Aviva prevailed at Ontario's Licence Appeal Tribunal after a claimant failed to prove her psychotherapist deserved a psychologist's higher hourly rate.
The dispute turned on a question claims professionals meet constantly: how much an insurer must pay for a service the provincial fee guideline does not price.
The claimant was injured in an automobile accident on July 20, 2020, and sought statutory accident benefits. A treatment clinic proposed a psychological treatment plan dated July 24, 2024, billing 12 one-hour sessions at $149.61 an hour, plus fees for "brokerage" and "planning" services and a progress report. After Aviva approved $1,397.00, the balance in dispute came to $1,855.92.
The hourly rate sat at the centre of the case. The claimant argued the treatment should be paid at $149.61 - the maximum the Professional Services Guideline sets for psychologists and psychological associates. Aviva approved $99.75 an hour, on the basis that the sessions were delivered by a psychotherapist.
The adjudicator noted the Guideline sets no rate for psychotherapists, pricing unregulated providers such as counsellors and psychometrists at $58.19 an hour. With the Guideline silent, the parties must settle a reasonable rate, she held - and the applicant carries the onus of justifying a higher one.
That onus was not met. The claimant filed no curriculum vitae or submissions establishing the provider's credentials, training, or experience, the adjudicator found. Absent evidence tying qualifications to a psychologist-level rate, she ruled $99.75 an hour reasonable.
Aviva also prevailed on the ancillary fees. The "brokerage" charge - communication with others - was unsupported, the adjudicator found, because the claimant never identified whom the provider would contact or why. The "planning" fee for ongoing evaluation was already covered within the provider's hourly rate, she held. The Guideline, she noted, bars fees that increase the effective hourly rate or the maximum payable for completing forms beyond what it permits.
The progress report fee failed on the same ground. The adjudicator accepted Aviva's position that progress information could be captured through a later treatment plan and requested and funded if needed.
The claimant had also argued that Aviva could not raise submissions beyond the reasons in its denial letter. The adjudicator rejected that reading of section 54 of the Schedule, finding the provision requires only a clear denial and notice of the right to dispute - not a limit on the insurer's submissions at a hearing.
Finally, the Tribunal denied a special award under section 10 of Regulation 664, which allows up to 50 per cent of benefits payable where an insurer unreasonably withholds or delays payment. The award standard targets conduct that is "excessive, imprudent, stubborn, inflexible, unyielding or immoderate." The adjudicator found none, adding that since the balance was not payable, there was no unreasonable denial.
The application was dismissed. The decision was released on June 22, 2026.
