Released Date: January 17, 2020
In the matter of an Application pursuant to subsection 280(2) of the Insurance Act, RSO 1990, c I.8., in relation to statutory accident benefits.
Between:
I. L. G.
Applicant
and
Aviva General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Derek Grant
APPEARANCES:
For the Applicant:
Rania Hafez, Paralegal
For the Respondent:
Peter Durant, J.D., Counsel
HEARD: In Writing
July 8, 2019
OVERVIEW
1The applicant (“I.L.G.”) was involved in an automobile accident on July 10, 2015 (“the accident”) and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (the ''Schedule''). I.L.G. was denied certain benefits by the respondent (“Aviva”) and applied to the Licence Application Tribunal - Automobile Accident Benefits Service (“the Tribunal”).
2Aviva argues that I.L.G.’s injuries fit the definition of “minor injury” prescribed by s. 3(1) of the Schedule and, therefore, fall within the Minor Injury Guideline (“the MIG”).1 I.L.G. disagrees.
3If Aviva is correct, I.L.G. is then subject to the $3,500.00 limit on benefits prescribed by s. 18(1) of the Schedule and, in turn, a determination of whether the claimed benefits are reasonable and necessary will not be needed as ILG has exhausted the $3,500.00 maximum benefit for minor injuries.
4I must, therefore, decide whether I.L.G.’s injuries are predominantly minor as defined by the Schedule. If they are not, I must then determine whether the disputed medical benefits, as well as the associated fees and expenses, are reasonable and necessary.
ISSUES
5The issues in dispute were identified and agreed to as follows:
i Did I.L.G. sustain predominantly minor injuries as defined under the Schedule?
ii Is the cost of examination in the amount of $2,000.00 for a chronic pain assessment recommended by Dr. Paul Bruni in a treatment plan (“OCF-18”) submitted on November 25, 2016, and denied on January 5, 2017, reasonable and necessary?
iii Is the cost of examination in the amount of $2,000.00 for a neurological assessment recommended by Dr. Paul Bruni in an OCF-18 submitted on January 18, 2017, and denied on January 23, 2017, reasonable and necessary?
iv Has I.L.G. provided proof of submission to the collateral benefits provider regarding the medical benefit in the amount of $1,496.14 for assistive devices recommended by Dr. Paul Bruni in an OCF-18 submitted on November 25, 2016, and denied on December 7, 2016?
v Is the cost of examination in the amount of $2,000.00 for an orthopaedic assessment recommended by Dr. Paul Bruni in an OCF-18 submitted on November 25, 2016, and denied on December 7, 2016, reasonable and necessary?
vi Is I.L.G. entitled to interest on any overdue payment of benefits?
RESULT
6Based on a review of all the evidence put before me, I find that I.L.G.’s physical and psychological injuries meet the definition of “minor injury” under the Schedule. It is therefore unnecessary for me to consider whether the treatment plans are reasonable and necessary or determine whether interest is payable.
LAW
Minor Injury Guideline
7The MIG establishes a framework for the treatment of minor injuries. The term “minor injury” is defined in subsection 3(1) of the Schedule as “one or more of a sprain, strain, whiplash associated disorder, contusion, abrasion, laceration or subluxation and includes any clinically associated sequelae to such an injury.” The terms “sprain”, “strain”, “subluxation”, and “whiplash associated disorder” are also defined in subsection 3(1).
8The onus is on I.L.G. to show that her injuries fall outside of the MIG.[