Licence Appeal Tribunal File Number: 24-003648/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:
Jimei Qu
Applicant
and
Co-operators General Insurance Company
Respondent
DECISION
ADJUDICATOR: Kathleen Wells
APPEARANCES:
For the Applicant: Rakesh Sharma, Counsel
For the Respondent: Nathalie Rosenthall, Counsel
HEARD: By way of written submissions
OVERVIEW
1Jimei Qu, the applicant, was involved in an automobile accident on June 19, 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.
ISSUES
2The issues in dispute are:
- 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 (“MIG”) limit?
- Is the applicant entitled to a non-earner benefit (“NEB”) of $185.00 per week from July 14, 2023 to June 19, 2025?
- Is the applicant entitled to $200.00 ($1,300.00 less $1,100.00 approved) for physiotherapy services, proposed by Total recovery Rehab Centre in a treatment plan/OCF-18 (“treatment plan”) submitted August 15, 2023?
- Is the applicant entitled to $2,144.93 for a psychological assessment, proposed by Somatic Assessments and Treatment Clinic in a treatment plan submitted February 5, 2024?
- Is the applicant entitled to $4,069.56 for physiotherapy services, proposed by Total Recovery Rehab Centre in a treatment plan submitted April 23, 2024?
- Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
- Is the applicant entitled to interest on any overdue payment of benefits?
3The applicant submits that the issue # 5 as set out in the Case Conference Report and Order (“CCRO”) for an OCF-6 for $45.00 for an ambulance fee has been resolved. As such, I have removed it as an issue in dispute.
RESULT
4I find that:
- The applicant remains subject to the MIG and its $3,500.00 funding limit.
- An NEB of $185.00 per week is payable from August 23, 2023 to October 18, 2023 in accordance with s. 36(5) of the Schedule.
- As I have found that the applicant is subject to the MIG, it is not necessary for me to consider whether the treatment plans in dispute are reasonable and necessary.
- The remaining balance of $200.00 for physiotherapy services in the treatment plan submitted August 13, 2023 is not payable under s. 38(11) of the Schedule.
- The treatment plan for $ 2,144.93 for a psychological assessment dated February 5, 2024 is payable under s. 38(11) of the Schedule.
- The treatment plan for $4,069.56 for