Licence Appeal Tribunal File Number: 25-001160/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:
Yue Xu
Applicant
and
Aviva Insurance Company of Canada
Respondent
DECISION
ADJUDICATOR:
Nadia Mauro
APPEARANCES:
For the Applicant:
Ryan Olson, Paralegal
For the Respondent:
Nirvana Harripersad, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Yue Xu, the applicant, was involved in an automobile accident on February 6, 2024, 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, Aviva Insurance Company of Canada, 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 $5,286.46 for chiropractic services, proposed by Total Recovery Rehab Centre in a treatment plan (“OCF-18”) submitted May 29, 2024?
ii. Is the applicant entitled to $1,994.56 for psychological services, proposed by Somatic Assessments and Treatment Clinic in an OCF-18 submitted October 3, 2024?
iii. Is the applicant entitled to $1,316.46 ($4,150.56 less $2,834.10 approved) for psychological care, proposed by Somatic Assessments and Treatment Clinic in an OCF-18 submitted March 13, 2025?
iv. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
v. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant is not entitled to the treatment plans in dispute, interest, or an award.
ANALYSIS
Chiropractic Services
4I find that the applicant has not established on a balance of probabilities that the proposed treatment plan is reasonable and necessary.
5To 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.
6The OCF-18 completed by chiropractor, Dr. Georgia Palantzas, dated May 29, 2024, sought funding for the following:
i. Assessment (examination) total body, in the amount of $200.00;
ii. 16 sessions of manipulation, multiple body sites, in the amount of $1,804.96;
iii. 16 sessions of exercise, spinal vertebrae, in the amount of $902.56;
iv. 16 sessions of acupuncture, multiple body sites, in the amount of $1,805.12;
v. Provider travel time, provider to treatment, in the amount of $320.00; and
vi. Documentation support activity, in the amount of $235.82.
7The goals of the treatment plan seek to achieve pain reduction, increased range of motion, increase strength, to minimize compensatory strain, to return to activities of normal living, pre-accident work activities, modified work activities, and to promote soft tissue healing.
8The applicant submits that the treatment plan for chiropractic services is reasonable and necessary because the entirety of the medical documentation provided supports the need for said treatment, relying on the s. 25 psychological assessment report of Dr. Tulika Anand and Dr. Harinder Mrahar, dated September 30, 2024, the s. 44 psychological assessment report of Dr. Rakesh Ratti, dated August 14, 2024, and the s. 44 orthopaedic assessment report of Dr. Edwin Urovitz, dated August 1, 2024. The applicant further submits the goals of the treatment plan are reasonable given his ongoing physical impairments and noted improvements as a direct result of physical treatment. It is the applicant’s position that this shows that the goals are gradually being met to a reasonable degree.
9I agree with the respondent’s position that the “medical documentation” relied on by the applicant refers to subjective reports of physical pain and impairments made by the applicant to psychological assessors and Dr. Urovitz. I give little weight to the psychological assessment report of Dr. Anand and Dr. Mrahar with respect to the reasonableness and necessity of the proposed physical therapy treatment plan because these assessors do not opine on the need for the recommended physical therapy. Additionally, in my view, comment on the need and reasonableness for physical therapy would be beyond the scope of practice for a psychologist.
10The applicant has not pointed me to a medical opinion recommending the need for chiropractic or acupuncture therapy. Moreover, the applicant does not make submissions with respect to the other line items: assessment, document support activity, and provider travel time. In the absence of any other medical opinion or evidence that comments on the subject treatment plan, I place significant weight on the s. 44 report of Dr. Urovitz, as this assessor was asked to opine on the OCF-18 in dispute. Dr. Urovitz ultimately opines that, given the amount of treatment the applicant received coupled with the results of object testing completed during the assessment, the treatment plan was deemed not medically necessary and reasonable.
11Therefore, I find that the applicant has not established, on a balance of probabilities, that the proposed treatment is reasonable and necessary.
Psychological Treatment
12I find that the applicant has not established, on a balance of probabilities, that he is entitled to the unapproved portions of the treatment plans for psychological services.
13The OCF-18 dated October 2, 2024, completed by psychologist, Dr. Harinder Mrahar, sought funding for the following:
i. 16 sessions of therapy, mental heath and addiction, in the amount of $2,393.76 ($149.61/hour);
ii. 16 sessions of brokerage, services in the amount of $598.40;
iii. 16 sessions of planning, services in the amount of $598.40;
iv. Documentation, support activity in the amount of $360.00; and
v. Documentation support activity for claim form in the mount of $200.00
14The OCF-18 dated March 11, 2025, completed by psychologist, Dr. Harinder Mrahar, sought funding for the following:
i. 16 sessions of psychotherapy, in the amount of $2,393.76 ($149.61/hour);
ii. 16 sessions of communication with others in the amount of $598.40;
iii. 16 sessions of ongoing evaluation and modification in the amount of $598.40;
iv. Progress report in the amount of $360.00; and
v. Documentation support activity for claim form in the mount of $200.00
15The applicant’s position is that the entirety of the treatment plans for psychological services are reasonable and necessary, relying on the diagnosis of post-traumatic stress disorder, moderate depressive episode, and somatic symptom disorder (with predominant pain) by Dr. Mrahar and Dr. Ratti. The applicant submits that Ms. Wai Yan Liu, a registered psychotherapist, should be paid at the same hourly rate of a psychologist, $149.61, rather than the approved $99.75 per hour. The applicant submits this is because Ms. Liu is providing the same cognitive behavioural therapy (CBT) and psychotherapy services as a psychologist. The applicant also submits that he does not speak proficient English, Ms. Liu is able to speak the applicant’s first language, and this would negate the need for interpretive services, thus minimizing the treatment provided.
16The respondent submits that the OCF-18 dated October 2, 2024 was partially approved in the amount of $2,156.00. The respondent submits that the OCF-18 dated March 11, 2025 was partially approved in the amount of $2,834.10. The respondent further submits that it adjusted the hourly rate of $149.61 per hour to $99.75 per hour, which has been found to be a reasonable hourly rate for psychotherapists in prior Tribunal decisions.
17I am not bound by Tribunal decisions; however, I find that the cases relied on by both the applicant and respondent to be helpful in this matter given that the dispute is based on a quantum of services that is not explicitly prescribed by any legislation.
18The applicant relies on the Tribunal decision in A.S v Aviva Insurance Company, 2020 CanLII 12787 (ON LAT) (“A.S”), where it was held that the treating psychotherapist was performing the same services as a psychologist and was thus entitled to payment at the same rate of a psychologist at $149.61 per hour. However, I distinguish A.S. from the present case because although the applicant has submitted Ms. Liu would be providing CBT, submissions are not evidence. The applicant has not directed me to evidence that would support that, in this case, the applicant would be receiving equivalent treatment from a psychotherapist as she would from a psychologist warranting payment at the rate of a psychologist. In any event, I note that the OCF-18s do not specify the applicant will receive CBT, rather it is simply indicated that the applicant will undergo “psychotherapy”.
19I am persuaded by the respondent’s reliance on the Tribunal decision in Bowen v. Aviva Insurance Company, 2024 CanLII 23451 (ON LAT), wherein it was found that there was no evidence that the psychotherapist has specialized training within the area of the proposed treatment plan, nor that the psychotherapist’s experience warrants being paid an hourly rate similar to a psychologist or psychological associate. The applicant has not provided the credentials of the treating practitioners for the proposed treatment plans to confirm the range and breadth of their experience. More importantly, the applicant has not provided any of the treating practitioner’s credentials as it would relate to the proposed treatment plans.
20I accept the applicant’s argument the Ms. Liu speaks the same language as him and therefore negates the need for an interpreter. However, I am unpersuaded that this in some way establishes a psychotherapist should be paid at the same rate as a psychologist. Ms. Liu has the ability to provide psychotherapy services – regardless of whether she is remunerated at a higher rate – in either language. In my view, it would be contrary to the consumer protection mandate of the Schedule to administer therapy services at a higher fee solely because the service is provided in a different language.
21With respect to the quantum of services, the respondent relies on the Tribunal decision in Jindal v Novex Insurance Company, 2023 CanLII 87429 (ON LAT) where it was found that $99.75 was appropriate in comparable circumstances. As indicated above, I am not pointed to the qualifications of the treating practitioners in the present case. Given that the respondent has approved the treatment in this amount and the applicant has not put forward evidence that would support a higher payment in the circumstances, I find $149.61 to not be reasonable and necessary.
22The respondent also submits that the unapproved portions of the treatment plan, in addition to the discrepancy in the hourly rate of the treatment providers, related to brokerage services and planning services. The respondent submits that the applicant has not made any specific submissions on these portions of the OCF-18s and therefore has not met his onus to establish they are reasonable and necessary.
23The Professional Services Guideline (the “Guideline”) states that “insurers are not liable for any administration or other costs, overhead, fees, expenses, charges or surcharges that have the result of increasing the effective hourly rate, or the maximum fees payable for completing fees, beyond what is permitted under the [Guideline].” I agree with the respondent’s position that the brokerage services and planning services relate to professional services. The applicant has not provided any submissions or directed me to evidence as to why these services would not be captured in the hourly rate of the service provider. Therefore, I find these goods and services are not reasonable and necessary.
24Given the foregoing, I find that the applicant has not proven, on a balance of probabilities, that the unapproved portions of the treatment plans for psychological services are reasonable and necessary.
Interest
25As there are no overdue benefits, the applicant is not entitled to interest pursuant to s. 51 of the Schedule.
Award
26The 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.
27As no benefits were unreasonably withheld or delayed, the applicant is not entitled to an award.
ORDER
28I find that:
i. The applicant is not entitled to the OCF-18 for chiropractic services, dated May 29, 2024;
ii. The applicant is not entitled to the unapproved portions of the OCF-18 for psychological services, dated October 2, 2024;
iii. The applicant is not entitled to the unapproved portions of the OCF-18 for psychological services, dated March 11, 2025;
iv. The applicant is not entitled to interest pursuant to s. 51 of the Schedule;
v. The respondent is not liable to pay an award; and
vi. The application is dismissed.
Released: May 27, 2026
Nadia Mauro
Adjudicator