Marroquin v. Sonnet Insurance Company, 2025 CanLII 102216

Citation: Marroquin v. Sonnet Insurance Company, 2025 CanLII 102216

Licence Appeal Tribunal File Number: 23-015583/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:

Daysi Marroquin

Applicant

and

Sonnet Insurance Company

Respondent

DECISION

ADJUDICATOR: Dagmar Boettcher

APPEARANCES:

For the Applicant: Kameliya Stancheva, Paralegal

For the Respondent: Sunjay Mistry, Counsel

HEARD: By Way of Written Submissions

OVERVIEW

1Daysi Marroquin, the applicant, was involved in an automobile accident on November 30, 2021, 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, Sonnet 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 Minor Injury Guideline (“MIG”) limit? The parties agree there is $15.48 remaining for treatment within the MIG limit as of the date of the case conference.

ii. Is the applicant entitled to chiropractic services, proposed by Mackenzie Medical Rehabilitation Centre in treatment plans/OCF-18s as follows:

a) $3,795.50 submitted December 6, 2021 and denied December 29, 2021?

b) $2,635.40 submitted April 12, 2022 and denied June 9, 2022?

c) $215.48 ($1,300.00 less $1,084.52 approved), submitted March 1, 2022 and partially approved March 8, 2022?

d) $2,229.50 submitted June 1, 2022 and denied June 9, 2022?

iii. Is the respondent liable to pay an award under s. 10 of Reg 664 because it unreasonably withheld or delayed payments to the applicant?

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

RESULT

3I find that the applicant has not met her burden of demonstrating that her injuries fall outside the definition of a “minor injury” as defined in s. 3 of the Schedule and she is therefore subject to treatment within the $3,500.00 MIG limit.

4As the applicant remains within the MIG there is no entitlement to the benefits at issue.

5No award is payable.

6No interest is payable.

7The application is dismissed.

ANALYSIS

The injuries are predominantly minor and the MIG applies:

8Section 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.”

9An insured may be removed from the MIG if they can establish that their accident-related injuries fall outside of the MIG, or, under s. 18(2), that they have a documented pre-existing condition combined with compelling medical evidence stating that the condition precludes recovery if they were kept within the confines of the MIG. The Tribunal has also determined that chronic pain with functional impairment or a psychological condition may warrant removal from the MIG. In all cases, the burden of proof lies with the applicant.

10The applicant’s submissions do not present an argument that she should be removed from the $3,500.00 MIG limit on any of the above grounds. The applicant does not put forward an argument that the accident-related injuries fall outside of the MIG or that the applicant has a pre-existing condition which would preclude recovery if kept within the MIG. The applicant does not discuss the American Medical Association Guides, 6th edition (“AMA Guides”) and does not align any mention of pain to the AMA Guides.

11The applicant’s submissions include clinical notes and records (“CNRs”) of two pages from the family doctor, Dr. Yoel Abells, which included an appointment on December 23, 2021 and another on November 9, 2022. During the December 23, 2021 appointment, Dr. Abells noted and explained to the applicant that she was experiencing primarily muscular pain and that she should continue physiotherapy.

12The applicant also submitted a Minor Injury Treatment Discharge Report dated March 1, 2022, by Dr. Ashley Narula, Chiropractor, in which Dr. Narula indicated that additional intervention outside the MIG was required and that she was submitting OCF-18s.

13The applicant also submits a number of Tribunal Decisions as “relevant law.” These include L.W. v. Co-operators General Insurance Company, 2016 CanLII 93133 (ON LAT), which found that the reduction of physical pain to improve function is a reasonable goal, even in the absence of formal chronic pain syndrome. In 17-002907 v. Aviva Insurance Company, 2018 CanLII 13153 (ON LAT), the applicant submits that the decision found that a chronic pain assessment is reasonable as the applicant was exhibiting enough symptoms/signs leading his practitioners to believe his injuries were more than sprain/strain. The applicant submits that the decision within 7-005218 v. RBC Insurance, 2018 CanLII 81889 (ON LAT), is relevant because in this decision the s. 44 assessor did not review the updated psychological report, and the adjudicator therefore placed more weight on the findings in the updated report. The applicant relies upon the decision within 17-006460 v. Scottish and York, 2018 CanLII 112111(ON LAT), as a psychological assessment was found to be reasonable and necessary on the basis that the MIG does not include in its definition psychological symptoms.

14The respondent submits that the applicant has not met her burden to prove, on a balance of probabilities, that her injuries should be treated outside the MIG, and that the disputed OCF-18s are reasonable and necessary.

15The respondent submits that the applicant does not present any arguments or evidence of any pre-existing medical conditions that may hinder recovery from her accident-related injuries, and that the medical records provided by the applicant support that the applicant sustained minor injuries as a result of the accident. The respondent also submits that the CNR of December 23, 2021 indicates that Dr. Abells noted and explained to the applicant that she was experiencing primarily muscular pain and that she should continue physiotherapy.

16The respondent relies upon the s. 44 General Practitioner report of Dr. Howard Platnick dated January 26, 2024, in which Dr. Platnick concludes that the applicant sustained soft tissue injuries to her neck and back as a result of the motor vehicle accident. Dr. Platnick’s diagnosis was cervical myofascial strain and lumbosacral myofascial strain with no accident-related impairment.

17The respondent references the Tribunal decisions provided by the applicant which pertain to psychological assessments and submits that the applicant has failed to provide any evidence of an accident-related psychological injury.

18The respondent submits that the applicant has failed to submit compelling medical evidence in support of the disputed treatment plans and that the treatment plans are not reasonable or necessary.

19I find that, on a balance of probabilities, the applicant has not pointed me to evidence in support of her claim that she has injuries that fall outside the definition of the MIG. The submissions do not support removal from the MIG based a pre-existing condition, chronic pain, or psychological impairments resulting from the motor vehicle accident. The applicant relies upon the record of Dr. Abells dated December 23, 2021 in which Dr. Abells states that she has explained to the applicant that her injuries, as a result of the motor vehicle accident, are primarily muscular pain. I find the diagnosis consistent with the fact that this appointment was only three weeks after the accident. During the November 9, 2022 appointment with Dr. Abells, the applicant did not mention any accident-related injuries and Dr. Abells assessed the applicant as healthy for her age.

20I have given more weight to the respondent’s submissions because the s. 44 report provided by the respondent indicates that the applicant has suffered post-accident injuries consistent with those categorized as minor and the applicant has not provided evidence that she should be removed from the MIG based on a pre-existing condition, chronic pain diagnosis, or a new psychological impairment.

21The applicant submits a number of Tribunal Decisions as “relevant law.” L.W. v. Co-operators General Insurance Company found that the reduction of physical pain to improve function is a reasonable goal, even in the absence of formal chronic pain syndrome. However, the submissions of the applicant did not point me to evidence to indicate that there was pain with functional impairment. Within 17-002907 v. Aviva Insurance Company, the Tribunal found that a chronic pain assessment was reasonable as the applicant was exhibiting signs and/or symptoms which led his practitioners to believe his accident-related injuries were more than sprains or strains. I was only pointed to two CNRs, and in neither did Dr. Abells assess the pain as chronic. The case law provided by the applicant in 17-005218 v. RBC Insurance and 17-006460 v. Scottish and York was not relevant to the issues in dispute as the applicant did not put forward any arguments or direct me to any evidence in support of a new psychological impairment as a result of the accident-related injuries.

22The applicant does not present arguments or evidence in support of any pre-existing condition. There was no mention of chronic pain or psychological impairments in the CNRs I was pointed to, and no evidence put forward of any functional impairments in the two-page CNRs or the OCF-24 Minor Injury Treatment Discharge Report dated March 1, 2022.

23I find that the applicant has not met her onus of proving that her injuries fall outside the definition of a “minor injury” as defined in s. 3 of the Schedule and she is therefore subject to treatment within the $3,500.00 MIG limit.

24As a result of the finding, the applicant remains within the MIG and it is not necessary to determine if the treatment plans are reasonable and necessary.

Award

25The applicant sought an award under s. 10 of Reg. 664. The Tribunal may grant an award under s. 10 of up to 50 per cent of the total benefits payable, if it finds that an insurer unreasonably withheld or delayed the payment of benefits. As the applicant remains within the Minor Injury Guideline there are no benefits that were unreasonably withheld or delayed, and no award is payable under s. 10 of Reg 664.

Interest

26As there is no overdue payment of benefits, the applicant is not entitled to interest pursuant to s. 51 of the Schedule.

ORDER

27I order the following

i. I find that the applicant has not met her burden of demonstrating that her injuries fall outside the definition of a “minor injury” as defined in s. 3 of the Schedule and she is therefore subject to treatment within the $3,500.00 MIG limit;

ii. As the applicant remains within the MIG there is no entitlement to the benefits at issue;

a) No award is payable;

b) No interest is payable; and

c) The application is dismissed.