Licence Appeal Tribunal File Number: 22-006562/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:
Marie Beauvais
Applicant
and
BelairDirect
Respondent
DECISION
ADJUDICATOR:
Robert Rock
APPEARANCES:
For the Applicant:
Mike Pryce, Counsel
For the Respondent:
Aaron Weinroth, Counsel
HEARD:
In Writing
OVERVIEW
1Ms. Marie Beauvais (hereinafter referred to as the Applicant), was involved in an automobile accident on November 23, 2019, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”). The applicant was denied benefits by the respondent, BelairDirect, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The 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 Minor Injury Guideline (“MIG”) limit?
ii. Is the applicant entitled to a medical benefit in the amount of $3,405.00 for Physiotherapy Services recommended by Scarborough Physio submitted on September 24, 2020.
iii. Is the applicant entitled to the assessments proposed by Scarborough Physiotherapy and Rehab as follows.
A. $2,200.00 for a chronic pain assessment in a treatment plan dated October 22, 2020.
B. $3,042.64 for a psychological assessment in a treatment plan dated April 14, 2020.
iv. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3I find that:
i. The applicant has failed to demonstrate that her accident-related impairments warrant removal from the MIG. As such, it is unnecessary to consider whether the treatment plans in dispute are reasonable and necessary. As no benefits are owing, no interest is payable. The application is dismissed.
ANALYSIS
The Minor Injury Guideline (“MIG”)
4Section 18(1) of the Schedule provides that medical and rehabilitation benefits are limited to $3,500.00 if the insured person sustains impairments that are predominantly minor injuries. 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.”
5An insured person may be removed from the MIG if it can be established that accident-related injuries fall outside of the MIG, or if there is documentation of a pre-existing injury or condition combined with compelling medical evidence stating that the condition precludes recovery if kept within the MIG, pursuant to s. 18(2) of the Schedule. The Tribunal has determined that chronic pain with a functional impairment or a psychological condition may warrant MIG removal.
6The burden is on the applicant to demonstrate, on a balance of probabilities, that her injuries fall outside of the MIG. In this instance, the applicant submits that she should be removed from the MIG due to a pre-existing injury, chronic pain and psychological impairments.
7The respondent argues that the applicant should not be removed from the MIG, as she has not substantiated any pre-existing injury, nor that she suffers from chronic pain or a psychological condition not defined as a minor injury in the Schedule.