Citation: Smith v. Economical Insurance Company, 2024 ONLAT 22-007996/AABS

Licence Appeal Tribunal File Number: 22-007996/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:

Tameik Smith

Applicant

and

Economical Insurance Company

Respondent

DECISION

ADJUDICATOR:

Kenneth Nixon

APPEARANCES:

For the Applicant:

Neha Kohli, Paralegal

For the Respondent:

Kevin So, Counsel

HEARD:

In Writing

OVERVIEW

1Tameik Smith, the applicant, was involved in an automobile accident on October 4, 2020, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”).

2The respondent, Economical Insurance Company denied the treatment in dispute on the basis that the applicant sustained predominantly minor injuries that are treatable within the Minor Injury Guideline (“MIG”)

ISSUES

3The issue(s) in dispute is/are:

i. Are the applicant’s injuries predominantly minor as defined in s.3 of the Schedule and therefore subject to treatment within the $3500.00 limit and in the MIG?

ii. Is the applicant entitled to $1920.53 for psychological services proposed by Mediwise Healthcare Centre in a treatment plan (OCF-18) dated January 11, 2021, and denied on February 2, 2021?

iii. Is the applicant entitled to $1215.35 for chiropractic services proposed by Mediwise Healthcare Centre in a treatment plan (OCF-18) dated July 19, 2021, and denied on August 6, 2021?

iv. Is the applicant entitled to $2500.13 for a neurological assessment proposed by Q Medical dated January 27, 2021, and denied on February 2, 2021?

v. Is the applicant entitled to interest on any overdue payments of benefits?

RESULT

4I find that the applicant sustained a minor injury as a result of the accident and is subject to the MIG and the $3,500.00 funding limit for a minor injury.

5The applicant is not entitled to the treatment and assessment plans in dispute, nor interest because they proposed goods and services that fall outside the MIG.

BACKGROUND

6The onus is on the Applicant to demonstrate that she sustained an injury that is not included in the minor injury definition outlined in section 3 of the Schedule.

ANALYSIS

Minor Injury Guideline (“MIG”)

7The applicant has not demonstrated that removal from the MIG is warranted. The MIG establishes a treatment framework available to injured persons who sustain a minor injury as a result of an accident. A “minor injury” is defined in the Schedule and includes sprains, strains, whiplash associated disorder, contusion, abrasion, laceration or subluxation and any clinically associated sequelae. The MIG provides that a strain is an injury to one or more muscles and includes a partial tear. Under section 18 of the Schedule, injuries that are defined as minor are subject to a $3,500.00 funding limit on treatment.

8The applicant’s position is that they should be removed from the MIG based on initial diagnosis of Blue Ridge Walk-In Clinic who advised the applicant to seek further assessments at an ER and recommended tests for the right shoulder. The applicant began physiotherapy treatment and was prescribed Lyrica for pain management. The applicant further relies on a care plan assessment from Hamilton Physio which indicates discogenic pain and MSD (Musculoskeletal Disorders) and Radiological reports which report mild thoracic scoliosis and degenerative changes in both thoracic and lumbar spine, however no acute abnormalities.

9The respondent’s position is that the walk-in records of Blue Ridge Walk-in Clinic contain no evidence that the applicant suffered a non-MIG injury and that the reports also indicated that there was no concussion.

10Based on the submission of both parties, I prefer the opinion of the respondent whereas there are no amounts payable to the applicant and that the applicant failed to demonstrate that she sustained an injury that is not in the minor injury definition outlined in section 3 of the Schedule.

11Accordingly, I do not find any compelling evidence demonstrating that the applicant suffered a non-MIG injury resulting from the accident.

Interest

12Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Having concluded that no benefits are payable, it follows that no payments went overdue, and no interest is payable.

ORDER

13The applicant has not demonstrated that removal from the MIG is warranted. The OCF-18 ‘s Psychological, Chiropractic Services and a Neurological Assessment are not reasonable or necessary and that interest does not apply.