In Knight v. Aviva General Insurance, 2025 ONLAT 23-004167/AABS, the Licence Appeal Tribunal delivered a timely reminder of the importance of transparency in accident benefits billing—particularly in the realm of psychological treatment.
The Case in Brief
The applicant sought reimbursement under two treatment plans proposing psychological services following a motor vehicle accident. In both instances, the respondent, Aviva General Insurance, approved partial funding but contested the balance—primarily on the basis that the services billed at psychologist rates were, in fact, delivered by a social worker and a psychotherapist, respectively.
The Tribunal sided with the insurer, finding that:
- There was no evidence to support the necessity or scope of supervision by the named psychologist;
- The actual service provider’s qualifications and the nature of the services rendered did not justify psychologist-level billing;
- The applicant failed to demonstrate that the disputed costs were reasonable and necessary, as required under the Statutory Accident Benefits Schedule (SABS).
The Tribunal made it clear that neither listing the provider as a psychologist on the treatment plan nor a generic assertion of “supervision” is enough to justify higher billing rates. The Professional Services Guideline, which provides rate caps for psychologists, does not cover social workers or psychotherapists, whose rates “are to be determined by the parties involved.” Insurers are therefore within their rights to challenge these inflated charges.
The Role of Supervision: Clarifying the Boundaries
“Supervision” in a clinical context does not automatically entitle a provider to bill at the supervisor’s rate. For supervision to carry weight in a benefits dispute, the following must be established:
- Direct Involvement: The supervising psychologist must play a meaningful role in the treatment.
- Clinical Justification: The supervision must be reasonable and necessary to the treatment goals.
- Documentation: The qualifications of the actual provider and the supervisory framework must be clearly explained in the treatment plan or accompanying records.
In Knight, none of these conditions were met. As such, the Tribunal found the higher billing unjustified and dismissed the applicant’s claim for the outstanding amounts.
Key Takeaways
The Knight decision reinforces the following principles:
- Billing transparency matters. Insurers are not obligated to pay psychologist rates for services rendered by lesser-qualified providers unless properly justified.
- Supervision must be more than a formality. If used to support higher rates, it must be substantively explained and documented.
- Challenging inflated treatment plans is a defensible position. Provided the denial is clearly explained and based on sound reasoning insurers will find support at the Tribunal.
Jonathan Charland was the lawyer on the file and is the author of this blog. If you have questions about a similar file or this decision, please contact Jonathan at 416-777-5241.
