Tribunal can only make submissions based on its denial letters or that it is not permitted to make new submissions. Rather, s. 54 simply requires an insurer provide a clear and unequivocal denial letter and advise the insured of their right to dispute the refusal. It says nothing about the respondent's right to make submissions at a hearing or that its submissions are confined to those contained in a denial letter.
14I find that the respondent has complied with s. 54 of the Schedule and provided the applicant with clear and unequivocal denials. It further advised the applicant of the right to dispute the refusal within these denials, as required by s. 54. I further find that the respondent is entitled to present its case as it sees fit, including submissions on its position and responses to the applicant's submissions and evidence.
The denial of a psychological assessment is compliant with s. 38(8)
15I find that the respondent's denial for the treatment plan in dispute is compliant with s. 38(8) of the Schedule as the respondent has denied the plans on the basis of the applicant's injuries falling within the minor injury guideline.
16Section 38(8) requires an insurer to inform an insured person, within 10 business days after it receives the treatment plan, of the medical and other reasons why it considered the goods and services not to be reasonable and necessary if it denies a plan. Pursuant to s. 38(11), if an insurer fails to comply with its obligations under section 38(8), it must pay for the goods and services that relate to the period starting on the 11th business day after the insurer received the application and ending on the day the insurer gives a notice described in s. 38(8) and it is prohibited from taking the position that the insured person has a impairment to which the MIG applies.
17The applicant submits that the denials for the treatment plan in dispute is not compliant with s. 38(8) as it does not contain specific references to medical conditions and simply cite the applicant's injuries as being within the definition of a minor injury.
18The respondent submits that the denial is compliant as it references the applicant's injuries falling within the minor injury guideline.
19I agree with the respondent. The denial letter of January 9, 2025 is compliant with section 38(8) of the Schedule because it identifies the plan and unequivocally denies funding for it. The denial also indicates that the respondent believes the MIG, which has a medical definition under the Schedule, applies to the applicant's claims.
20In other words, standing within the MIG is a medical reason as it indicates that the applicant's impairments are minor, which is a medical definition in the Schedule.
21As the denial letter is compliant with s. 38(8), I find that the treatment plan is not payable under s. 38(11).
Section 38(3) does not force the insurer to approve any plan by a regulated health practitioner
22The applicant submits that the plan was submitted by a regulated health professional in compliance with s. 38(3) of the Schedule and should therefore be deemed reasonable and necessary.
23The applicant further submits that as the plan was completed by a regulated health practitioner. Therefore, the adjuster, who is not a regulated health practitioner does not have standing to deny the plan.
24I note that s. 38(3) states the criteria for completing a treatment and assessment plan. However, to 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.
25In this case, the applicant has not submitted medical evidence in support of the plan. The applicant has also submitted no authorities to support a finding of entitlement to the treatment plan on the basis plan being compliant with s. 38(3).
26Therefore, I find that the applicant has not proven entitlement to the disputed treatment plan.
Interest
27Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no benefits are overdue, there is no entitlement to interest.
Award
28The 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.
29As there is no benefit that has been withheld, there is no entitlement to an award under s.10 of Reg 664.
ORDER
30For the reasons above, I find that:
i. The applicant remains within the MIG;
ii. The applicant is not entitled to the sole treatment plan in dispute; and
iii. The applicant is not entitled to interest or an award under s. 10 of Reg 664.
31This application is dismissed.
Released: April 14, 2026
Julian DiBattista
Vice-Chair