Licence Appeal Tribunal File Number: 20-007889/AABS
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:
Ohene Darteh
Applicant
and
Wawanesa Insurance
Respondent
DECISION AND ORDER
ADJUDICATOR:
Stephanie Kepman
APPEARANCES:
For the Applicant:
Sana Jaffery, Paralegal
For the Respondent:
Elizabeth Scott, Counsel
HEARD:
By way of written hearing
REASONS FOR DECISION AND ORDER
BACKGROUND
1The applicant was involved in an automobile accident on November 4, 2018, and sought benefits pursuant to the Statutory Accident Benefits Schedule Effective September 1, 2010 (including amendments effective June 1, 2016)1. The applicant was denied certain benefits by the respondent and submitted an application to the Licence Appeal Tribunal - Automobile Accident Benefits Service (“Tribunal”).
PRELIMINARY ISSUE
2The respondent raised a preliminary issue in its written submissions for the substantive issues in dispute. The respondent alleged that the applicant failed to comply with the Tribunal’s production order2, which required the applicant to provide his specified disclosure3 and any other disclosure the applicant plans on relying on for the hearing by March 26, 2021.
3The respondent alleged that the following documents were not provided by the applicant until April 14, 2021:
i. Notes and records of Dr. Okafor from November 2019 to August 2020;
ii. Notes and records of Complete Rehab Centre;
iii. Notes and records of Healthcare Rehabilitation Centre;
iv. OHIP Summary, and
v. Maplehurst Correctional Centre Records.
4The respondent also alleged that the applicant failed to provide:
i. The applicant’s ODSP file from 2 years pre-accident to date;
ii. Notes and records from Brampton Civic Hospital (from May, 2019 on);
iii. Notes and records from South Riverdale Community Centre (from May, 2019 on);
iv. Updated tax returns (from 2018 on), and
v. To advise how long the applicant will be at Maplehurst Correction Centre and the restrictions on his activities while there.
LAW
5Rule 9 of the Tribunal’s Common Rules of Practice and Procedure (‘Rules’) sets out the rules for the production and exchange of evidence that the parties intend to rely on for the hearing.
6Rule 9.1 allows the Tribunal to order a party to provide disclosure as the Tribunal considers necessary for a full and satisfactory understanding of the issues in the proceeding.
7Rule 9.2(a) states that a party shall, at least 10 days before the hearing or at any other time ordered by the Tribunal, disclose to the other parties the existence of every document and anything else the party intends to present as evidence at the hearing, while Rule 9.2(c) requires a party to serve a copy of the documents, numbered consecutively, on the other parties.
8Rule 9.3(a) states that a party may seek an order from the Tribunal at any stage of a proceeding, ordering a party to disclose the existence of every document and anything else the party intends to rely on as evidence at the hearing.
9Rule 9.4 states that if a party fails to comply with any Rules, directions or orders with respect to disclosure or inspection of documents/things, the party may not rely on the document or thing as evidence, without the consent of the Tribunal.
Submissions
10The respondent submitted that it has been prejudiced by the applicant’s noncompliance with the Tribunal’s production orders, as the respondent was not given enough time to review and, if needed, respond to the late evidence provided by the applicant.
11The respondent requested that the Tribunal exclude the documents that were submitted late by the applicant and that the Tribunal draw a negative inference from the applicant’s failure to produce the outstanding evidence.
12The applicant did not make submissions to address the preliminary issue.
Analysis
13As noted by the respondent, parties have an obligation to comply with the Tribunal’s orders, as seen in 16-000879 v Unifund Assurance Company4.
14The Tribunal’s case conference order is very clear with respect to deadlines.
15I accepted that the applicant failed to comply with the Tribunal’s production order, as the applicant did not refute or address this in his submissions.
16There is no record of the applicant bringing a motion to change the production deadline, nor did the applicant request the consent from the Tribunal to consider the late-submitted evidence for this hearing5. As the applicant failed to address this issue in his reply submissions and/or via motion, I have not been presented any reason as to why the applicant failed to comply with the Tribunal’s order.
17I agree that the respondent does have the right to review and, should it choose, reply to the evidence relied upon by the applicant, and that the applicant’s late production prejudices the respondent as it was unable to investigate or respond to the evidence the applicant provided in contravention of the Tribunal’s order.
18Therefore, I have excluded the following documents from the hearing:
i. Notes and records of Dr. Okafor from November 2019 to August 2020;
ii. Notes and records of Complete Rehab Centre;
iii. Notes and records of Healthcare Rehabilitation Centre;
iv. OHIP Summary, and
v. Maplehurst Correction Centre Records.
19The respondent requested that I draw a negative inference against the applicant for failing to produce the remaining documents in accordance with the Tribunal’s order. The Tribunal has the discretion to draw a negative inference where, in the absence of a reasonable explanation, a party fails to produce evidence that is within its control (or is equally available to all parties) and such evidence is material to the dispute. Here, the applicant failed to provide an explanation or reason as to why he failed to comply with the Tribunal’s Order. Considering the substantive issues in dispute, the nature of the evidence not produced, and the applicant having control over such evidence, I agree with the respondent and will be drawing a negative inference from the following documents that were not produced by the applicant:
i. The applicant’s ODSP file from 2 years pre-accident to date;
ii. Notes and records from Brampton Civic Hospital (from May, 2019 on);
iii. Notes and records from South Riverdale Community Centre (from May, 2019 on);
iv. Updated tax returns (from 2018 on), and
v. To advise how long the applicant will be at Maplehurst Correctional Centre and the restrictions on his activities while there.
SUBSTANTIVE ISSUES
20The following issues are to be decided by the Tribunal:
I. Is the applicant entitled to receive a non-earner benefit of $185.00 per week from December 2, 2018, to November 4, 2020?
II. Are the applicant’s injuries predominantly minor injuries as defined in s. 3 of the Schedule and therefore subject to treatment within the Minor Injury Guideline (the “MIG”) and the $3,500.00 limit in s.18(1) of the Schedule?
III. Is the applicant entitled to $2,659.01 for chiropractic and massage therapy services from Complete Rehab Center, recommended by Rahim Jessa in a treatment plan (OCF-18) dated June 19, 2019, denied by the respondent on July 3, 2019?
IV. Is the applicant entitled to $2,029.35 for chiropractic and massage therapy services from Complete Rehab Center, recommended by Rahim Jessa, chiropractor, in a treatment plan (OCF-18) dated November 1, 2019, submitted November 25, 2019, denied by the respondent on December 9, 2019?
V. Is the applicant entitled to $1,803.75 for chiropractic and massage therapy services from Complete Rehab Center, recommended by Rahim Jessa in a treatment plan (OCF-18) dated May 20, 2020, denied by the respondent on June 1, 2020?
VI. Is the applicant entitled to $2,680.00 for a chronic pain assessment from Complete Rehab Center, recommended by Rahim Jessa in a treatment plan (OCF-18) dated May 13, 2020, submitted June 11, 2020?
VII. Is the applicant entitled to $2,460.00 for a psychological assessment from Complete Rehab Center, recommended by Dr. Mills, psychologist, in a treatment plan (OCF-18) dated May 8, 2020, submitted May 14, 2020, denied by the respondent on 2019?
VIII. Is the applicant entitled to interest on any overdue payment of benefits?
LAW
21Section 3(1) of the Schedule states that a minor injury consists of one or more a sprain, strain, whiplash associated disorder, contusion, abrasion, laceration or subluxation and includes any clinically associated sequelae to such an injury. Section 3(1) of the Schedule also establishes the treatment framework regarding minor injuries.
22Section 3(7) of the Schedule states that a person suffers a complete inability to carry on a normal life as a result of an accident if, as a result of the accident, the person sustains an impairment that continuously prevents the person from engaging in substantially all of the activities in which the person ordinarily engaged before the accident.
23Section 12(1)1 of the Schedule states that the insurer shall pay a non-earner benefit to an insured person who sustains an impairment as a result of the accident if the insured person suffers a complete inability to carry on a normal life as a result of, and within 104 weeks after the accident and does not qualify for an income replacement benefit (an ‘IRB’).
24Sections 14 and 15 of the Schedule states that an insurer shall pay medical benefits to, or on behalf of an applicant so long as said person sustains an impairment as a result of an accident and that the medical benefit in dispute is a reasonable and necessary expense incurred by the applicant as a result of the accident.
25Section 18(1) of the Schedule states that when an insured person sustains an impairment that is predominantly a minor injury, the total cost of his/her/their medical and rehabilitation benefits payable shall not exceed $3,500.00.
26Section 18(2) of the Schedule provides that the $3,500.00 funding limit does not apply if an applicant provides compelling medical evidence that he/she/they has a pre-existing medical condition that will prevent him/her/them from achieving maximal recovery from the minor injury if she is subject to the MIG funding limit.
27Section 51(2) of the Schedule states that interest is due on a benefit that is overdue if the insurer does not pay the benefit within the time stated by the Schedule.
Non-earner benefit from December 2, 2018, to November 4, 2020
Submissions
28The parties agree that the applicant has health issues that pre-existed the accident, which include a history of back pain, low mood and anxiety.
29The applicant submitted that after the accident, he immediately complained of headaches, spine pain, and stiffness throughout his back and given a neck collar6. The applicant then attended South Riverside Walk-in Clinic7 complaining that his chronic pain was intensified, where the applicant was encouraged to contact the hospital to arrange for physiotherapy. The applicant then began attending physical therapy at Healthcare Rehab Centre8.
30The applicant relied on a disability certificate (‘OCF-3’) completed by Nimisha Patel, physiotherapist9. This OCF-3 states that the applicant suffers a substantial inability to perform housekeeping and home maintenance and suffers a complete inability to carry on a normal life, with an estimated duration of 9 to 12 weeks. Ms. Patel opined that the applicant’s accident-related injuries included whiplash associated disorder (‘WAD2’) with complaints of neck pain with musculoskeletal signs, sprain and strain of the thoracic spine, lumbar spine, sacroiliac joint, headaches and radiculopathy.
31The applicant then attended his family doctor, Dr. Innocent Okafor10, where the applicant was encouraged to continue physical therapy.
32A second OCF-3 was completed by Dr. Rahim Jessa, chiropractor11. This second OCF-3 echoes the opinion of Ms. Patel, in that the applicant suffered a complete inability to live a normal life and suffered a substantial inability to perform the housekeeping and home maintenance as a result of the accident, with an estimated duration of 9 to 12 weeks. Dr. Jessa opined that the applicant’s accident-related injuries included sprain and strain of the cervical, thoracic, and lumbar spine, shoulder joint – bilateral, temporomandibular joint disorders (‘TMJ’) – bilateral, possible concussion, headache, disorders of initiating and maintaining sleep and stress not elsewhere classified.
33The applicant continued following up with Dr. Okafor in the summer of 201912, where the applicant complained of neck, back, waist and thigh pain, which Dr. Okafor described as accident-related myalgia. Dr. Okafor encouraged the applicant to continue physiotherapy and attend closer follow-up appointments with the doctor13.
34When the applicant returned to see Dr. Okafor, he described still experiencing on and off neck pain, and low back pain, which the applicant described as an “8/10”. Dr. Okafor opined these injuries were a neck sprain/whiplash associated disorder (‘WAD’).
35The applicant also directed the Tribunal’s attention to clinical notes and records from Dr. Okafor, dated December 4, 2019. The applicant submitted that he displayed signs of Cauda Equina Syndrome (‘CES’), Saddle anesthesia and bladder incontinence and was told to attend the emergency room.
36The applicant also wished to rely on clinical notes and records from Dr. Okafor from March 9, June 10, June 23, and July 24, 2020, where the applicant allegedly complained about pain and sleep issues to Dr. Okafor.
37However, I have already excluded Dr. Okafor’s clinical notes and records from November 2019 to August 2020 and therefore will not consider this evidence.
38The applicant relied on I.D.C. v Aviva Insurance Canada14, where Adjudicator Sharda applied the Heath principles in consideration of chronic pain, as alleged by the applicant.
39The applicant was then incarcerated at the Maplehurst Correctional Complex (‘Maplehurst’), with his medical records beginning in August of 2020.
40The respondent submitted that the applicant is not entitled to an NEB as he has failed to establish, based on a balance of probabilities, that he is entitled to the benefit.
41The respondent relied on its section 44 assessments15, conducted by Dr. Cameron Bruce Paitich, orthopod, Dr. Tony Hunt, psychologist and L. Cottrell, occupational therapist. All 3 assessments found that the applicant did not suffer a complete inability to live a normal life. Dr. Paitich, Dr. Hunt and Ms. Cottrell all noted that the applicant was uncooperative during his assessments, refused to provide details, was observed to be evasive and was unwilling to answer questions from the assessors.
42The respondent submitted that the applicant has not shown that his accident-related injuries were more than minor injuries.
43The respondent argued that the applicant has failed to demonstrate that his impairments were caused by the accident and apply the applicable “but for” test, as seen in Sabadash v. State Farm16 and M.V. v Pembridge Insurance Company17.
44The respondent submitted that the applicant had not shown that his injuries are not as a result of his 2010 police assault and/or injuries the applicant sustained when arrested and tasered in March 2020.
45The respondent directed the Tribunal’s attention the applicant’s pre-accident medical records18, which showed that the applicant complained of chronic back pain as a result of the police assault, which the applicant noted was chronic and impacted his sleep and caused him pain when using the bathroom.
46The respondent also drew the Tribunal’s attention to the applicant’s clinical notes and records of Dr. Okafor19, where the applicant was noted as having “normal independent functionality”. Dr. Okafor20 later noted that the applicant was “thriving” and had “stable low pain scores” and “no current functional loss”; at no point does Dr. Okafor opine that the applicant sustained a complete inability to live a normal life.
47The respondent also relied on its section 44 assessment conducted21 by Dr. Howard Ginsberg, neurosurgeon. Dr. Ginsburg did not find a physical cause for the applicant’s pain but found his magnetic resonance imaging (‘MRI’) and examination to be normal.
48The respondent also relied on the Court of Appeal’s leading decision in Heath v. Economical22, which found that the test for non-earner benefit is one of the most rigid tests under the Schedule. This test is subjective and requires a comparison between the insured person’s “normal life” before and after the accident over a reasonable period of time.
49There are six factors from Heath that the Court of Appeal considered when determining if an insured person suffers a complete inability to carry on a normal life pursuant to section 3(7) of the Schedule23 and, therefore, for the purposes of eligibility for a non-earner benefit. This includes a comparison of the applicant’s activities before and after the accident, examined over a reasonable amount of time.
50The respondent submitted that as the applicant has failed to fulfil the requirements of Heath, he is not entitled to the NEB.
Analysis
51After considering the submissions and evidence of the parties, based on a balance of probabilities, I find that the applicant had not shown that he suffers a complete inability to live a normal life as a result of the accident.
52The applicant’s medical records clearly indicate that he was involved in a police incident in 2010 that left him with chronic back pain. The applicant’s submissions failed to address causation for either the 2010 or 2020 police incidents. Therefore, I agreed with the respondent’s arguments in relation to causation, as the applicant had not persuaded me that his impairments were caused by the accident.
53The applicant also failed to lead any direct evidence comparing his pre-accident and post-accident ADLs and compare them, thereby not satisfying the requirements of Heath.
54In terms of relying on I.D.C. v Aviva Insurance Canada24, I distinguish it from the current matter because, in I.D.C., the applicant’s chronic pain had been accepted by her medical doctors, there were no issues with causation, and the applicant provided an affidavit to support her limitations.
55Finally, the applicant failed to address why the OCF-3s he relied on stated that his impairments should be resolved in 9 to 12 weeks but did not. The applicant did not present medical evidence that supported his assertion of having a complete inability to live a normal life as a result of the accident, but instead presented medical evidence from Dr. Okafor. While that evidence may show that the applicant lives with limitations but, it has not shown that these limitations are as a result of the accident and cause a complete inability to live a normal life. For these above reasons, I find the applicant is not entitled to a NEB.
APPLICABILITY OF THE MINOR INJURY GUIDELINE – PRE-existing chronic pain
56The applicant argued that his injuries are not minor, as he suffers from chronic pain as a result of the accident. In the alternative, the applicant submitted that as a result of his pre-existing chronic pain, anxiety and depression the applicant should be excluded from the monetary limits of the MIG.
57The standard for excluding an impairment on the basis of pre-existing condition(s) is well-defined and strict. A pre-existing condition will not automatically exclude a person’s impairment from the MIG: it must be shown to prevent maximal recovery within the cap imposed by the MIG.
Submissions
58The applicant submitted that as a result of his accident, his pre-existing chronic, depression and anxiety pain was exacerbated. To support this position, he relied on the applicant’s pre-accident medical records25, which showed that the applicant complained of chronic back pain, which impacted his sleep and caused him pain when using the bathroom. The applicant also had a history of anxiety and low mood.
59The applicant relied on the clinical notes and records of Dr. Okafor from November 6, December 4, 2019, and December 16, 2020. where the applicant alleged Dr. Okafor diagnosed the applicant with accident-related neuralgia and recommended the applicant continue his physical therapy and medication.
60The applicant also relied on Dr. Okafor’s clinical notes and records of July 24, 2020, where the applicant allegedly reported issues with his ADLs.
61The applicant’s submissions referred to his impairments and supports such with clinical notes and records of Dr. Okafor. However, I have already excluded the clinical notes and records from November 2019 to August 2020, as previously discussed.
62The respondent disagreed with the applicant’s position and argued that the applicant’s injuries were minor in nature.
63The respondent relied on Dr. Paitich’s section 44 assessment of the applicant26. Dr. Paitich found that the applicant suffered myofascial strain of his cervical and thoracolumbar spine as a result of the accident and that the applicant’s pre-accident pain may be contributing to the applicant’s pathology. Dr. Paitich opined that the applicant’s accident-related injuries had resolved.
64The respondent submitted that the applicant has failed to demonstrate, based on a balance of probabilities, that his on-going pain issue are as a result of the accident and therefore, has not met his evidentiary burden27.
65Finally, the respondent submitted that the applicant had failed to show, based on a balance of probabilities, that his pre-existing pain issues, low mood and anxiety would prevent him from achieving maximal recovery from the minor injury if subject to the MIG funding limit.
Analysis
66After considering the submissions of the parties, based on a balance of probabilities, I find that the applicant’s chronic back pain, low mood and anxiety does not warrant removal from the MIG.
67The applicant failed to demonstrate, based on a balance of probabilities28, that the accident caused the applicant’s chronic back pain. As discussed previously, the applicant has a noted history of chronic back pain, unrelated to the accident.
68Since the applicant did not make any submissions regarding the cause of his chronic back pain, he did not prove that his injuries were as a result of the subject accident.
69The second issue that prevented the applicant from being removed from the MIG was the fact that, based on a balance of probabilities, he failed to show that the back pain he is experiencing is more than clinically associated sequalae, as seen in section 3 of the Schedule.
70In terms of the applicant’s back pain, low mood and anxiety being pre-existing, after considering the submissions, based on a balance of probabilities, the applicant has not shown that these pre-existing issues warrant removal from the MIG.
71As noted by the respondent, the applicant did not provide any compelling evidence that his pre-existing issues would prevent him from achieving maximal medical recovery if subjected to the MIG’s funding limits such as contemporaneous clinical records from his family doctor to support this position.
APPLICABILITY OF THE MINOR INJURY GUIDELINE – psychological injuries
72Psychological injuries, if established, may fall outside the MIG, because the MIG only governs “minor injuries” and the prescribed definition does not include psychological impairments.
Submissions
73The applicant also argued that as a result of his psychological injuries, the applicant should be removed from the MIG.
74The applicant relied on the OCF-3 of Dr. Jessa29, where the doctor noted that the applicant was dealing with disorders of initiating and maintaining sleep and stress not elsewhere classified. Dr. Jessa also recommended that the applicant attend “a rehabilitation program”, that a psychological assessment was strongly advised and advised the applicant to attend a neurological and functional abilities assessment.
75The applicant also wished to rely on the clinical notes of Dr. Okafor of March 9, 2020, where the applicant alleged that he reported his sleep issues to Dr. Okafor. However, as I have previously excluded Dr. Okafor’s clinical notes and records from November 2019 to August 2020, I will not consider this evidence.
76The respondent submitted that the applicant has failed to demonstrate, based on a balance of probabilities, that his on-going pain issues are as a result of the accident and therefore, has not met his evidentiary burden30.
77The respondent also submitted that as a result of the accident, the applicant did not suffer a psychological injury. The respondent relied on its section 44 assessment of Dr. Hunt31. As described above, there were issues with conducting the actual assessment, as the applicant was uncooperative with Dr. Hunt. As a result, Dr. Hunt was not able to gather valid psychometrics from the applicant and could not opine if the applicant suffered a psychological injury as a result of the accident. Based on this, Dr. Hunt found that the applicant did not have a psychological injury as a result of the accident.
78The applicant argued that Dr. Hunt had also noted the applicant’s self-reporting regarding his sleep and energy levels32.
Analysis
79After considering the submissions and evidence of the parties, based on a balance of probabilities, I find that the applicant has not shown that he suffered a psychological injury as a result of the accident.
80As previously discussed, the issue of causation was not broached by the applicant. As the applicant has a noted history of low mood and anxiety, he has the onus of showing “but for the accident”33 his psychological injury would not have developed. As he made no submissions to address this, he has failed to do so.
81However, I also noted that the applicant relied mainly on the OCF-3 of Dr. Jessa, chiropractor34. I found this evidence to be less persuasive in support of the applicant’s alleged psychological injury, as it is not normally in a chiropractor’s scope of practice to address psychological issues. Instead, I gave less weight to this evidence of Dr. Jessa observing the applicant’s symptomology. However, as the applicant has not shown that said symptoms were caused by the accident, he has not met his evidentiary burden.
82As the applicant has exhausted the MIG’s limits, I do not need to consider if the disputed treatment plans are reasonable and necessary.
interest
83As I have found that no benefits are overdue, no interest is owing.
CONCLUSION and order
84The applicant is not entitled to the non-earner benefit.
85The applicant’s injuries are found to be within the MIG. The applicant’s MIG funding is exhausted. I do not need to conduct an analysis as to whether any of the disputed treatment plans are reasonable and necessary.
86The applicant is not entitled to interest.
Released: June 28, 2022
__________________________
Stephanie Kepman
Adjudicator
Footnotes
- O. Reg. 34/10 as amended.
- Issued on December 15, 2020.
- Meaning the applicant’s ODSP file from 2 years pre-accident to date, Clinical notes and records of Dr. Okafor, GP, Clinical notes and records of Healthcare Rehabilitation Centre, Clinical notes and records of Complete Rehab Centre, Clinical notes and records of Brampton Civic Hospital, Clinical notes and records of South Riverdale Community Health Centre, Clinical notes and records of Maplehurst Correctional Centre, Updated OHIP decoded list of services, Updated Tax returns to present and advise how long applicant will be at Maplehurst, and restrictions on activities, and the reason why he is there.
- 16-000879 v Unifund Assurance Company, 2017 CanLII 9811 (ON LAT)/
- Of the case conference report and order dated December 15, 2020.
- Based on the clinical notes and records from William Osler Hospital dated November 4, 2018.
- On November 7, 2018.
- As of December 1, 2018.
- Dated December 1, 2018.
- On April 24, 2019.
- Dated May 7, 2019.
- On July 15 and August 8, 2019.
- Based on the clinical notes and records of Dr. Okafor dated July 15, 2019.
- I.D.C. v Aviva Insurance Canada, 2019 CanLII 101540 (ON LAT) at para. 29.
- Which were conducted on or around August 7, 2019.
- Sabadash v. State Farm et al., 2019 ONSC 1121.
- M.V. v Pembridge Insurance Company, 2020 CanLII 40339 (ON LAT).
- Of South Riverside Community Health Centre Records dated August 16, 2016.
- Dated July 15, 2019.
- Dated September 24, 2019.
- And assessed on February 8, 2017.
- Heath v. Economical Mutual Insurance Company, 2009 ONCA 391
- Galdamez v. Allstate Insurance Company of Canada, 2012 ONCA 508.
- I.D.C. v Aviva Insurance Canada, 2019 CanLII 101540 (ON LAT).
- Of South Riverside Community Health Centre Records dated August 16, 2016.
- Dated August 7, 2019.
- As seen in Sabadash v. State Farm et al., 2019 ONSC 1121.
- As seen in Sabadash v. State Farm et al., 2019 ONSC 1121.
- Dated May 7, 2019.
- As seen in Sabadash v. State Farm et al., 2019 ONSC 1121.
- Dated August 7, 2019.
- Psychologist’s Report of Dr. Hunt dated August 7, 2019.
- As seen in Sabadash v. State Farm et al., 2019 ONSC 1121.
- Dated May 7, 2019.

