Licence Appeal Tribunal File Number: 20-008457/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:
Jules Bergeret
Applicant
and
Wawanesa Mutual Insurance Company
Respondent
DECISION
ADJUDICATOR: Bruce Stanton
APPEARANCES:
For the Applicant: Julia Z. Hou, Counsel
For the Respondent: Nicole A Dowling, Counsel
HEARD: By Way of Written Submissions
BACKGROUND
1The applicant, Jules Bergeret, was involved in an automobile accident on January 10, 2018, and sought benefits pursuant to the Statutory Accident Benefits Schedule Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”).
2The respondent concluded that Mr. Bergeret’s injuries fell within the Minor Injury Guideline (“MIG”) and is therefore subject to the $3,500.00 funding limit for medical and rehabilitation benefits under the Schedule. The applicant was denied certain benefits by the respondent and therefore submitted an application to the Licence Appeal Tribunal - Automobile Accident Benefits Service (“Tribunal”) to resolve the dispute.
ISSUES
3The following issues are to be decided:
i. Are the applicant’s injuries predominantly minor as defined in s. 3 of the Schedule and therefore subject to treatment within the $3,500.00 limit and in the Minor Injury Guideline?
ii. Is the applicant entitled to $1,517.34 for physiotherapy services, proposed by Focus Therapy in a treatment plan/OCF-18 (“plan”) dated July 30, 2018?
iii. Is the applicant entitled to $200.00 for physiotherapy services, proposed by Focus Therapy in a plan dated July 22, 2019?
iv. Is the applicant entitled to interest on any overdue payment of benefits pursuant to s. 51 of the Schedule?
Result
4I find that the applicant has not demonstrated, on a balance of probabilities, that his pre-existing health condition prevented maximal recovery from his accident-related injuries within the MIG. Accordingly, the applicant’s medical and rehabilitation benefits are subject to the $3,500.00 limit provided by s. 18(1) of the Schedule.
5The treatment plan by Focus Therapy for $1,517.34, though subject to the $3,500.00 MIG limit, is otherwise reasonable and necessary and is therefore partially payable to the extent of the MIG limit.
6Interest is payable on the portion of the MIG limit not expensed to date, in accordance with s. 51 of the Schedule.
ANALYSIS
The Minor Injury Guideline (“MIG”)
7The MIG establishes a framework of treatment, described in Superintendent’s Guideline No. 01/14, February 1, 2014, available to injured persons who sustain a minor injury as a result of an accident. A “minor injury” is defined in s. 3(1) of the Schedule as, “one or more of a strain, sprain, whiplash associated disorder, contusion, abrasion, laceration or subluxation and includes any clinically associated sequelae to such an injury.” The terms, “strain,” “sprain,” “subluxation,” and “whiplash associated disorder” are defined in the Schedule.
8Section 18(1) of the Schedule limits funding for medical and rehabilitation benefits for predominantly minor injuries to $3,500.00. It is the applicant’s burden to establish entitlement to coverage