Licence Appeal Tribunal File Number: 25-000529/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:
Kornkate Sornsingchai
Applicant
and
Co-operators General Insurance Company
Respondent
DECISION
ADJUDICATOR: Jeff Chatterton
APPEARANCES:
For the Applicant: Yan Li, Counsel
For the Respondent: Simran Walia, Counsel
HEARD: In Writing
OVERVIEW
1Kornkate Sornsingchai, the applicant, was involved in an automobile accident on January 12, 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, 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 $2,486.00 for a psychological assessment, proposed by MyoHealth Rehab and Wellness Centre in a treatment plan/OCF-18 (“plan”) submitted January 22, 2024 and denied February 7, 2024?
Is the applicant entitled to $4,282.87 for psychological services, proposed by MyoHealth Rehab and Wellness Centre in a plan submitted March 28 24, 2024 and denied April 12, 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?
RESULT
3The applicant has demonstrated that her injuries are not minor as defined under the Schedule, and she is no longer subject to the MIG limits.
4The applicant is entitled to the treatment plan for a psychological assessment.
5The applicant is partially entitled to the treatment plan for psychological services, in the amount of $1,146.57.
6Interest is payable, as per s. 51 of the Schedule.
7An award is not payable.
ANALYSIS
Should the applicant be removed from the MIG due to a psychological condition?
8The applicant has met her onus to demonstrate she should be removed from the MIG due to a psychological condition.
9Section 18(1) of the Schedule provides that medical and rehabilitation benefits are limited to $3,500.00 if the insured sustains impairments that are predominantly a minor injury. Section 3(1) defines a “minor injury” as “one or more of a sprain, strain, whiplash associated disorder, contusion, abrasion, laceration or subluxation and includes any clinically associated sequelae to such an injury.”
10An insured may be removed from the MIG if they can establish that their accident-related injuries fall outside of the MIG or, under s. 18(2), that they have a documented pre-existing injury or condition combined with compelling medical evidence stating that the condition precludes recovery if they are kept within the confines of the MIG. The Tribunal has also determined that chronic pain with functional impairment or a psychological condition may warrant removal from the MIG. In all cases, the burden of proof lies with the applicant.
11The applicant argues she should be removed from the MIG because she suffers from motor vehicle accident (“MVA”) related anxiety, post-traumatic stress disorder and depression. To support her claim, she relies on the Clinical Notes and Records (“CNRs”) from her family physician, Dr. Nadya Sankat, as well as a s. 25 Psychological Report authored by Psychotherapist Ms. Julia Kogut, under the supervision of Psychologist Dr. Peter Waxer, dated March 13 2024, as well as a Psychological Counseling Progress Report authored by Psychotherapist (Qualifying) Ms. Mitasha Bhalla, dated August 8 2024.
12The CNR’s of the applicant’s family doctor indicate that the applicant has a history of prior psychological concerns, with the first reported concern reflected in 2021. It appears the applicant was doing better, but that psychological concerns resurfaced after the accident.
13Regarding the accident, the applicant first began making MVA-related complaints of psychological concerns to Dr. Sankat on January 18, 2024, approximately one week after the accident. Dr. Sankat noted general anxiety, vehicular anxiety and poor sleep. The applicant indicated that she was ‘overall much improved’ on February 21 2024, but was intending on starting counseling for ‘anxiety when crossing the street.’
14She did not visit her primary care physician, Dr. Sankat, again until January 2025, where she again expressed concern about vehicular-related anxiety. The respondent points to this gap in primary care and argues that this indicates the applicant is not suffering from a psychological condition, but mere psychological sequalae from the accident. The respondent notes that the applicant only complained of anxiety three times over the span of two years, and that she did not complain of any psychological issues between February 21 2024 and January 8 2025.
15The respondent also states “Her family doctor referred her to counselling, which she reports to have done but has not produced any evidence that she took advantage of this OHIP referral.” I have reviewed the CNR’s from Dr. Sankat, as well as the applicant’s OHIP summary, and do not see a reference to OHIP funded counseling.
16Regardless, I am persuaded by the applicant’s evidence. I make this finding for the following reasons:
i. The applicant has clearly submitted objective medical evidence indicating that she had psychological symptoms as reported in the CNR’s from her family physician. As noted in paragraph 13, she relayed psychological concerns on January 18 2024, February 21 2024, and January 8 2025.
ii. Those CNR’s also clearly indicate that the psychological concerns expressed by the applicant were explicitly MVA related.
iii. Although the respondent raises concerns about the gap in primary care physician notes between February 2024 and January 2025, I see multiple references in the evidence to indicate that the applicant sought psychological counseling in that time frame. The s. 25 report under the supervision of Dr. Waxer was dated March 13, 2024, and reports that the applicant “has been experiencing moderate to severe emotional distress since the accident, mostly in the form of somatic concerns and symptoms of depression and anxiety.” The team of Kogut/Waxer diagnosed the applicant with Major Depressive Episode and Features of Post-Traumatic Stress Disorder.
iv. In addition, the Psychological Progress Report was dated August 8 2024. I find this supports the claim that the applicant was seeking, and continued to seek help for psychological concerns stemming from the accident. The report indicated that the applicant had been attending counseling to assist her with accident related PTSD, depression and anxiety, but that progress was slow. The report recommended a further 14 sessions of therapy.
v. Although I am alive to the concerns expressed by the respondent regarding the claim that the applicant did not take advantage of OHIP funded counseling, as noted in paragraph 15, I do not see a reference to OHIP funded counseling in the family doctor CNRs.
17In summary, the applicant reported psychological concerns as a result of the accident, and received psychological counseling. Three separate mental-health professionals (Waxer, Kogut and Bhalla) have diagnosed the applicant with depression, anxiety and PTSD. And furthermore, the CNR’s from Dr. Sankat corroborate the applicant’s reports of accident-related concerns both soon after the accident, and in January 2025.
18For these reasons, I find the applicant has, on the balance of probabilities, met her onus to demonstrate she should be removed from the MIG on the basis of a psychological condition.
Is the applicant entitled to a Psychological Assessment?
19The applicant is entitled to the treatment plan for a psychological assessment.
20To 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.
21The purpose of an assessment is to determine whether a condition exists. For an insured, they bear the onus to demonstrate that there are grounds on which to believe that a condition exists that would warrant further investigation by way of an assessment.
22The applicant submits that the proposed psychological assessment was reasonable and necessary in light of pre-existing psychological impairments and ongoing psychological injuries.
23The respondent argues that the burden of proof rests with the applicant to provide evidence and submissions and not merely reproduce treatment plans.
24I find that a psychological assessment is reasonable and necessary. I find the applicant has produced objective evidence indicating that she was suffering from psychological symptoms as a result of the accident, in the form of Dr. Sankat’s CNR’s with psychological concerns expressed in both January and February 2024, which I find is contemporaneous to the treatment plan in dispute dated February 7, 2024.
25For these reasons, I find the applicant has met her onus to demonstrate, on the balance of probabilities, that a psychological assessment is reasonable and necessary.
Is the applicant entitled to Psychological Services?
26The applicant is partially entitled to the treatment plan for psychological services.
27In dispute is an OCF-18 submitted March 28, 2024, proposed by Psychotherapist Li Wen (Mandy) Fang, requesting counseling services in the amount of $4,282.87. The treatment plan calls for 14 counseling sessions, brokerage service, planning service, and documentation support activity, all with a stated goal of a return to the activities of normal living.
28The applicant argues the psychological services were reasonable and necessary pursuant to the Schedule. The applicant argues that the services detailed in the OCF-18 directly correlate to the applicant’s impairments and are in line with the psychological assessment report dated March 13, 2024 and the progress report of August 8, 2024.
29The respondent states that psychological counseling is not reasonable and necessary. To support its claim, the respondent points to the lack of complaints between February 2024 and January 2025. Furthermore, the respondent argues that the applicant has been offered OHIP funded counseling services, but has not taken advantage of that, thus establishing that further counseling is not reasonable or necessary.
30The respondent also raises concerns about the amounts outlined in the OCF-18, stating that the OCF-18 calls for psychologist hourly rates, but the services were to be offered by a psychotherapist (qualifying.) The respondent argues that a psychotherapist should be paid at a lower hourly rate, which according to the Professional Services Guideline, is $58.19 per hour, versus the Psychologist rate of $149.61 per hour.
31The respondent also raises a concern over $1,047 in brokerage and planning fees, stating those should be covered under the $200 document fee prescribed by the Professional Services Guideline.
32The applicant did not make submissions regarding the hourly rates, nor did she make submissions regarding the brokerage and planning services.
33As I have ruled that the applicant has indeed demonstrated that she is suffering from a psychological condition due to the accident, I find the applicant has, on a balance of probabilities, met the onus to demonstrate she is entitled to psychological counseling sessions. However, she has not met the onus to demonstrate she is entitled to the OCF-18 in its entirety.
34In the absence of submissions from the applicant regarding why a higher hourly rate should be paid, or why the brokerage or planning services were reasonable and necessary, I find that the applicant is entitled to 14 sessions of counseling at the psychotherapist rate of $58.19 per hour, as well as $200 in documentation and support activities. This revised rate is ($58.19 x 14 = $814.66) plus $200 documentation and support activities, plus HST ($131.91) which equals a total of $1,146.57. The applicant has not established entitlement to the remaining balance of the treatment plan.
35In summary, I find the applicant is partially entitled to the OCF-18 in dispute, in the amount of $1,146.57.
Interest
36Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Interest applies on the treatment plans in dispute as per s. 51 of the Schedule.
Award
37The 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.
38While I have found that the applicant is entitled to be removed from the MIG, I find that the respondent’s conduct does not rise to the level of an award. It is well-settled that an award should not be ordered simply because an adjudicator determined that an insurer made an incorrect decision. The applicant has not established that the respondent’s actions rose to the level of excessive, imprudent, stubborn, inflexible, unyielding, or immoderate. For this reason, no award is payable.
ORDER
39I find that:
i. The applicant has demonstrated that her injuries fall outside of the MIG, and she is no longer subject to the MIG limits.
ii. The applicant is entitled to the treatment plan for a psychological assessment.
iii. The applicant is partially entitled to the treatment plan for psychological services, in the amount of $1,146.57.
iv. Interest is payable, in accordance with s. 51 of the Schedule.
v. An award is not payable.
Released: June 17, 2026
Jeff Chatterton
Adjudicator