Licence Appeal Tribunal File Number: 24-014152/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:
Angela Jeffrey
Applicant
and
Co-operators General Insurance Company
Respondent
DECISION
VICE-CHAIR:
Robert Maich
APPEARANCES:
For the Applicant:
Aleksa Pace, Counsel
Anthony Gullo, Counsel
For the Respondent:
Bruce Keay, Counsel
HEARD: In Writing
OVERVIEW
1Angela Jeffrey, the applicant, was involved in an automobile accident on July 14, 2017, 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.
2The application was ordered to a nine day oral video conference hearing by Case Conference Report and Order ("CCRO") dated March 17, 2025. Subsequent to the case conference the issue of catastrophic impairment was no longer in dispute. A consent motion was brought by the applicant resulting in a Motion Order ("MO") dated September 5, 2025 directing the remaining issues in dispute to be heard by way of a written hearing.
ISSUES
3The issues in dispute are:
Is the applicant entitled to attendant care benefits ("ACB") in the amount of $171.57 ($591.87 less $420.30 approved) per month from April 24, 2023 to July 24, 2023?
Is the applicant entitled to ACB in the amount of $591.87 per month from July 26, 2023 to date and ongoing?
Is the applicant entitled to social worker counselling in the amount of $5,052.55 ($6,725.00 less $1,672.45 approved) submitted November 7, 2022?
Is the applicant entitled to social worker counselling in the amount of $5,052.55 ($6,725.00 less $1,6725.00 approved) submitted January 20, 2023?
Is the applicant entitled to occupational therapy services in the amount of $4,154.00 submitted February 8, 2023?
Is the applicant entitled to assistive devices in the amount of $11,101.43 submitted February 23, 2024?
Is the applicant entitled to social rehab counselling in the amount of $21,223.66 ($22,801 less $1,577.34 approved) submitted March 7, 2023?
Is the applicant entitled to medical services in the amount of $3,264.57 submitted June 6, 2023?
Is the applicant entitled to $18,233.00 for a catastrophic impairment assessment, submitted June 8, 2023?
Is the applicant entitled to mileage expense reimbursement in the amount of $2,740.00 from June 9, 2023 and ongoing?
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?
RESULT
4The applicant is not entitled to ACB in the amount of $171.57 ($591.87 less $420.30 approved) per month from April 24, 2023 to July 24, 2023.
5The applicant is entitled to ACB in the amount of $420.30 per month from July 26, 2023 to date.
6The applicant is not entitled to social worker counselling in the additional amount of $5,052.55 in a plan submitted November 7, 2022.
7The applicant is not entitled to social worker counselling in the additional amount of $5,025.55 in a plan submitted January 20, 2023.
8The applicant is entitled to occupational therapy services in the amount of $798.00 in a plan submitted February 8, 2023.
9The applicant is entitled to assistive devices in the partial amount of $5,628.84 in a plan submitted February 23, 2024.
10The applicant is not entitled to social rehab counselling in the amount of $21,223.66 ($22,801 less $1,577.34 approved) in a plan submitted March 7, 2023.
11The applicant is entitled to medical services in the amount of $3,264.57 proposed in a plan submitted June 6, 2023.
12The applicant is entitled to $4,000.00 for a catastrophic impairment assessment, in a plan submitted June 8, 2023.
13The applicant is not entitled to mileage expense reimbursement in the amount of $2,740.00 from June 9, 2023 to date.
14The respondent is not liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant.
15The applicant is entitled to interest on any overdue payment of benefits.
ANALYSIS
ACB
16Section 19 of the Schedule states that an insurer shall pay for all reasonable and necessary expenses incurred by or on behalf of an insured person as a result of an accident for attendant care services provided by an aide or attendant. The amount of a monthly ACB is determined in accordance with the approved version of the document entitled Assessment of Attendant Care Needs ("Form 1") that is required to be submitted under s. 42. ACB's are only payable for non-minor injuries. The maximum payable for ACB under the Schedule is $3,000.00 per month for non-catastrophically impaired insured persons, and $6,000.00 per month for catastrophically impaired insured persons.
Is the applicant entitled to ACB in the amount of $171.57 ($591.87 less $420.30 approved) per month from April 24, 2023 to July 24, 2023? And is the applicant entitled to ACB in the amount of $591.87 per month from July 26, 2023 to date and ongoing?
17The applicant is not entitled to ACB in the amount of $171.57 per month from April 24, 2023 to July 24 2023 and the applicant is entitled to ACB in the amount of $420.30 per month from July 26, 2023 to date.
18The applicant submits she is entitled to ACB of $591.87 per month from January 31, 2023 to date and ongoing based upon the Form-1 completed by M. Landry, occupational therapist ("OT") dated January 31, 2023.
19The applicant also submits the respondent partially approved said Form-1 in the amount of $420.30. On July 25, 2023, the respondent subsequently denied the Form-1 in full following an insurer In-Home Assessment by K. Berardi, OT, dated July 19, 2023 ("Berardi report").
20The applicant further submits the In-Home Activities of Daily Living Assessment by M. Landry, OT, dated January 31, 2023 ("Landry report"), indicates that the Ms. Jeffrey requires assistance with shaving, toenails, preparing serving and feeding meals, cleaning tub shower and sink, bedding, ensuring comfort safety and security in the bedroom, and maintenance of supplies and equipment.
21The applicant submits that the insurer's Berardi report is inconsistent with the assessor's own observations. Specifically, K Berardi observed: "Ms. Jeffrey's low tolerance for activity secondary to pain does impact her engagement in these tasks", "She lacks the tolerance to complete a thorough cleaning of the bathroom" and "Changing the bed linen is difficult secondary to pain in the upper extremities." The applicant submits the Berardi report conclusion that no ACB is needed is not supported by the evidence reviewed in the Berardi report; to the contrary the observations in the Berardi report clearly establishes functional limitation in personal care and housekeeping tasks as well as assistance to ensure the applicant's safety.
22The applicant further submits the denial of ACB by the respondent has forced the applicant to rely on publicly funded providers such as Home and Community Care Support Services ("HCCSS"). The applicant relies on a letter from HCCSS dated September 27, 2023, stating the applicant requires ACB and corroborates the Form 1 by M. Landry.
23In addition, the applicant submits ACB is supported by the respondent's CAT Assessment by Dr. Joseph, psychiatrist, dated March 25, 2025 ("Joseph report") who opined the applicant sustained a class 3 or moderate impairment in activities of daily living in including personal care.
24The respondent submits the applicant's ACB Form-1 included emotional support that is not an insured benefit under the Schedule. The respondent relies upon the case of M.G. v Economical, 2012 ONFSCDRS 153, wherein the Tribunal concluded that "ensuring a person's emotional wellbeing and providing emotional support are helpful for rehab purposes, but I do not agree that they are appropriate uses of the type of attendant care services intended in the Form 1." The respondent submits it accordingly reduced the approved benefit to $420.30 to exclude the emotional support component in the Form-1. The respondent also submits it approved $420.30 per month by letter dated February 13, 2023, however the applicant never incurred this expense and has never submitted any claims for ACB to the insurer subsequent to that approval.
25The respondent also submits in addition to the Berardi report it relies upon the In-Home Assessment by N. Livadas dated July 22, 2021 ("Livadas report") which found the applicant did not require ACB for her personal care including hygiene and feeding.
26In respect to the Berardi report, the respondent denies the applicant's suggestion of inconsistency and submits the assessor's observations were based upon the applicant's movements throughout her home during the assessment noting she was independent with respect to medication management, she is able to prepare meals as required, though she may have some pain and fatigue as a result, she was independent with driving over short distances, and no significant concerns were identified with respect to shopping for groceries, running errands, attending appointments in town, or managing her finances.
27Further the respondents submits the applicant has a significant pre-accident medical history including a 2004 accident resulting in life long injuries to her neck and back and a cervical fracture. In addition, a Disability Tax Credit Form signed by her family physician in September, 2017 indicated that she has been disabled since 2014 due to significant restrictions.
28I have reviewed the Landry report and find it based upon a review of the applicant's medical history, interview and objective testing and accordingly assign it significant weight. I have also reviewed the respondent's response dated February 13, 2023 and find the reductions in ACB of $171.57 due to areas being referenced to emotional support to be an accurate assessment within the caselaw. Accordingly, I find the ACB benefit of $420.30 as of the claimed date to be reasonable and necessary.
29I have reviewed the Berardi report and find it does include inconsistencies with its conclusions in that the observed function of the applicant does not match the recommendations and conclusions; accordingly, I assign the Berardi report less weight. I have also reviewed the Livadas report and find it includes the similar inconsistencies between observed function and recommendations; accordingly, I assign the Livadas report less weight.
30Given the weight assigned to the respective reports I find there is no medical evidence to vary the ACB of $420.30 to date. However, I find no evidence to support the applicant's submission that the ACB need is ongoing and find the applicant did not meet her onus.
31I find the submissions of the applicant to be persuasive in part and find she is entitled to ACB in the amount of $420.30 from April 24, 2023 to date.
Legal Test
32To 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.
Is the applicant entitled to social worker counselling in the amount of $5,052.55 ($6,725.00 less $1,672.45 approved) submitted November 7, 2022? And is the applicant entitled to social worker counselling in the amount of $5,052.55 ($6,725.00 less $1,6725.00 approved) submitted January 20, 2023?
33The applicant is not entitled to $5,052.55 for the treatment plan submitted November 7, 2022 and not entitled to $5,052.55 for the treatment plan submitted January 10, 2023
34The applicant submits the goals of the treatment plan submitted November 7, 2022 are: pain reduction, to provide counselling and emotional support to address barriers to her limitations since the accident, to assist with client pain management, difficulty sleeping, and loss of employment. The respondent partially approved the plan on November 21, 2022, in the amount of $1,672.45. Line 1, 2, 5, and 6 were approved up to hourly rate of $91.43 consistent with the FSCO Guideline, however, the applicant also submits no medical and any other reasons were provided as to why the time allotted for Lines 1, 2, and 5 were excessive, as required by s. 38(8) making them payable under s. 38(11). Further, that the respondent's blanket refusal to deny Line 4 for provider travel time ignores the applicant's actual circumstances and effectively denies her access to treatment, contrary to the Schedule.
35The applicant further submits that she experienced significant psychological impairments as a result of the accident. The respondent's assessor, Dr. Tsang, psychiatrist, diagnosed her with the following as a result of the accident: post-traumatic stress disorder (PTSD"); somatic symptom disorder ("SSD") with predominant pain, persistent, severe; and anxiety disorder. In addition, the respondent's assessor, Dr. Joseph, psychiatrist, diagnosed the applicant with the following: SSD, predominant pain, moderate severity (partially as a result of the accident); adjustment disorder ("AD"), depressed type (as a result of the accident); possible persistent depressive disorder with anxious distress (as a result of the accident). Dr. Joseph further opined that the applicant suffers from a 15% Whole Person Impairment ("WPI") for a psychological perspective, a class 3 moderate impairment in activities of daily living, social functioning, and adaptation, and a class 2–3 mild to moderate impairment in concentration, persistence, and pace ("CCP").
36The applicant submits the medical evidence from the respondent's assessors confirm that the applicant's psychological injuries are severe, ongoing, and causally related to the accident; further the treatment plan for social worker counselling directly addresses the conditions diagnosed by both Dr. Tsang and Dr. Joseph.
37The applicant also submits the treatment plan submitted January 20, 2023 with the same treatment goals as the November 7, 2022 plan, was partially approved by the respondent in the amount of $1,672.00 for the same reasons. The applicant repeats the same submissions of the plan of November 7, 2022 for the plan of January 20, 2023.
38The respondent submits the denial letter of November 21, 2022 noted that the treatment plan submitted November 7, 2022 claimed 1.5 hour counselling sessions at $150.00 per hour which were approved for one hour sessions at $91.43 per hour; the respondent noted that social workers do not appear as regulated health care professionals on the PSG per Guideline 03/14. The fee submitted is above the rate provided for other health care professionals and the insurer agreed to contribute $91.43 per hour, which is in keeping with the level of education of other health care professionals listed in the Guideline. Nor was the respondent provided with compelling evidence to indicate that 1.5 hour sessions are more effective or beneficial than 1 hour sessions, and if the extra half hour was for documentation and note taking, this would effectively increase the overall hourly rate described in the PSG. The respondent denied $375.00 in regard to planning and noted that 30 minutes per session of planning is excessive and agreed to pay 15 minutes of planning per session; other planning services such as communications, texts, reminders, calls, and emails are not listed or part of the counselling sessions and are not payable; the respondent also agreed to pay one hour of preparation time. The respondent also denied provider travel time of $3,000.00 as the applicant's accident related injuries did not prevent her from travelling for treatment, nor was travel expenses applicable under FSCO Guidelines.
39The respondent also submits that reasons were provided in its letter of November 21, 2022 in the denial of lines 1, 2 and 5. The respondent also submits the treatment plan proposed 2.5 hours of travel time for each session at a cost of $375.00 in travel time for each session and a total cost of $3,000.00 over the scope of the plan; further the applicant did not provide evidence why $150.00 per hour should be paid for travel time. The respondent submits it has agreed to pay for social work and the dispute is about the hourly rate to be paid, as well as travel time, brokerage, planning, and service fees.
40The respondent also submits the treatment plan submitted January 10, 2023 was partially approved for the same reasons as detailed in its letter of January 18, 2023.
41I have reviewed the medical evidence of Dr. Tsang and Dr. Joseph as well as the submission by the respondent that social work is not in dispute and agreed by the parties to be reasonable and necessary. I have reviewed the treatment plans submitted November 7, 2022 and January 19, 2023, both for $6,725.00 with $1,672.00 approved and $5,052.55 denied. Upon review of the letters of denial, I find both to be in compliance with s.38(8) of the Schedule, as sufficient reasons are provided for the applicant to know the reasons for the denial. Upon review of both plans. I find the applicant has not directed the Tribunal to any evidence that the higher hourly rate and the longer session length are reasonable and necessary.
42I find the rate approved by the respondent of $91.43 for social work to be the correct rate that best fits the treatment plan under the FSCO Guidelines. In respect to travel time, I also find the submissions of the respondent to be correct and no travel time is permitted under the FSCO Guidelines in the circumstances herein. Further I agree with the respondent's analysis of the planning and services fees and make no further award for those items; I also agree the preparation time of 15 minutes per session to be reasonable for a one hour service and that 30 minutes would be excessive.
43I find the applicant is not entitled to $5,052.55 for the treatment plan submitted November 7, 2022 and not entitled to $5,052.55 for the treatment plan submitted January 10, 2023.
Is the applicant entitled to occupational therapy services in the amount of $4,154.00 submitted February 8, 2023?
44The applicant is entitled to occupational therapy services in the amount of $798.00 submitted February 8, 2023.
45The applicant submitted the goals of the treatment plan are to provide ongoing occupational therapy services as recommended in the Landry report to address continuing difficulties with executive functioning tasks, including motivation, energy conservation, and chronic pain management. The applicant also relies upon HCCSS OT records that corroborate she requires professional support to manage daily activities and mitigate the impact of chronic pain and cognitive fatigue.
46The respondent submitted by letter dated February 23, 2023, it denied funding for the treatment plan pending the outcome of a s.44 insurer examination. The denial letter noted that the proponent of the plan suggested that the applicant was struggling with executive functioning tasks in and around her home. Further, the respondent submits the planning and services elements of the treatment plan are excessive for items which are not therapeutic in nature and disproportionate to the amount of direct treatment time; specifically 8 hours of treatment time, along with 6 hours of planning, 4 hours of preparation, 6 hours of brokerage. By letter dated July 25, 2023, the respondent advised the applicant based upon the Livadas report and the Berardi report, that the treatment plan was neither reasonable nor necessary.
47I find the applicant's submissions as to why the treatment plan is reasonable and necessary based upon the Landry report and the HCCSS records to be persuasive; I previously assigned less weight to the respondent's Berardi report and do not find its evidence to be persuasive. I find the applicant did meet her onus that the occupational therapy services proposed in the treatment plan to be reasonable and necessary. However, I find the respondent's submissions that planning and preparation to be excessive and brokerage time to be not payable. Upon review of the treatment plan submitted February 8, 2023 for occupational therapy, I find only line 5 for OT time to be payable for a sum total of $798.00 under the plan.
48I find the applicant is entitled to occupational therapy services in the amount of $798.00 submitted February 8, 2023.
Is the applicant entitled to assistive devices in the amount of $11,101.43 submitted February 23, 2024?
49The applicant is entitled to assistive devices in the partial amount of $5,628.84 for assistive devices submitted February 23, 2024.
50The applicant submits the goals of the treatment plan are: pain reduction, to cover cost of assistive devices recommended in the Form-1 report, and to optimize safety and independence with daily occupations, reduce pain and symptoms while participating in daily activities, increasing occupational performances to pre-accident level of functioning. The plan includes a bidet, toilevator and bidet installation, adjustable bed with bed rail, electrical snow thrower, utility cart, heat/burn resistant gloves, vegetable peeler, food processor, perching stool, gym membership, vacuum cleaner, bathtub set, incontinence briefs, orthotics, bed rail, deliver costs and labour costs.
51The applicant relies upon the recommendations for assistive devices in the Landry report and an HCCSS commissioned occupational therapy assessment by J. Krupa, OT, dated July 14, 2022 ("Krupa report") that recommended bathtub grab bars and a tub transfer bench. The Krupa report author also recommended by letter of September 27, 2023 assistive devices for cooking tasks including electric can opener, electric peeler, burn-proof gloves, kitchen utility cart, perching stool and anti-fatigue mat; a grab bar for toileting; and pedestals for washer/dryer to assist with laundry tasks.
52The respondent submits the applicant is fully functional and does not require assistive devices of any nature and relies upon the Livadas report which details normal function.
53The respondent also submits that it settled the matter of a sleep system of $4748.00 plus bed rail for $95.00 in a settlement and partial release dated November 15, 2024 in the amount of $3,000.00.
54I have reviewed the claim for assistive devices of $11,101.43 submitted February 23, 2024 and the partial release for the sleep system and rail dated November 15, 2024. I find the applicant's submissions to be persuasive in part and upon review of the Landry report, Krupa report and letter of September 27, 2023 I find that the assistive devices recommended to be reasonable and necessary. I do not find the respondent's submissions relied upon in the Livadas report to be persuasive as I have previously assigned the report les weight; however, upon review of the partial release dated November 15, 2024, I find the respondent's submissions in respect to the settlement of the issues therein to be persuasive. Accordingly, I find the applicant's claim for $11,101.43 to be reduced by the settled items of a sleep system for $4,748.00 and bed rail for $95.00 totaling $4,843.00 plus HST of $629.59 for a total reduction of $5,472.59 from the claimed amount of $11,101.43 with a resulting balance of $5,628.84.
55I find the applicant is entitled to assistive devices in the partial amount of $5,628.84 of the assistive devices submitted February 23, 2024.
Is the applicant entitled to social rehab counselling in the amount of $21,223.66 ($22,801 less $1,577.34 approved) submitted March 7, 2023?
56The applicant is not entitled to social rehab counselling in the amount of $21,223.66 ($22,801.00 less $1,577.34 approved) submitted March 7, 2023.
57The applicant submits the goals of the treatment plan are: pain reduction and to cover cost of assistive devices recommended in the therapist's Form-1 report. The treatment plan was partially approved in the amount of $1,577.34,The applicant alseo submits by explanation of benefits letter dated March 21, 2023. Line 1 and were approved up to hourly rate of $91.43 consistent with the FSCO Guideline, however, no medical and any other reasons were provided as to why the time allotted for Lines 1 and 2 were excessive to support the reduction in both the number and duration of sessions, as required by s. 38(8) making them payable under s. 38(11).
58The applicant submits medical reports indicate that she is tangential in her thought process and has difficulty maintaining focus and concentration; clinical observations explain the need for longer counselling sessions to allow her to meaningfully engage in therapy. Line 4 for provider travel time was denied, however the applicant submits she resides in a remote area where access to local providers is limited. As a result, her occupational therapist, M. Fortier, OT, recommended that travel time be approved in order to allow her to attend in-person therapy. In addition, on August 10, 2023, the applicant's primary care physician, Dr. Pridham, indicated "Ms. Jeffrey has medical conditions which necessitate in person examinations."
59The respondent submits it approved $1,577.34 of the plan by letter dated March 21, 2023; the respondent agreed to approve 1 hour sessions at $91.43 per hour as opposed to 1.5 hour sessions at $150.00 per hour and the respondent reduced the amount for planning and services, preparation services, and documentation; the respondent submits it refused to pay provider travel time of $11,250.00 as excessive.
60I have reviewed the explanation of benefits letter dated March 21, 2023 and find the respondent was in compliance with s.38(8) and s.38(11) does not apply; the respondent need not provide a detailed medical reason for each line item of a treatment plan for its denial, particularly in circumstances where a one hour therapy session is the standard and it would be upon the applicant to demonstrate a variation from the standard to 1.5 hours was reasonable and necessary.
61Further I find the line 3 denial of $1,125.00 for planning services was justifiable as the amount claim was significantly greater than the amount permissible under the FSCO Guidelines. The line 4 denial of provider travel time of $11,250.00 was in my view unreasonable to provide $1,500.00 in counselling services. Remote location cannot be used as a shield to defend patently unreasonable travel expenses drastically out of proportion to the value of the services rendered. The choice of provider must be reasonable in relation to the costs of transportation. I find remote location cannot be interpreted as carte blanche for associated travel expenses and it is not the intention of the Schedule.
62I find the applicant is not entitled to social rehab counselling in the amount of $21,223.66 in a plan submitted March 7, 2023.
Is the applicant entitled to medical services in the amount of $3,264.57 submitted June 6, 2023?
63The applicant is entitled to medical services in the amount of $3,264.57 in a plan submitted June 6, 2023.
64The applicant submits the plan was prepared by Dr. Lee, physician, from Apollo Applied Research Inc. ("Apollo"), and submitted on June 6, 2023, with the goal of pain reduction. The plan includes pharmacotherapy medical cannabis, medical management, instruction, and documentation.
65The applicant also submits correspondence dated August 10, 2023 from Dr. Pridham, primary care physician, who wrote directly to the respondent, advising that the applicant had reported some improvement in her symptoms when she previously used medical cannabis and a further trial of cannabis would be reasonable given her current worsening pain, anxiety, and insomnia.
66The respondent submits that Dr. Lee had not completed a thorough review of the applicant's medical history. The insurer referred to the College of Family Physicians April, 2014 Guideline regarding the use of cannabis and Dr. Lee had not fully explored the recommendations and contraindications noted in the Guideline. Further, the respondent submits the College of Physicians considers medical documents authorizing patient access to marijuana to be the equivalent to a prescription, therefore, the respondent questioned whether this item should be charged to OHIP, as opposed to the insurer. Further, doctors must not charge patients for completing medical documents or any associated activities with completing medical documentation, including but not limited to assessing the patient, reviewing her chart, educating or informing the patient about the risk or benefits of marijuana (as these are services covered under OHIP).
67I do not find the respondent's submissions to be persuasive; the prescription was made by a qualified physician and supported by the applicant's primary care physician. Regulatory issues in respect to whether guidelines were adhered to are matters between a physician and the governing body and are not a valve by which an insurer may escape liability. Further the respondent produced no evidence that the prescription is payable by OHIP or that the applicant is insured by OHIP. I find that the applicant has meet her onus that the treatment plan is reasonable and necessary.
68I find the applicant is entitled to medical services in the amount of $3,264.57 proposed by Apollo in a plan submitted June 6, 2023.
Is the applicant entitled to $18,233.00 for a catastrophic impairment assessment, submitted June 8, 2023?
69The applicant is entitled to $4,000.00 for a catastrophic impairment assessment, submitted June 8, 2023.
70The applicant submits that on June 9, 2025 a s. 25 Catastrophic Impairment Occupational Therapy Assessment was completed by L. De Feo, OT, ("Feo report") and on June 20, 2025, a Catastrophic Impairment Psychiatric Assessment was completed by Dr. Rosenblat, psychiatrist, ("Rosenblat report"). The applicant further submits that the assessments were reasonable and necessary given applicant's post-accident presentation; since the accident she has been unable to secure or maintain meaningful employment, has consistently required physical, psychological, and rehabilitative treatment, and her clinical records are replete with references to her ongoing inability to complete housekeeping tasks. A catastrophic designation would have granted her access to housekeeping and other benefits essential to her care and rehabilitation. She submits while the respondent's assessors rated the applicant's function to be class 3 moderate in most domains of function, it indicates she was close to a CAT designation and the need for a CAT assessment was reasonable and necessary.
71The respondent submits there is no evidence that the applicant expended the $18,133.00 for the CAT assessments and that applicant failed to provide sufficient evidence that the assessment was reasonable and necessary. In the alternative the respondent submits that the maximum payable for the two assessments are $2,000.00 each as provided by s.25 of the Schedule.
72I find the applicant's submissions to be persuasive in that the nature of the applicant's injuries are sufficient to warrant further investigation as provided in the Feo report and the Rosenblat report. I also find the respondent's submissions to be persuasive that the assessments are limited to $2,000.00 each under the Schedule.
73I find the applicant is entitled to $4,000.00 for a catastrophic impairment assessment, comprising of two assessments submitted June 8, 2023.
Is the applicant entitled to mileage expense reimbursement in the amount of $2,740.00 from June 9, 2023 and ongoing?
74The applicant is not entitled to mileage expense reimbursement in the amount of $2,740.00 from June 9, 2023 to date.
75The applicant submits the expense form dated June 9, 2023, in the amount of $2,740.00 was submitted on June 9, 2023, which included mileage expenses to medical appointments with Dr.Pridham, Smooth Rock Falls Hospital, Dr. Flondra, Timmins District Hospital, Dr. Essue, Dr. Bodley, and Dr. Singh from October 7, 2021 to January 27, 2023. The applicant also submits the respondent in its denial letter requested clinical note and records ("CNR") of each provider for the dates listed with the claim; the applicant submits the CNR were provided throughout the course of the claim and were delivered to the respondent, however, the respondent never responded.
76The respondent submits the amounts submitted were for medical appointments that were not related to the accident.
77I find the submissions of the respondent to be persuasive as the applicant did not submit any evidence that the medical appointments related to the accident.
78The applicant is not entitled to mileage expense reimbursement in the amount of $2,740.00 from June 9, 2023 to date.
Interest
79Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. The applicant is entitled to interest on the payment of overdue benefits in accordance with s. 51 of the Schedule.
Award
80The 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.
81The applicant submits the insurer refused to review with an open mind, updated medical documentation as it was received. Accordingly, the applicant submits the insurer's position is one of inflexibility and stubbornness.
82The respondent submits an award is only payable in the event that an insurer acted so unreasonably that it acted imprudently and failed to assess all available evidence. The respondent submits there is absolutely no evidence that the insurer has acted in imprudently; to the contrary, the insurer provided detailed and clear reasons for its denial of each of the benefits in issue.
83I find that an insurer is not held to a standard of perfection; rather, the insurer had medical evidence to support each of its denials. I find the circumstances herein do not give rise to the insurer conduct that would draw an award.
ORDER
84The Tribunal's final Orders:
i. The applicant is not entitled to ACB in the amount of $171.57 ($591.87 less $420.30 approved) per month from April 24, 2023 to July 24, 2023.
ii. The applicant is entitled to ACB in the amount of $420.30 per month from July 26, 2023 to date.
iii. The applicant is not entitled to social worker counselling in the additional amount of $5,052.55 submitted November 7, 2022.
iv. The applicant is not entitled to social worker counselling in the additional amount of $5,052.55 submitted January 20, 2023.
v. The applicant is entitled to occupational therapy services in the amount of $798.00 in a plan submitted February 8, 2023.
vi. The applicant is entitled to assistive devices in the partial amount of $5,628.84 in a plan submitted February 23, 2024.
vii. The applicant is not entitled to social rehab counselling in the amount of $21,223.66 ($22,801 less $1,577.34 approved) in a plan submitted March 7, 2023.
viii. The applicant is entitled to medical services in the amount of $3,264.57 proposed in a plan submitted June 6, 2023.
ix. The applicant is entitled to $4,000.00 for a catastrophic impairment assessment, submitted June 8, 2023.
x. The applicant is not entitled to mileage expense reimbursement in the amount of $2,740.00 from June 9, 2023 to date.
xi. The applicant is entitled to interest on the payment of overdue benefits in accordance with s. 51 of the Schedule.
Released: June 18, 2026
__________________________
Robert Maich
Vice-Chair
