LAT Rules Social Worker Entitled to Higher Hourly Rate for CBT Services
A recent decision from the Licence Appeal Tribunal (LAT) reminds insurers that dismissing a treatment provider’s qualifications without reviewing the full clinical record can be a costly oversight.
Background
Christine De Angelis was injured in a motor vehicle collision on May 12, 2022. Her treating provider, Elizabeth Waisberg — a social worker and psychotherapist at Social Work Consulting Group — submitted two treatment plans for social work services to Aviva Insurance Company of Canada.
Aviva partially approved both plans but refused to fund Ms. Waisberg’s hourly rate of $139, instead approving only $100 per hour. The disputed amounts from the rate differential — totaling $2,362 — were the subject of this LAT proceeding.
Treatment Provider’s Rate Must Reflect Their Education, Training and Experience, When the FSCO Guideline Does Not Set a Maximum Rate
At the core of the dispute was the fact that the Financial Services Commission of Ontario (FSCO) Professional Services Guideline does not set a maximum hourly rate for social workers or psychotherapists. Where the guideline is silent, the rate is to be negotiated between the parties. If no agreement is reached, the insured must apply to the LAT to resolve the dispute. The onus falls on the insured to demonstrate that the proposed rate for their treating provider is appropriate given the provider’s education, training and experience.
Aviva argued that a higher rate is only justified where a provider has specialized training and where the treatment plan itself specifically identifies a specialized modality — such as Cognitive Behavioural Therapy (CBT) — as the proposed treatment method. Because neither of Ms. Waisberg’s treatment plans explicitly referenced CBT, Aviva maintained that $100 per hour was reasonable.
The LAT Rejected Aviva’s Narrow Approach
The adjudicator rejected Aviva’s narrow approach and held that Aviva had a duty to continuously adjust the file, which included reviewing the progress reports for evidence of the services actually being delivered. While the treatment plans did not explicitly reference CBT, Ms. Waisberg’s progress reports — dated November 28, 2022, August 14, 2023 and February 13, 2024 — clearly documented the use of CBT during counselling sessions, including how those skills were being imparted to the insured for her benefit.
On the question of qualifications, the adjudicator found that Ms. Waisberg was fully credentialed to provide CBT and the controlled act of psychotherapy, citing her accreditation from the Adler Graduate Professional School in Cognitive Behaviour Therapy and her registration with the Ontario College of Social Workers. The adjudicator relied on D.J. v. Aviva Insurance Company of Canada, 2020 CanLII 40340, affirming that psychotherapy falls within the scope of practice of OCSW-registered social workers under the Regulated Health Professions Act, 1991.
Because Ms. Waisberg’s services were comparable to those of a psychologist or psychological associate — billable at $149.61 per hour under the guideline — the adjudicator found her proposed rate of $139 per hour to be entirely reasonable and payable.
The insured was awarded the full disputed amounts of $1,014 and $1,348, plus interest.
