Aviva tried paying a registered psychotherapist less than a psychologist. Ontario's Licence Appeal Tribunal rejected that logic and ordered the balances paid.
The decision in Gunes v Aviva General Insurance Company, 2026 CanLII 53781 (ON LAT), released June 4, 2026, turns on a question claims adjusters face constantly: what hourly rate is reasonable when treatment comes from a provider the fee guideline does not specifically cover.
Muzafer Gunes was injured in an automobile accident on March 22, 2024, and sought statutory accident benefits. Aviva denied or partly approved several treatment and assessment plans, and Gunes took the dispute to the Tribunal's Automobile Accident Benefits Service.
At the centre was psychotherapy billed at $149.61 per hour. Aviva funded it at $99.75, arguing the lower figure applied because the service was delivered by a registered psychotherapist rather than a psychologist. The insurer did not dispute that the treatment was clinically required; it challenged the rate and the session length.
Adjudicator Harouna Saley Sidibé declined to tie the rate to a job title. Superintendent's Guideline No. 03/14 caps hourly rates for certain providers, including psychologists, but sets no rate for registered psychotherapists. It fixes $58.19 per hour only for unregulated providers such as counsellors. With no capped psychotherapist rate, the adjudicator looked to the substance of the services, integrated cognitive behavioural therapy supervised by a psychologist, and found $149.61 reasonable, along with the 90-minute sessions and related preparation time.
Aviva also lost on chiropractic care and two assessments. The insurer leaned on an examination report by Dr. Howard Platnick, dated September 16, 2024, concluding the soft-tissue injuries had resolved. The adjudicator gave that report less weight because Platnick reviewed records only through June 4, 2024, missing the family physician's later notes of ongoing neck pain, back pain and headaches. The chiropractic plan at $3,284.96, a neurological assessment at $2,670.00, and a chronic pain assessment at $2,410.00 were all approved.
The insurer did score wins. The Tribunal refused a $21,818.59 multidisciplinary chronic pain program, finding it overlapped with already-approved treatment and lacked objective support for the severity described. The adjudicator also noted the program was proposed by a chiropractor, cautioning that opinions on complex chronic pain extend beyond that provider's primary expertise.
Gunes also sought a special award under section 10 of Regulation 664, available where an insurer unreasonably withholds or delays benefits, conduct the Tribunal describes as "excessive, imprudent, stubborn, inflexible, unyielding or immoderate." Although the adjudicator agreed Aviva's denials did not fully engage with key medical evidence, that fell short of the high threshold. Aviva had obtained examinations, approved some benefits, and advanced positions that, while unsuccessful, were not immoderate. The award was dismissed.
For claims professionals, the lesson is concrete. Where the fee guideline is silent, reimbursement turns on the nature and supervision of the treatment, not the provider's professional designation. Interest is payable on the overdue benefits, and the case was decided on written submissions.
