Licence Appeal Tribunal File Number: 21-004331/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:
Charanjit Pabla
Applicant
and
Certas Home and Auto Insurance Company
Respondent
DECISION
ADJUDICATOR:
Robert Rock
APPEARANCES:
For the Applicant:
Robert Verta, Counsel
For the Respondent:
Yann Grand-Clement, Counsel
HEARD:
By way of written hearing
OVERVIEW
1Mr. Charanjit Singh Pabla (the applicant) was involved in an automobile accident on July 11, 2019, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016). The applicant was denied benefits by the respondent, Certas Home and Auto Insurance Company 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 limit and in the Minor Injury Guideline (“MIG”)?
ii. Is the applicant entitled to $2,155.00 for chiropractic services, proposed by Wanless Rehab & Wellness Centre (WRWC) in a treatment plan/OCF18 (“plan”) submitted on February 10, 2020, and denied on February 13, 2020?
iii. Is the applicant entitled to $2,200.00 for chronic pain assessment, proposed by Mississauga Active Physiotherapy (MAP) in a plan submitted on June 11, 2020, and denied on June 26, 2020?
iv. Is the applicant entitled to $2,200.00 for psychological assessment, proposed by MAP in a plan submitted on February 11, 2021, and denied on February 26, 2021?
v. Is the applicant entitled to $3,042.56 for psychological services, proposed by MAP in a plan submitted on March 15, 2021, and denied on March 31, 2021?
vi. Is the applicant entitled to $70.80 for prescription medication, submitted on a claim form (OCF-6) on February 10, 2021, and denied on February 19, 2021?
vii. Is the applicant entitled to $202.25 ($1,270.00 less $1,067.75 approved) for chiropractic services, proposed by WRWC in a plan submitted on October 26, 2019, and denied on November 09, 2019?
viii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
ix. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3I find that the applicant has not proven on a balance of probabilities that he suffers from chronic pain with a functional impairment or a psychological condition that warrants removal from the MIG.
4As the applicant remains in MIG, he is bound by the MIG funding limits and is not entitled to the treatment plans in dispute.
5As no payments were unreasonably withheld or delayed, no award under s. 10 of Reg. 664 is due.
6As no money is owing, no interest is due.
ANALYSIS
The Minor Injury Guideline (“MIG”)
7Section 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.”
8An 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.
9The burden is on the applicant to demonstrate, on a balance of probabilities, that his injuries fall outside of the MIG. In this instance, the applicant submits that he should be removed from MIG due to chronic pain with a functional impairment and a psychological condition.
10The respondent argues that the applicant has not met the burden of proof that he suffers chronic pain with a functional impairment or a psychological condition.
The applicant remains within the MIG
11I find that the applicant has not met his onus and demonstrated on a balance of probabilities that he suffers from chronic pain with a functional impairment.
12I find that the applicant has not met his onus and demonstrated that on a balance of probabilities he suffers from a psychological condition that warrants his removal from MIG.
Does the applicant suffer from chronic pain with a functional impairment?
13I the applicant has not proven on a balance of probabilities that he suffers from chronic pain with a functional impairment.
14The applicant submits that he suffers from chronic pain with a functional impairment due to the motor vehicle accident. The applicant relies on the Clinical Notes and Records (CNRs) of his family doctor, Dr. Saini.
15The respondent relies on the lack of any objective medical evidence submitted by the applicant to substantiate a chronic pain assessment.
16I find that the CNRs of Dr. Saini, the applicant’s family doctor, consistently diagnosed the applicant with sprain/strain type injuries. The CNRs also show the doctor describing the accident-related musculoskeletal issues as resolved. I am not directed to any notes in the CNRs of Dr. Saini which would establish any concern of chronic pain, or any functional impairments suffered by the applicant in association with his ongoing pain reporting.
17Reviewing the evidence, I find that the applicant has not proven on a balance of probabilities that the injuries he suffered in the accident have led to chronic pain with a functional impairment of the lack of objective medical evidence that chronic pain with a functional impairment is present in the applicant. I was not directed to any evidence to corroborate chronic pain with a functional impairment.
18The applicant has not satisfied his onus to prove on a balance of probabilities that he suffers from chronic pain with a functional impairment that warrants removal from the MIG.
Does the applicant suffer from a psychological condition?
19I find that the applicant has not proven on a balance of probabilities that he suffers from a psychological condition that warrants removal from the MIG.
20The applicant submits that he suffers from a psychological condition because of the motor vehicle accident. The applicant relies on the CNRs or Dr. Saini and a psychological assessment by Dr. Aghamohseni.
21The respondent submits that that the applicant has not met the burden of proof that he suffers a psychological condition. The respondent relies on the CNRs of Dr. Saini, and CNRs of Dr. Rehman, Psychiatrist, at Etobicoke General Hospital.
22A psychological assessment report was completed on March 15, 2021 by Ms. Aghamohseni, psychologist. Ms. Aghamohseni diagnosed the applicant with major depressive disorder, somatic symptom disorder, and specific phobia, vehicular. I find this assessment report was not persuasive as it is contradicted by other contemporaneous reporting of the applicant to his family doctor, and to his treating psychiatrist, Dr. Rehman. The applicant consistently refers to the source of his anxiety and depression as his daughter’s health issues with both Dr. Rehman and Dr. Saini.
23Dr. Saini’s CNRs note on three separate occasions that the applicant associates his ongoing anxiety to his daughter’s genetic disability. There is one note that the applicant reports that the anxiety is related to the motor vehicle accident. This is noted in the CNR, but Dr. Saini does not endorse that as a cause. This entry is contradicted by multiple reports by the applicant that the source of his anxiety is related to his daughter’s health. That source is corroborated by the applicant’s ongoing reporting to Dr. Rehman, psychiatrist. I am not directed in the CNRs of Dr. Saini to a diagnosis or opinion that the applicant’s anxiety relates to the motor vehicle accident. The CNRs show a clear pattern that the applicant felt comfortable in discussing his anxiety with Dr. Saini. Over the many entries in the CNRs that note anxiety, none are attributed to the motor vehicle accident by Dr. Saini.
24The CNRs of Dr. Rehman, psychiatrist, show the same source of the applicant’s anxiety as the CNRs of Dr. Saini. The applicant identifies that his daughter’s health may be a perpetuating factor of his anxiety and depression. The rest of the CNRs of Dr. Rehman show a consistent pattern of the applicant’s progress in recovering from his ongoing anxiety and culminate with the applicant stopping his medication. At no point in the nearly two years of progress reports is the motor vehicle accident even discussed with Dr. Rehman.
25In review of the evidence, I find that the applicant has not met his burden to prove on a balance of probabilities that he suffers from a psychological condition that warrants his removal from MIG.
26I was led to this conclusion by the CNRs of both Dr. Saini and Dr. Rehman both of whom report that the applicant attributed his ongoing anxiety to his daughter’s health and not the motor vehicle accident. I find it to be significant that the motor vehicle accident was never discussed with Dr. Rehman in all the applicant’s visits with him. I place less weight on Ms. Aghamohseni’s report because Ms. Aghamohseni never met the client in person, nor does her report indicate that she reviewed any of the existing CNRs so did not have the context of the applicant’s anxiety complaints to either Dr. Saini or Dr. Rehman.
27I find that the applicant has not satisfied his onus to prove on a balance of probabilities that he suffers from a psychological condition due to the motor vehicle accident.
Conclusion
28For the reasons noted above, the applicant has not proven that he suffers chronic pain with a functional impairment, or a psychological condition that would warrant removal from MIG.
The Treatment Plans
29As I have found the applicant remains within the MIG, he is subject to its limits for treatment plans. The applicant is entitled to treatment up to the MIG funding limits.
Special Award
30As no payments were unreasonably withheld or delayed, no award under s. 10 of O. Reg. 664 is due.
Interest
31As the applicant is not entitled to any payments no interest is due.
ORDER
32I find that:
i. The applicant remains subject to the MIG.
ii. The applicant is not entitled to payment for the disputed treatment plans.
iii. The applicant is not entitled to a payment of an award under s.10 of Reg. 664.
iv. As nothing is owed, no interest is due.
v. The application is dismissed.
Released: October 15, 2024
Robert Rock
Adjudicator