Citation: Talampalli v. Economical Insurance, 2024 ONLAT 22-003342/AABS

Licence Appeal Tribunal File Number: 22-003342/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:

Gururaj Talampalli

Applicant

and

Economical Insurance

Respondent

DECISION

ADJUDICATOR:

Lisa Holland

APPEARANCES:

For the Applicant:

Michael Pryce, Paralegal

For the Respondent:

Kelechi Onuigbo, Counsel

HEARD:

By Way of Written Submissions

OVERVIEW

1Gururaj Talampalli, the applicant, was involved in an automobile accident on February 23, 2020, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”).

2The applicant was denied the treatment in dispute on the basis that he sustained predominantly minor injuries that are treatable within the Minor Injury Guideline (“MIG”). The applicant disagreed and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

ISSUES

3The issues in dispute are:

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 MIG? Note: The parties agree the MIG limits have been exhausted.

ii. Is the applicant entitled to $1,564.29 for a physiotherapy services, proposed by Alma Rehab in a treatment plan/OCF-18 (“plan”) dated June 25, 2020?

iii. Is the applicant entitled to $1,995.33 for a psychological assessment, proposed by Alma Rehab in a plan dated August 4, 2020?

iv. Is the applicant entitled to $1,748.55 for physiotherapy services, proposed by Alma Rehab in a plan dated December 10, 2020?

v. Is the applicant entitled to $2,425.41 for physiotherapy services, proposed by Alma Rehab in a plan dated November 13, 2020?

vi. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

4I find that the applicant sustained predominantly minor injuries that are treatable within the MIG. Since the applicant’s injuries fall within the MIG and the MIG limits have been exhausted, he is not entitled to the treatment and assessment plans in dispute.

5As no payment for benefits is overdue, it follows that the applicant is not entitled to interest on any overdue payment of benefits pursuant to s. 51 of the Schedule.

6The application is dismissed.

ANALYSIS

Applicability of the Minor Injury Guideline

7I find the medical evidence indicates that the applicant sustained minor injuries and has not demonstrated that removal from the MIG is warranted.

8The MIG establishes a framework available to injured persons who sustain a minor injury as a result of an accident. Section 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. However, the applicant may receive funding for treatment beyond the $3,500.00 limit if he can provide evidence of a pre-existing condition documented by a health practitioner that prevents maximum medical recovery under the MIG. He may also be removed from the MIG if he can provide evidence that he suffers from chronic pain or a psychological impairment that prevents his recovery under the MIG. The applicant bears the burden of proof to elevate his level of benefits outside the MIG.

9The applicant submits that the physical and psychological impairments he sustained as a result of the accident, including whiplash, sprain and strain of the neck, back, fatigue, dizziness, headache, nervousness, restlessness, agitation, irritability and anger require treatment beyond the MIG. The applicant relies on the clinical notes and records of Alma Rehab which include a Disability Certificate dated March 4, 2020, completed by chiropractor Dr. Mandeep Braich and a consultation report dated August 20, 2021 by Sasha James, social worker, and the records of his family physician, Dr. Ihsan Waraich, as evidence that his impairments are not minor injuries. The applicant submits that he is suffering from chronic pain or chronic pain syndrome with both physical and psychological sequalae. In particular, the applicant submits that he requires further treatment to address his physical and psychological complaints.

10In response, the respondent submits that the applicant’s injuries are soft tissue in nature and fall within the definition of minor injury under the Schedule. The respondent argues that the applicant has not mentioned any pre-existing conditions in a psychological pre-screening report dated July 20, 2020 by Dr. Konstantinos Papazoglou. Further, it submits that he did not report any lingering physical or psychological symptoms to his treating physician, Dr. Waraich. The applicant’s family doctor has not diagnosed chronic pain, functional impairment or any psychological condition as a result of the accident. The respondent relies on a s.44 psychological report of Dr. Arnold H. Rubenstein who noted that the applicant returned to work after the accident with muscle relaxants and pain medication for 3 months. The assessor indicated that the applicant took Ativan on an as needed basis for those 3 months, and he continues to drive with caution. Dr. Rubenstein concluded that the applicant did not suffer a mental disorder as a result of the accident.

The applicant has failed to demonstrate that he suffers from accident-related injuries that warrant removal from the MIG

11On the evidence, I find that the applicant sustained sprain and strain type injuries which fall under the definition of “minor injury” under the Schedule. There is no evidence to suggest that the applicant’s injuries are severe enough to require treatment beyond the MIG. He does not report any pre-existing physical or psychological conditions to his doctors.

12Even if I accept that the applicant has persistent physical pain and psychological complaints since the accident, there is no evidence that his injuries are not minor in nature to warrant removal from the MIG. The clinic notes recommending further treatment and assessments are not corroborated by Dr. Waraich. The applicant has not provided any medical reports to rebut the findings of Dr. Rubenstein that there is no evidence of any psychological impairment requiring psychological treatment.

13I agree with the respondent that there is no evidence of chronic pain with functional impairment or psychological impairment in the medical documentation to warrant removal from the MIG. To the contrary, the applicant has continued to work full-time as a pharmacy technician with no missed time from work since the accident. By his own admission to Dr. Rubenstein, the applicant does home-based exercises on a daily basis. He doesn’t require any formal treatment. The prescription history also confirms the applicant has not required medication for accident-related complaints since 3 months after the accident.

14The applicant has not provided any supporting medical evidence of a chronic pain diagnosis. The clinical notes and records of his treating physicians do not mention any complaints of chronic pain or functional limitations as a result of the accident. There is no medical evidence to contradict that the applicant sustained uncomplicated soft tissue injuries with no residual functional impairment. The applicant has not demonstrated that his accident-related injuries fall outside the MIG.

15The applicant also seeks removal from the MIG on psychological grounds. There is no medical evidence from his doctor describing an accident-related psychological condition. There is only a provisional diagnosis of adjustment disorder by psychologists, Dr. K. Papazoglou and Dr. Harinder Mrahar in a treatment plan dated August 3, 2020 for a psychological assessment. Although the plan mentions goals of treatment to include pain management and return to prior psychological functioning, there is no corroborating medical evidence in support of these objectives. There is no evidence that the applicant has not returned to his pre-accident level of functioning. He has returned to work and driving. The applicant has not mentioned any inability to return to his pre-accident level of work and social functioning.

16Overall, I find that the applicant has not met his onus of establishing entitlement to treatment beyond the MIG since he sustained predominantly minor injuries.

Are the treatment plans payable?

17I find that the treatment plans in dispute are not payable.

18Here, the applicant seeks payment for plans in the amounts of $1,564.29, $1,748.55 and $2,425.41 for physiotherapy services and a plan in the amount of $1,995.33 for a psychological assessment at Alma Rehab.

19Since the applicant has not demonstrated that his accident-related injuries warrant removal from the MIG, and the MIG limits have been exhausted, it is not necessary to consider whether the plans are reasonable and necessary.

Interest

20Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since the applicant’s injuries do not warrant removal from the MIG and the MIG has been exhausted, no benefits are owing and interest does not apply.

ORDER

21The application is dismissed.