Licence Appeal Tribunal File Number: 20-013812/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:
Demitri Salnikov
Applicant
and
TD General Insurance Company
Respondent
DECISION
ADJUDICATOR: Jesse A. Boyce, Vice-Chair
APPEARANCES:
For the Applicant: Pasquale Maiolo, Paralegal
For the Respondent: Amanda Colarossi, Counsel
HEARD: By way of written submissions
OVERVIEW
1The applicant was involved in an accident on January 30, 2020 and sought benefits from the respondent, TD, pursuant to the Statutory Accident Benefits Schedule Effective September 1, 2010 ("Schedule").1 TD denied his claims based on its determination that he sustained predominantly minor injuries as a result of the accident and was therefore subject to treatment within the Minor Injury Guideline ("MIG"). The applicant disagreed and applied to the Tribunal for resolution of the dispute.
ISSUE IN DISPUTE
2According to the Case Conference Order, the issues in dispute are as follows:
a. 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 MIG?
b. Is the applicant entitled to $1,890.00 for other goods and services proposed in a treatment plan/OCF-18 ("plan") dated April 21, 2020?
c. Is the applicant entitled to $2,000.00 for chiropractic services proposed by 2430307 Ontario Limited in a plan dated July 28, 2020?
d. Is the applicant entitled to $225.62 for pre-screening proposed in a plan dated July 28, 2020?
e. Is the applicant entitled to $998.88 for chiropractic services proposed by 2430307 Ontario Limited in a plan dated February 28, 2020?
f. Is the applicant entitled to $1,293.80 for chiropractic services proposed by 2430307 Ontario Limited in a plan dated June 11, 2020?
g. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant has not met his burden of proof. He is subject to treatment within the MIG and is not entitled to any of the benefits claimed or interest.
ANALYSIS
Applicability of the MIG
4Section 18(1) of the Schedule provides that medical and rehabilitation benefits are limited to $3,500.00 if the insured sustains impairments that are predominantly a minor injury in accordance with the MIG. Section 3(1) defines a "minor injury" 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." An insured may be removed from the MIG if they can establish that their accident-related injuries fall outside of the definition of a minor injury.
5Despite having representation and several attempts by the Tribunal to contact him, the applicant failed to file submissions or evidence for this written hearing to demonstrate that his injuries require treatment beyond the MIG. The applicant did not file submissions by the agreed upon deadline of October 4, 2021 and did not file reply submissions in response to TD's submissions and evidence that were properly filed on October 18, 2021. While the Tribunal was able to review the medical documentation provided by TD, in the absence of specific submissions or compelling evidence from the applicant, I cannot find that the applicant has met his burden of proof. On the evidence available, I see no reason to interfere with TD's determination that the applicant's accident-related impairments are treatable within the MIG, which was supported by the s. 44 Insurer's Examination reports of physiatrist Dr. Ko and psychologist Dr. Silverman. Accordingly, the applicant is subject to the MIG.
Are the treatment plans reasonable and necessary?
6Having determined the applicant did not satisfy his onus that removal from and treatment beyond the MIG is required, it is my understanding that the limits of the MIG have been exhausted. Accordingly, an analysis of the treatment and assessment plans in dispute is not required and no interest applies.
ORDER
7The applicant has not met his burden of proof. He is subject to treatment within the MIG and is not entitled to any of the benefits claimed or interest.
Released: February 11, 2022
__________________________
Jesse A. Boyce
Vice-Chair
Footnotes
- O. Reg. 34/10, as amended.