Licence Appeal Tribunal File Number: 24-005264/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:
Fan Yan
Applicant
and
Belair Insurance Company Inc.
Respondent
DECISION
ADJUDICATOR:
Nadia Mauro
APPEARANCES:
For the Applicant:
Sareena Samra, Counsel
For the Respondent:
Christine McKenna, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Fan Yan, the applicant, was involved in an automobile accident on March 14, 2021, 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, Belair Insurance Company Inc., and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
2A case conference was held on August 30, 2024, wherein the matter was scheduled for a videoconference hearing to begin on March 31, 2025, as one of the disputed issues was catastrophic impairment. The parties subsequently resolved the issue of whether the applicant sustained a catastrophic impairment (CAT).
3On February 20, 2025, the applicant filed a Notice of Motion requesting, on consent, that the Tribunal withdraw the catastrophic impairment issue and convert the videoconference hearing to a written hearing.
4By way of Motion Order dated February 24, 2025, the videoconference hearing was vacated, and the remaining issues were set to proceed via written hearing on April 30, 2025.
ISSUES
5The issues in dispute are:
i. Is the applicant entitled to the CAT assessments proposed by Somatic Assessments & Treatment Clinic in the amount of $5,411.04 ($14,750.81 less $9,339.77 approved) on a treatment plan (“OCF-18”) dated January 16, 2023?
ii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
iii. Is the applicant entitled to interest on any overdue payments of benefits?
6The applicant confirmed in his submissions that issues 1-8, 9(a)(b)(d), and 10-11, as listed on the Motion Order dated February 24, 2025, have been resolved. The remaining issues are as listed above.
RESULT
7The applicant is not entitled to the unapproved portion of the treatment plan, dated January 16, 2023, interest, and award.
ANALYSIS
The applicant is not entitled to the unapproved portions of the treatment plan
8I find that the applicant has not proven, on a balance of probabilities, that the unapproved portions of the treatment plan, dated January 16, 2023, are reasonable and necessary.
9To 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.
10The OCF-18, authored by occupational therapist, Mr. Raymond Wong of Somatic Assessments & Treatment Clinic Inc., dated January 16, 2023, was partially approved for several catastrophic assessments, as follows:
| Line | Description | Amount | Approved/Denied |
|---|---|---|---|
| 1. | Catastrophic determination assessment – physiatry assessment | $2,000.00 | Approved |
| 2. | Catastrophic determination assessment – OT assessment (In-Home) | $2,000.00 | Approved |
| 3. | Catastrophic determination assessment – Psychology Assessment | $2,000.00 | Approved |
| 4. | Catastrophic determination assessment – Clinic File Review Assessment by Dr. Joseph Siu-Wah Wong | $2,000.00 | Denied |
| 5. | Catastrophic determination assessment – Overall Assessment Summary, Analysis | $2,000.00 | Approved |
| 6. | Catastrophic determination assessment – Clinic File Review Assessment by Raymond Wong | $1,000.00 | Denied |
| 7. | Catastrophic determination assessment – Clinic File Review Assessment by Dr. Sedigheh Naisi | $1,000.00 | Denied |
| 8. | Documentation support activity for claim form (e.g. for insurance, third party payor, worker’s compensation) | $200.00 | Partially approved in the amount of $99.75 |
| 9. | Documentation support activity for claim form (e.g. for insurance, third party payor, worker’s compensation) | $200.00 | Approved |
| 10. | Interpretation Service | $200.00 | Denied |
| 11. | Claimant transportation to treatment | $400.00 | Denied |
| 12. | Claimant transportation to treatment | $112.81 | Denied |
11The applicant submits that the fees for the completion of the CAT assessment were reasonable and necessary given the severity of his physical and psychological symptoms that deem him catastrophic.
12The respondent submits that the denied portions of the OCF-18 are duplicative, redundant and exceed s. 25(5)(a) of the Schedule, which limits the cost of any one assessment or examination inclusive of the report to $2,000.00.
13The applicant has the onus to prove that the proposed services are reasonable and necessary, and in the present case, I find that the applicant has fallen short of meeting his burden.
14First, I agree with the respondent, in that a file review is not an assessment or evaluation, rather it is a summary of medical documentation. Section 25(5) of the Schedule specifies that the insurer is not obligated to pay more than a total of $2,000.00 with respect to fees and expenses for “conducting any one assessment or examination” and for preparing reports in connection with it. A file review is a necessary component of each assessment and is not an independently billable task. I also note that this is similar to the decision relied on by the applicant in Tetruashvili v Toronto Transit Commission, 2021 CanLII 134542 (ON LAT).
15Second, the applicant does not make submissions with respect to the reasonableness and necessity of the line items not approved within the OCF-18, such as the transportation expenses, the interpretation services, the unapproved portion of the documentation support activity for claim form, and HST. I am also not pointed to evidence that supports these line items, and their cost, are reasonable and necessary. I note that the respondent’s denial letter, dated February 1, 2023, requested the applicant submit any expenses incurred with respect to transportation and translation services on an expense claim form (OCF-6) for consideration. The applicant has not made submissions nor directs me to evidence to support this information was provided to the respondent. As such, I find that the applicant has fallen short of meeting his burden to prove that the interpretation, transportation, form completion charge, and HST are reasonable and necessary.
16Lastly, I am not bound by the Tribunal decisions relied upon by the applicant, however, I am persuaded by his reliance on [The Applicant] vs. Allstate Insurance, 2019 CanLII 101614 (ON LAT) wherein it was held that duplicated entries on the treatment plan were unreasonable, as there was no reasonable explanation for why the amount was more than allowable under the Professional Service Guidelines. In the present case, “documentation support activity” and “claimant transportation” are listed twice and the applicant has not made submissions or provided a reasonable explanation for these line items.
17Taken together, I find that the applicant has not proven, on a balance of probabilities, that the unapproved portion of the treatment plan is reasonable and necessary.
Interest
18As there are no overdue benefits, the applicant is not entitled to interest pursuant to s. 51 of the Schedule.
Award
19The 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.
20As there are no overdue benefits, the applicant is not entitled to an award.
ORDER
21I find that:
i. The applicant is not entitled to the unapproved portions of the OCF-18 for CAT assessments, dated January 16, 2023;
ii. The applicant is not entitled to interest pursuant to s. 51 of the Schedule;
iii. The respondent is not liable to pay an award; and
iv. The application is dismissed.
Released: April 17, 2026
Nadia Mauro
Adjudicator