Licence Appeal Tribunal File Number: 23-013510/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:
Meng Qiao Liu
Applicant
and
Echelon Insurance
Respondent
DECISION
ADJUDICATOR:
Rasha El Sissi
APPEARANCES:
For the Applicant:
Ryan Olson, Paralegal
For the Respondent:
Gabrielle Nigro, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Meng Qiao Liu, the applicant, was involved in an automobile accident on February 25, 2022, 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, Echelon Insurance, 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 section 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 $4,457.20 for physiotherapy treatment proposed by Uheal Rehabilitation Centre in a treatment plan/ OCF-18 (“plan”) submitted August 1, 2022?
iii. Is the applicant entitled to $2,200.00 for psychological treatment, proposed by Somatic Assessments and Treatment Clinic in a plan submitted April 1, 2022?
iv. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
v. Is the applicant entitled to interest on any overdue payment of benefits?
3On January 17, 2025, the respondent advised the Tribunal and the applicant by email that the issue of the partial denial of the treatment plan for chiropractic treatment listed as issue 2.a) in the Case Conference Report and Order released on May 7, 2024 (“CCRO”) had been resolved. The respondent provided a copy of a letter to the applicant from the respondent’s representative, Raman Singh, Accident Benefits Claims Adjuster, dated January 17, 2025. The letter indicates that the respondent had reconsidered the treatment plan from Uheal Rehabilitation Centre in the amount of $1,300.00, submitted May 26, 2022, which the respondent had partially approved for $1,050.62. The letter states that the respondent has determined that the treatment plan is reasonable and necessary as a result of the applicant’s injuries sustained in the subject accident and has been approved in full. In her submissions, the applicant did not dispute that this issue has now been resolved.
4Accordingly, issue 2.a) as listed in the CCRO is no longer an issue in dispute for this hearing.
RESULT
5I find that:
i. The applicant’s injuries are predominantly minor and therefore subject to treatment within the $3,500.00 limit of the MIG;
ii. The applicant is not entitled to the treatment plans in dispute; and
iii. No interest or an award is payable.
ANALYSIS
MIG
6Section 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. 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.”
7The applicant may be removed from the MIG if she can establish her accident-related injuries fall outside of the MIG or, under section 18(2), that she has a documented pre-existing condition combined with compelling medical evidence stating that the condition precludes maximal recovery if she is kept within 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.
The applicant’s injuries
8I find that the applicant has not met her onus to demonstrate that her accident-related impairments warrant removal from the MIG.
9The applicant submits that she sustained serious physical and psychological injuries in the accident.
10The respondent submits that the applicant has not provided compelling medical evidence to prove that her accident-related injuries fall outside of the MIG.
11With respect to her physical injuries, it is not clear whether the applicant is arguing that she should be removed from the MIG on this basis. The applicant submits that she consulted with Mr. Ahmed Afifi, physiotherapist, of Uheal Rehabilitation Centre. However, the applicant did not provide any medical evidence about her physical injuries, nor did she provide records from Uheal Rehabilitation Centre. The respondent further submits that the applicant did not consult an OHIP funded medical practitioner for physical and pain symptoms after the accident. The applicant did not dispute this or clarify her physical impairments in reply. Without any specific submissions or medical evidence on the issue of accident-related physical impairments, I find no basis to remove the applicant from the MIG due to physical injuries.
12With respect to her psychological injuries, the applicant points to a psychological consultation report dated March 29, 2022, by Dr. Sharleen McDowall, psychologist, and Ms. Mandy Fang, registered psychotherapist. She also points to a consultation with a physician, Dr. Ramtin Samie, on July 21, 2022, about her mental health since the accident.
13The respondent submits that the evidence of psychological symptoms submitted by the applicant is insufficient to remove her from the MIG. The respondent points to a number of Tribunal cases in support of its position.
14I find that there is evidence that the applicant initially experienced psychological symptoms related to the accident, based on the consultation note of Dr. Samie, on July 21, 2022, about five months after the accident.
15However, the applicant does not direct me to any medical evidence that she continued to report psychological symptoms related to the accident after this encounter with Dr. Samie. There is no evidence that she discussed her symptoms or sought any treatment for her psychological symptoms with any physician post-July 2022, including Dr. Samie.
16Thus, I am not persuaded that the applicant should be removed from the MIG due to a psychological condition because there is a lack of evidence that she required treatment for accident-related psychological impairments beyond the initial period after the accident. A measure of psychological impact is expected to accompany minor injuries and is specifically contemplated in the MIG’s “functional restoration approach”.
17Dr. Samie’s note on July 21, 2022 records the applicant’s mental health concerns, consisting of flashbacks, anxiety and depressive symptoms since the accident. Dr. Samie assessed “GAD” (generalized anxiety disorder). He noted she reported a history of depression. His note records “PHQ-9: 16 – Moderate Depression” and “GAD-7: 20 – Severe Anxiety”, suggesting Dr. Samie performed testing during the encounter. Dr. Samie referred the applicant to Dr. Michael Kaufmann, psychiatrist. Dr. Samie counselled follow-up with a mental health counsellor or psychologist if the wait time for Dr. Kaufmann was too long, and follow-up with Dr. Samie in one month.
18The respondent submits that the applicant did not follow-up with Dr. Samie or see Dr. Kaufmann or consult any other OHIP-funded practitioner for mental health concerns after July 21, 2022, until the end of the evidentiary record in 2024. The applicant did not address the lack of ongoing reports of psychological symptoms in her reply.
19I find that Dr. McDowall’s psychological consultation report, dated in March 2022, a month after the accident, corroborates Dr. Samie’s assessment that the applicant was experiencing accident-related psychological symptoms in the initial months after the accident. However, Dr. McDowall’s report, conducted only one month post-accident, pre-dates Dr. Samie’s assessment and therefore is also evidence only pertaining to the initial period after the accident. There is no evidence that the applicant followed up with Dr. McDowall, or any other mental health counsellor or psychologist, after April 2022.
20The respondent cites the Tribunal decision Mathyaparanam v TD General Insurance Company, 2023 CanLII 19836 (ON LAT) (“Mathyaparanam”). In Mathyaparanam, the respondent submits that the Tribunal concluded that the applicant did not sustain a psychological impairment warranting removal from the MIG, as there was no evidence that he reported ongoing psychological symptoms to a primary care physician or mental health practitioner after the initial post-accident period, or that he sought any form of mental health treatment. The respondent submits that the Tribunal further stated that, while the applicant obtained a psychological report two months post-accident, it would not be unexpected that the applicant would be experiencing some psychological distress around that time.
21While I am not bound by other decisions of the Tribunal, I agree with the reasoning in Mathyaparanam that lack of evidence of ongoing accident-related psychological symptoms results in the applicant not establishing that they should be removed from the MIG because of a psychological condition. The applicant did not put forward any cases on this issue in her written submissions or reply.
22The applicant submits that, because the respondent did not obtain a section 44 assessment of the applicant’s psychological condition, on a balance of probabilities, it should be found that the applicant suffers from a psychological impairment that removes her from the MIG.
23The respondent submits that the applicant has failed to submit any medical documentation to the respondent that would establish injuries beyond the MIG or to support a need for section 44 examinations.
24The applicant has the onus to establish, more likely than not, that she sustained accident-related injuries that fall outside the MIG. In this case, I find that the applicant has not led sufficient objective medical evidence to meet her burden of proof.
25I agree that while an insurer may require a section 44 examination, it is not required to do so, especially in a case where the objective medical record doesn’t support it. The burden is on the applicant to prove she should be removed from the MIG, not on the respondent to prove she should remain.
26On the totality of the evidence, I find that the applicant does not have a psychological impairment as a result of the accident that warrants removal from the MIG.
27As I find that the applicant’s accident-related injuries are predominantly minor, these injuries are subject to treatment within the MIG limit. Therefore, it is not necessary for me to consider whether the plans in dispute are reasonable and necessary.
28The applicant submitted that the respondent failed to meet the requirements of section 38(8) of the Schedule and the consequences of section 38(11) should apply. The applicant stated that this pertains to the treatment plan dated May 25, 2022 that was received by the respondent on May 26, 2022. This appears to be the treatment plan identified as issue 2a) in the CCRO that was subsequently paid in full by the respondent and thus is no longer an issue in dispute for this hearing. Accordingly, I have not addressed this submission because the issue is moot.
Interest
29Interest applies on the payment of any overdue benefits pursuant to section 51 of the Schedule. As no payments of benefits are overdue, the applicant is not entitled to any interest.
Award
30The applicant sought an award under s. 10 of Reg. 664. Under s. 10, the Tribunal may grant an award 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 I find that no benefits were withheld, there is no basis for an award.
ORDER
31For the reasons stated above, I find that:
i. The applicant’s injuries are predominantly minor and therefore subject to treatment within the $3,500.00 limit of the MIG;
ii. The applicant is not entitled to the treatment plans in dispute; and
iii. No interest or an award is payable.
Released: October 8, 2025
Rasha El Sissi
Adjudicator