Licence Appeal Tribunal File Number: 25-000884/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:
Christina Semenya
Applicant
and
Belair Insurance Company Inc.
Respondent
DECISION
ADJUDICATOR: Melanie Malach
APPEARANCES:
For the Applicant: Roger R. Foisy, Counsel Rusald Laloshi, Paralegal
For the Respondent: Itse Ezomo, Counsel
HEARD: By way of written submissions
OVERVIEW
1Christina Semenya, the applicant, was involved in an automobile accident on July 30, 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, Belair Insurance Company Inc., 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 $781.54 ($1,679.29 less $897.75 approved) for an in-home occupational therapy examination, proposed by FunctionAbility Rehabilitation Services Inc., in a treatment plan dated January 10, 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 payment of benefits?
RESULT
3I find that the applicant is partially entitled to the balance of the OCF-18 in dispute in the amount of $598.50, plus interest payable pursuant to s. 51 of the Schedule.
4I find that the respondent is not liable to pay an award.
PROCEDURAL ISSUES
Exhaustion of Available Medical and Rehabilitation Limits
5Section 18(3)(a) of the Schedule provides that the sum of the medical, rehabilitation and attendant care benefits paid in respect of an insured person who is not subject to the financial limit of the Minor Injury Guideline, shall not exceed $65,000.00 for any one accident.
6The respondent submits that the applicant has exhausted the available funding for non-catastrophic medical and rehabilitation benefits under s. 18(3)(a) of the Schedule. The respondent’s letter to the applicant dated September 18, 2024, confirms that the total of payments or approvals made as of September 16, 2024, is $69,094.57. The respondent therefore submits that where there are no remaining funds available to the applicant, unless she is deemed catastrophically impaired, it follows that the Tribunal has no jurisdiction to order payment of the treatment plan in dispute.
7The applicant submits that based on the Standard Benefit Statement, dated July 2, 2025, only $62,988.26 has been paid to date. This leaves $2,011.74 remaining within the $65,000.00 medical/rehabilitation/attendant care limit under s. 18 of the Schedule, which would cover the $781.54 presently at issue.
8I find that there is no evidence before me that the total funding limit of $65,000.00 has been paid by the respondent. However, even if the funding limit has been reached, I find that there is nothing in the Schedule that prevents the applicant from disputing a treatment plan even if the funding limits have been exhausted. The Tribunal’s jurisdiction to determine disputes over entitlement stems from s. 280 of the Insurance Act, RSO 1990, c. I.8. Section 280 provides that an insured person or the insurer may apply to the Tribunal to resolve a dispute in respect of an insured person’s entitlement to statutory accident benefits or in respect of the amount of statutory accident benefits to which an insured person is entitled. In this matter, the applicant has made an application about her entitlement to the balance of a disputed treatment plan. Accordingly, I will decide the issue of entitlement on the disputed treatment plan.
ANALYSIS
Entitlement to the Balance of the Treatment Plan for an In-Home Occupational Therapy Assessment
9The applicant claims entitlement to the balance of the treatment plan (“OCF-18”) dated January 10, 2023, proposed by FunctionAbility Rehabilitation Services Inc., recommending an in-home occupational therapy examination report in the amount of $1,679.29. The OCF-18 recommends the following:
Line 1 – Documentation, support activity for claim form: $200.00 Line 2 – In-Home Assessment session – 3 hours: $299.25 Line 3 – Provider travel time, provider to treatment: $82.79 Line 4 – Documentation (Initial Report) – 9 hours: $897.75 Line 5 – Brokerage, service – 2 hours: $199.50
10By correspondence dated January 23, 2023, the respondent partially approved the OCF-18 in the amount of $897.75. The following was denied by the respondent:
Line 1 – Documentation, support activity for claim form: denied $100.25 Line 3 – Provider travel time, provider to treatment: denied $82.79 Line 4 – Documentation (Initial Report) – 9 hours: denied $598.50
Documentation, support activity for claim form
11The applicant is not entitled to the balance of $100.25 for the completion of the OCF-18 form.
12The Professional Services Guideline – Superintendent’s Guideline No. 03/14 (“the Guideline”), provides that $200.00 is the maximum fee for completion of an OCF-18 form.
13The OCF-18 in dispute claims $200.00 for the cost of preparing the OCF-18 form. The respondent approved one hour for completion of the OCF-18 form in the amount of $99.75 and denied the balance of $100.25.
14The applicant submits that the initial documentation line captures initial file setup and plan preparation (gathering client/insurer information, intake call, drafting, sending for signature, follow-ups). The applicant claims that the content of the OCF-18, including the drafting of a detailed “Additional Comments” section, reflects that work. The applicant argues that nothing in the respondent’s decision explains why that proposed preparation time was limited to one hour.
15The respondent submits that $200.00 is the standard amount for an OCF-18 form completion, but it is not automatically payable. The respondent submits that it approved one hour for the service provider to complete the OCF-18 form which was $99.75. The respondent submits that in its January 23, 2023 correspondence, it indicated that: “Please discuss with your service provider and have them submit further details or support explaining why such time for documentation is required”. The respondent argues that the service provider did not subsequently address this issue or provide the details requested to support why the completion of the OCF-18 form required more than the one hour approved. The respondent further submits that in reference to the “Additional Comments” portion of the OCF-18, aside from the paragraph referring to “Client Concerns” and the introductory sentence prior to it, the remainder of the comments are generic in nature and unrelated to the applicant. The respondent therefore submits that the additional amount of time to complete the OCF-18 form has not been proven to be reasonable and necessary.
16I find that while the $200.00 fee for completion of an OCF-18 is the maximum permitted under the Guideline, it is not automatically payable, and the onus is on the applicant to prove that she is entitled to the full $200.00.
17I find that the respondent in its letter dated January 23, 2023, requested further particulars from the provider as to why it needed more than one hour to complete the OCF-18. Upon review of the correspondence from the provider dated January 10, 2023 and January 12, 2023, there is no mention of the time required to complete the OCF-18. I therefore find that the applicant’s provider did not respond to the respondent’s request for further particulars regarding the completion time for the OCF-18.
18The applicant argues that the OCF-18 took longer to complete because of gathering client/insurer information, the intake call, drafting, sending for signature, and follow-ups. She further submits that the OCF-18 took longer to complete because of the detailed “Additional Comments” section. I find that there are no further particulars provided from the applicant as to how long each of these components took or the level of complexity in this matter that would require more time to complete the OCF-18 form. Upon review of the “Additional Comments” portion of the OCF-18, I agree with the respondent that there is a single paragraph about the “Client Concerns” and the remainder of the comments are generic. There is insufficient evidence to support that drafting the “Additional Comments” portion of the OCF-18 form took an extended amount of time. I therefore do not find that the applicant has met her onus of proving that the OCF-18 form took longer than one hour to complete.
19For the reasons outlined above, I find that the applicant has not proven on a balance of probabilities that she is entitled to the balance of $100.25 for completion of the OCF-18 form.
Provider travel time, provider to treatment
20The applicant is not entitled to the “provider travel time, provider to treatment” expense claimed in the OCF-18 in dispute.
21Section 15(2)(c) of the Schedule provides that an insurer is not liable to pay medical benefits for transportation expenses other than authorized transportation expenses. Section 3(1) of the Schedule defines “authorized transportation expenses” as expenses related to transportation (a) that are authorized by, and calculated by applying the rates set out in the most recent transportation expenses guideline published by the Financial Services Regulatory Authority (“FSRA”) of Ontario, and (b) that unless the insured person sustained a catastrophic impairment as a result of the accident, relate to transportation expenses incurred only after the 50 kilometres of a trip.
22The applicant claims entitlement to $82.79 for “provider travel time, provider to treatment”, claimed in the OCF-18 in dispute.
23The applicant submits that the respondent’s reliance on the Transportation Expense Guideline, conflates insured-person travel (mileage/parking) with provider travel time required as part of an in-home examination. The applicant submits that where an insurer accepts that the in-home format of an assessment is reasonable, the associated professional travel time is a component of the s. 25(1) examination cost and is payable at the applicable Guideline rate, as long as it does not exceed the $2,000.00 cap for such an examination. The applicant relies on the FSRA directive and the FSRA Announcement, issued July 29, 2025, that the expense is payable at the Guideline rate for the professional time spent on services rendered for the insured.
24The respondent submits that the applicant has not provided a reasonable explanation as to why the attending service provider would require travel time to the assessment above regular business practice. The applicant relies upon the Tribunal decision in Witkowski v. Belair Direct Insurance, 2024 CanLII 112992 (ON LAT) (“Witkowski”), where the Tribunal stated that in accordance with s. 15(2)(c) of the Schedule, provider time is not a payable benefit under the Schedule unless it is an authorized transportation expense.
25The applicant in her reply submissions submits that the decision in Witkowski is distinguishable as the applicant in that matter sought “travel time” during their treatment sessions in addition to the social worker’s hourly session rate, which was already approved for exposure therapy sessions. The $75.00 claimed for “travel time” during exposure therapy was an additional fee for the same time being spent which is a duplicity in these claims. The applicant relies upon the Tribunal decisions in Vila v. Aviva Insurance Company, 2023 CanLII 50529 (ON LAT); Butler v. Allstate Insurance, 2021 CanLII 28679 (ON LAT), and Soto v. Pembridge, 2025 CanLII 5881 (ON LAT), which ordered travel time as a payable expense under the Schedule, as long the proposed services are reasonable and necessary.
26I find that the respondent’s letter dated January 23, 2023, denied the cost of “provider travel time, provider to treatment” for the following reasons:
We are unable to consider funding for the provider travel time as no reasonable explanation has been specified as to why the attending service provider would require travel time to the treatment sessions(s) above regular business practice.
27I agree with the applicant that the respondent has approved an In-Home Assessment that would require the provider to travel to her home. However, the applicant has not provided a reasonable explanation as to why the provider’s time for travel would be above regular business practice. I find that the provider travelling to the insured’s home to perform an in-home assessment is a component of the actual assessment performed, which was approved, and is therefore part of the regular business practice of performing this type of assessment. I therefore find that the applicant has not met her onus of proving that “provider travel time, provider to treatment” is a payable benefit under the Schedule as it is not an authorized transportation expense.
28I note that I am not bound by previous Tribunal decisions. Upon review of the Tribunal cases relied upon by both parties, I find that the fact scenarios are unique to each matter and are distinguishable from the matter before me based on the circumstances of the insureds and the type of treatment proposed in the OCF-18s in dispute. I therefore give no weight to these decisions in reaching my decision in this matter.
29For the reasons outlined above, I find that the applicant has not proven on a balance of probabilities that she is entitled to $82.79 for the cost of “provider travel time, provider to treatment”.
Documentation (Initial Report)
30The applicant is entitled to the balance of the cost of providing “documentation (initial report)” claimed in the OCF-18 in dispute.
31The applicant claims entitlement to $598.50 for the balance of the cost of providing “documentation (initial report)” in the treatment plan in dispute. The respondent approved $299.25 of the $897.75 claimed.
32The applicant claims nine hours for completion of the Documentation (initial report), estimating the preparation of the Form 1 to be one hour and preparation of the report to be eight hours. The applicant submits that the occupational therapist delivered a 29-page assessment report and prepared a five-page Form 1. The applicant argues that upon a reasonable review, the volume of charting and standard outputs (Form 1, assessment narrative, testing, scoring, analysis and formulation of recommendations) readily aligns with the proposed documentation time. The applicant further argues that the total cost of the OCF-18 is far below the $2,000.00 cap permitted under s. 25 of the Schedule, which supports that the provider is not requesting an unreasonable amount of time for provision of the assessment and the report. The applicant further submits that the respondent’s denial gave no medical or task-based rationale for finding that nine hours was “excessive”.
33The applicant submits that the provider by letter to the respondent dated January 12, 2023, provided a further explanation for the requirement of 9 hours for the documentation time. The provider advises that the documentation expense is for the completion of the initial assessment report which is a detailed report after the assessment. The provider states that the 9 hours for this report is based on the industry standard for documentation. The provider refers to the College of Occupational Therapist’s Standards for Record Keeping.
34The respondent approved three hours ($299.25) of the nine hours ($897.75) claimed for “Documentation (initial report)” in the subject OCF-18. The respondent acknowledges that the assessment report provides a comprehensive overview but submits that the Form 1 prepared entails the entry of hours and numbers obtained from the main assessment report. The respondent argues that the hours approved under this OCF-18 were sufficient for the services provided.
35The applicant in her Reply submissions submits that the respondent has offered no task-based or clinical reasons why the hours proposed are unreasonable, providing bare conclusions completely detached from the work product the respondent relied upon including the Occupational Therapist’s report and the approved Form 1. The applicant submits that the Form 1 is 5-7 pages in length and requires detailed entries, calculations and computations to complete within the one hour proposed for its completion.
36I find that neither party has pointed the Tribunal to any authorities which support the amount of time that should be ordered to complete an In-Home Assessment report and Form 1. As such, I am relying on my review of the actual report completed and an analysis of the amount of detail and thoroughness of the report itself.
37I find that the respondent has not provided any explanation or justification for approving three hours to complete this report. Upon review of the In-Home Assessment report prepared by FunctionAbility, I find that the total report is 29 pages in length. Within those 29 pages, there is a detailed assessment provided including a summary of the findings; the findings of the occupational therapy assessment including background information, subjective reports, objective findings and observations, functional impact, attendant care assessment, housekeeping and home maintenance assessment; and a conclusion. The contents of this report are extremely detailed and thorough. I find that it is clear that this report would have taken more than the three hours approved by the respondent and it was reasonable for the provider to request eight hours for completion.
38I further find that the provider’s estimate that the Form 1 would take one hour to complete is reasonable. I agree with the applicant’s argument that completion of a Form 1 requires more time and detail than completion of an OCF-18 which the respondent agreed would take one hour to complete. I find this comparison made by the applicant to be logical when considering the time it would take to make individual calculations for attendant care services on the Form 1. I accept the applicant’s submissions that the Form 1 is not simply inputting numbers, but requires detailed entries, calculations and computations.
39For the reasons outlined above, I find that the applicant is entitled to $598.50 for the balance of the cost of providing “documentation (initial report) in the treatment plan in dispute.
Interest
40Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As I have found that the applicant is entitled to the balance of $598.50 of the OCF-18, dated January 10, 2023, interest is payable on the overdue amount in accordance with s. 51 of the Schedule.
Award
41The applicant sought an award under s. 10 of Reg. 664. Under s. 10, the Tribunal may grant an award of up to 50 percent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits.
42The applicant claims that she is entitled to an award based on concerns regarding the adequacy of the respondent’s reasons in denying the treatment plan in dispute; unreasonable use of Independent Medical Evaluation assessors; failure to consider records; and privacy compliance.
43The applicant submits that the correspondence in this matter shows a pattern of adjustment that was stubborn and needlessly protracted, resulting in the ongoing withholding of the balance of the treatment plan in dispute. The applicant submits that at the outset of her counsel’s retainer, the respondent did not timely produce the Accident Benefits file, delivered an incomplete copy, and did not engage in substantive reassessment when further particulars were provided. The applicant argues that this conduct is inconsistent with the duty to adjust fairly and promptly.
44The applicant submits that on April 1, 2024, a claims manager of the respondent, advised that multiple partial approvals and denials on the file would be overturned following a review of the claim. He also committed that the respondent would “review medical documents on file, should we be missing documents to make a supporting decision - before proceeding to IE, insurer should request missing medical documents before proceeding to an IE.” The applicant argues that despite this agreement, the denial of the OCF-18 in dispute was not re-reviewed or re-adjusted by the respondent.
45The applicant further submits that the communications with the respondent reflects ongoing adjustment problems, a failure to request/review/consider relevant medical information, failure to apply rationality to claims handling, stubborn responses to reasonable requests, and repeatedly ignoring communication, with very little explanation offered in response to repeated inquiries for rationale. The applicant argues that taken together these communications support a finding that the respondent’s behaviour and handling of this matter do not lead to the conclusion that the respondent simply made an error.
46The applicant submits that the totality of the respondent’s conduct satisfies the unreasonably withheld or delayed threshold under s. 10 of the Schedule. The applicant seeks a meaningful and proportionate lump-sum award, within the 50% ceiling calculated using the method summarized in Ross v. Aviva General Insurance, 2024 CanLII 43457 (ON LAT). She further seeks interest at 2% per month, compounded monthly on the award.
47The respondent submits that the Tribunal has confirmed that the conduct to attract an award must rise above being an incorrect decision and “excessive, imprudent, stubborn, inflexible, unyielding or immoderate”. The respondent submits that any partial approval of the treatment plan in dispute was not maintained in bad faith. The respondent argues that as of September 2024, it had approved benefits up to and in excess of the non-CAT limits which is not evidence of an insurer purposely withholding benefits. The respondent submits that no benefits were unreasonably withheld or delayed and as such no award is payable.
48I find that specifically with respect to the OCF-18 in dispute, the respondent had reasonable grounds to partially approve the treatment plan in dispute. This is supported by the fact that I have found that the applicant is only partially entitled to the balance of the OCF-18 in dispute with only the disputed “Documentation (initial report)” being found reasonable and necessary. I find that the applicant has not provided sufficient evidence to support that this OCF-18 should have been reconsidered by the respondent and that its decision be reversed. Insurers are entitled to make errors and are not held to a standard of perfection. I do not find that the applicant has proved on a balance of probabilities that the respondent unreasonably withheld or delayed the payment of the balance of this OCF-18.
49With respect to the applicant’s submissions about the handling of the claim as a whole, the entire accident benefits file has not been provided for my review and therefore I am not privy to all of the deficiencies and conduct alleged by the applicant. Based on the Standard Benefit Statement, dated July 2, 2025, the respondent has paid a total of $62,988.26 in benefits which supports that the file has been adjusted, and a considerable amount of benefits have been paid. I therefore find that the applicant has not provided sufficient evidence to support that the respondent acted “excessive, imprudent, stubborn, inflexible, unyielding or immoderate”.
50For the reasons outlined above, I find that the applicant has not proven on a balance of probabilities that she is entitled to an award.
ORDER
51For the reasons outlined above, I find;
i. The applicant is partially entitled to the balance of the OCF-18 in dispute in the amount of $598.50, plus interest payable pursuant to s. 51 of the Schedule; and
ii. The respondent is not liable to pay an award.
Released: June 10, 2026
Melanie Malach
Adjudicator```