Aviva has fended off a claim at Ontario's License Appeal Tribunal over planning and preparation fees an occupational therapist built into a treatment plan.
The tribunal dismissed an accident benefits claimant's bid to recover $1,835.44 that the insurer had refused to pay, finding she had not shown the disputed services were reasonable and necessary.
The claimant was injured in an automobile accident on May 30, 2020, and sought benefits under the Statutory Accident Benefits Schedule. Her occupational therapist submitted a treatment plan, an OCF-18, on November 3, 2022, proposing $4,728.48 in occupational therapy services aimed at returning her to pre-accident daily living activities.
Aviva partially approved the plan up to $2,893.04. It covered eight 2.5-hour occupational therapy sessions at $99.75 per hour - the maximum rate for an occupational therapist on non-catastrophic claims under the Professional Services Guideline - along with service and equipment coordination, report completion, and preparation of the plan.
What the insurer refused to pay were two line items: "Planning, service," billed as eight sessions totaling $638.40, and "Preparation, service," billed as eight sessions totaling $1,197.04. Together, those denials made up the $1,835.44 in dispute.
The claimant argued Aviva had misread the Guideline by treating the planning and preparation work as administrative overhead, or expenses related to professional services. She characterized the services as a constituent part of the actual treatment, including the coordination of care with other providers, and said they did not inflate the therapist's hourly rate.
Aviva's position, set out in an Explanation of Benefits letter dated November 9, 2022, was that such fees are folded into the permitted hourly rate and are not separately payable. The letter warned that invoices including the denied fees would not be paid and that no further correspondence would follow.
Adjudicator Laura Goulet sided with the insurer. She noted that the burden rested with the claimant to prove the disputed services were reasonable and necessary, and that it was not the insurer's job to seek further information from the provider.
The adjudicator also found the claimant had not pointed to evidence from the occupational therapist about what the disputed services involved, observing that submissions are not evidence. On the preparation fees - eight 1.5-hour sessions amounting to twelve hours of communication - she said the claimant had not explained who the other providers were or why that much time was needed.
The adjudicator concluded that "the hourly rate for professional services includes communication with others," treating it as a related fee already captured by the Guideline's definition.
The tribunal dismissed the application. Because no benefits were overdue, no interest was awarded, and because Aviva had not unreasonably withheld or delayed payment, the claimant was denied an award under section 10 of Regulation 664. The decision was released June 19, 2026.
