LAT 21-001708/AABS
Licence Appeal Tribunal File Number: 21-001708/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:
Shota Zautashvili
Applicant
and
Intact Insurance Company
Respondent
DECISION
VICE-CHAIR:
Brett Todd
APPEARANCES:
For the Applicant:
Kateryna Vlada, Paralegal
For the Respondent:
Robbie Brar, Counsel
HEARD BY WAY OF WRITTEN SUBMISSIONS
OVERVIEW
1Shota Zautashvili (the “applicant”) was involved in a motor vehicle accident on September 28, 2018 and sought benefits pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”). Intact Insurance Company (the “respondent”) determined that the applicant should be treated within the Minor Injury Guideline (“MIG”) and its $3,500.00 limit on treatment and denied certain benefits. The applicant submitted an application to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
2The applicant submits that he sustained sprain and strain of the cervical, thoracic, lumbar, and sacroiliac regions in the accident that resulted in the development of psychological sequelae such as depressed mood, nervousness, anxiety, emotional distress, and sleep disturbances. As psychological conditions are not in the definition of a minor injury in the Schedule, he argues that these warrant his removal from the MIG. The applicant also claims entitlement to four treatment plans and interest on any overdue and incurred amounts.
3The respondent counters that the applicant has not produced compelling medical evidence to prove that he has sustained injuries that fall outside of the definition of a minor injury and should therefore be held within the MIG. Intact also argues that the treatment plans have not been shown to be reasonable and necessary, and as a result these amounts are not payable, nor is interest.
4In submissions, the respondent noted that medical benefits have been approved up to the full $3,500.00 limit of the MIG. This was not disputed by the applicant. As a result, I accept that the MIG is exhausted. The applicant must be found to warrant treatment outside of the MIG to be entitled to any of the treatment plans in dispute.
ISSUES IN DISPUTE
5The following issues are in dispute:
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 of the MIG?
Is the applicant entitled to $1,830.08 for physiotherapy services, recommended by Downsview Healthcare Inc. in a treatment plan/OCF-18 dated July 9, 2019?
Is the applicant entitled to $2,000.00 for psychological services, recommended by Downsview Healthcare Inc. in a treatment plan/OCF-18 dated July 16, 2019?
Is the applicant entitled to $1,563.72 for spinal decompression, recommended by Downsview Healthcare Inc. in a treatment plan/OCF-18 dated March 19, 2019?
Is the applicant entitled to $2,000.00 for a chronic pain assessment, recommended by Downsview Healthcare Inc. in a treatment plan/OCF-18 dated March 20, 2019?
Is the applicant entitled to interest on any overdue payment of benefits pursuant to s. 51 of the Schedule?
RESULT
6I find that:
i. The applicant has failed to demonstrate that he suffers from injuries that are not defined as minor in the Schedule, and as a result he remains within the MIG and its $3,500.00 limit on treatment.
ii. As the applicant remains within the MIG and as the MIG limit has been exhausted, he is not entitled to the treatment plans in dispute, nor interest.