Sarah Khaledi was involved in an automobile collision on July 30, 2022, following which she sought statutory accident benefits from Intact Insurance Company (Intact), her accident benefits (AB) insurer. Intact denied portions of several treatment plans and Khaledi appealed to the Licence Appeal Tribunal (LAT) for resolution of the dispute. The matter proceeded on June 23, 2025, before Adjudicator Timothy Porter.
Issues in Dispute
The dispute centred on seven partially approved treatment plans submitted by Khaledi’s treatment providers. The plans covered physiotherapy, chiropractic services, a psychological assessment, an in-home assessment and a driving assessment. In each case, the amounts in dispute were relatively modest, ranging from approximately $50 to $100 per plan. The core disagreement in every instance was not over the approved treatment itself but over the documentation support activity fee — specifically, the form completion charge associated with each OCF-18 treatment plan submission. Providers billed $200 per plan on a “PR” (per procedure) basis, while Intact chose to reimburse only one hour of provider time on an “HR” (per hour) basis, resulting in a partial denial of each plan. A secondary issue was whether Intact was liable to pay an award for unreasonably withholding or delaying benefits and whether interest was owed on overdue amounts.
Positions of the Parties
Khaledi’s counsel argued that Intact failed to comply with section 38(8) of the Statutory Accident Benefits Schedule (SABS), which requires an insurer, within ten business days of receiving a treatment plan, to provide notice identifying what it agrees to pay for and, critically, the medical and all other reasons why it considers any proposed goods or services to be unreasonable or unnecessary. Khaledi contended that Intact’s denial letters contained no genuine rationale — only a bare reference to section 25 of the SABS and the Professional Services Guideline (PSG) — and therefore triggered the deemed approval provision under section 38(11), which requires the insurer to pay for all goods and services described in the plan when proper notice is not given.
Intact maintained that the applicant bore the burden of proving the fees were reasonable and necessary, that no medical treatment had been denied and that its adjusters had acted in good faith. It argued its explanatory letters were sufficient and that the issue of the driving assessment should not be added to the hearing, as it had not been included in the Case Conference Report and Order.
Findings and Reasoning
The LAT found in Khaledi’s favour on all seven treatment plans. Adjudicator Porter held that Intact’s denial notices did not comply with section 38(8). The letters referenced section 25 and the PSG without explaining how those provisions applied to the specific facts of Khaledi’s file, how the “PR” charge fell outside allowable PSG expenses or why the per-procedure fee was considered unreasonable. Adjudicator Porter characterized the insurer’s explanation as a statement rather than a reason, noting it failed to provide a principled rationale accessible to unsophisticated parties. Critically, the adjudicator noted that the $200 “PR” charge billed in each plan did not exceed the PSG maximum, further undermining Intact’s position.
Despite this finding, the LAT declined to grant an award. While Adjudicator Porter acknowledged that Intact had made consistent errors in applying the SABS, he found the insurer’s conduct did not reach the threshold of being excessive, stubborn, inflexible or immoderate required to justify an award under section 10 of Regulation 664. Khaledi was awarded interest on all overdue amounts pursuant to section 51 of the SABS.
