Aviva prevails as tribunal rejects claimant's social worker rate and treatment plans.
An Ontario tribunal has sided with Aviva, rejecting a claimant's bid for disputed psychological, social work and chiropractic benefits as unproven and unnecessary.
The dispute followed a December 28, 2022 automobile accident. The claimant sought several treatment plans under the Statutory Accident Benefits Schedule and, after Aviva denied them, applied to the Licence Appeal Tribunal for resolution.
A central fight was over hourly rates. The claimant's social worker billed at $149.61 an hour, but the insurer approved only $100. The adjudicator noted the Professional Service Guideline sets no rate for social workers, leaving the parties to settle one - and placed the burden on the claimant to justify the higher figure. With no evidence of the provider's credentials, training or typical rate, the tribunal found $100 reasonable.
For claims professionals, the reasoning is instructive. The adjudicator observed the claimant incurred the treatment at the approved rate without objecting until filing with the tribunal, and had passed up the insurer's invitation to negotiate. Charges of $500 for retesting and $500 for a progress report were also rejected as unsupported.
The psychological claims turned on the medical evidence. The insurer's assessor had diagnosed the claimant in 2023 with a mild, single-episode depressive disorder and recommended 12 sessions. But a follow-up examination in 2025 found the claimant no longer met the criteria for any mental health diagnosis and recommended no further treatment. The adjudicator gave weight to the later report, which relied on psychometric testing.
The claimant argued the insurer's examinations deserved less weight because they were produced for litigation. The adjudicator rejected that, finding the insurer had signalled its intention to examine the treatment plan before the tribunal application was filed.
The chiropractic claim, valued at $4,639.78, met the same fate. The insurer's examiner concluded the claimant had soft tissue injuries consistent with "minor injuries," found no objective neurological findings, and noted he had returned to full-time work as an assembly line worker immediately after the crash. The family physician's records diagnosed chronic back pain but, the adjudicator found, offered no description of the pain's severity or functional impact.
The tribunal reiterated a familiar principle: a treatment plan is not itself evidence of impairment. It also noted the claimant had not pointed to any clinic records or progress reports showing improvement or ongoing limitations.
The claimant also sought an award under section 10 of Regulation 664, which lets the tribunal order up to 50 per cent of benefits payable where an insurer unreasonably withholds or delays payment. The claimant filed no submissions supporting it, and the request was refused. Because no overdue benefits were payable, no interest applied.
The application was dismissed on July 16, 2026.
