Licence Appeal Tribunal File Number: 23-013910/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:
Faaizah Mohammed
Applicant
and
Unifund Assurance Company
Respondent
DECISION
ADJUDICATOR:
Melanie Malach
APPEARANCES:
For the Applicant:
Kelisa Reyes, Paralegal
For the Respondent:
Paige Schubert, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Faaizah Mohammed, the applicant, was involved in an automobile accident on September 5, 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, Unifund Assurance 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?
ii. Is the applicant entitled to $2,476.00 for a psychological assessment, proposed by Centre for Psychological and Counseling Services in a treatment plan submitted on November 14, 2023?
iii. Is the applicant entitled to $2,200.00 for a chronic pain assessment, proposed by Rehab Pain Management, in a treatment plan submitted on December 8, 2020?
iv. Is the applicant entitled to an income replacement benefit (“IRB”) in the amount of $262.50 per week from September 5, 2021 to June 15, 2022?
v. Is the respondent entitled to a repayment in the amount of $1,227.49 (weekly IRB amount of $262.50, from February 14, 2022 to June 28, 2022), plus interest, for overpayment of IRBs?
vi. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
vii. Is the applicant entitled to interest on any overdue payment of benefits?
3The Case Conference Report and Order (“CCRO”) lists issue 2 as, “Is the applicant entitled to an income replacement benefit in the amount of $400.00 per week from June 29, 2022, to ongoing?” In the applicant’s submissions, she states that the issue in dispute is IRBs in the amount of $262.50 per week from June 29, 2022 to present. She then states in the body of her submissions that she will be limiting her IRB claim from the date of loss to the stoppage date of June 15, 2022. Therefore, the issue in dispute is actually, “Is the applicant entitled to an income replacement benefit in the amount of $262.50 per week from September 5, 2021 to June 15, 2022?”
RESULT
4The applicant’s accident-related injuries are predominantly minor and she is therefore subject to treatment within the $3,500.00 limit of the MIG.
5The applicant is not entitled to the treatment plans for a chronic pain assessment or a psychological assessment.
6The applicant is not entitled to additional IRBs, interest or an award.
7The respondent is entitled to a repayment of $1,227.49, plus interest for overpayment of IRBs.
8The respondent is not required to pay an award.
9The applicant is not entitled to interest on any overdue payment of benefits.
ANALYSIS
The applicant sustained predominantly minor injuries as defined under the Schedule
10I find that the applicant’s accident-related injuries are predominantly minor and she is therefore subject to treatment within the $3500.00 limit of the MIG.
11Section 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) of the Schedule defines a “minor injury” as “one or more of a strain, sprain, whiplash associated disorder, contusion, abrasion, laceration or subluxation and includes any clinically associated sequelae to such an injury.”
12An 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) of the Schedule, that they have a documented pre-existing condition combined with compelling medical evidence stating that the condition precludes maximal medical recovery if they are 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.
13In this matter, the applicant submits that she should be removed from the MIG based on her pre-existing medical condition. She further submits that she should be removed from the MIG because she suffers ongoing pain and a psychological impairment.
a. The applicant is not removed from the MIG based on a pre-existing condition
14I find that the applicant has not proven on a balance of probabilities that she suffers from a pre-existing medical condition that would warrant removal from the MIG.
15The applicant submits that she should be removed from the MIG based on a pre-existing back fracture sustained in 2017.
16The respondent submits that there is no medical evidence to support any issues with the applicant’s back, either before or after the accident. The respondent relies upon the Consultation Report of Dr. Angel of William Osler Health System, dated October 24, 2017 which stated, “For a couple of months, Ms. Mohammed had difficulty bending forward, but with time and physiotherapy things have gradually improved and she has gotten back to her baseline of function.”
17While I accept the applicant’s evidence that she suffered a back injury in 2017, I find that the applicant has not met her onus of providing evidence from a health practitioner that a pre-existing medical condition will prevent her from achieving maximal medical recovery if she is subject to the MIG limits.
18For the reasons set out above, I find that the applicant has not proven on a balance of probabilities that she suffers from a pre-existing medical condition that would prevent maximal medical recovery if she is subject to the MIG and therefore she is not removed from the MIG on this basis.
b. The applicant is not removed from the MIG based on a chronic pain condition
19I find that the applicant has not proven on a balance of probabilities that she suffers from a chronic pain condition as a result of the accident that would warrant removal from the MIG.
20Chronic pain conditions are not included in the minor injury definition. In order to establish that the applicant has a chronic pain condition, he must demonstrate that his pain causes a functional impairment which adversely affects his well-being. The Tribunal has found that the criteria for a chronic pain condition outlined by the American Medical Association’s Guides to the Evaluation of Permanent Impairment (“AMA Guides”) to be a useful interpretive tool. A diagnosis of chronic pain, absent evidence of an ongoing functional impairment due to pain, is insufficient to establish a non-minor injury.
21The applicant submits that she should be removed from the MIG because her ongoing pain complaints have become chronic. The applicant argues that she should be removed from the MIG because the respondent found that she met the pre-104-week test for IRBs and sustained a substantial inability to perform the essential tasks of her pre-accident employment as a result of the accident. The applicant submits that it is inconsistent for the respondent to acknowledge that her injuries prevent her from returning to work, and simultaneously maintain that her injuries fall within the MIG confines.
22The applicant relies upon the Clinical Notes and Records (“CNRs”) from Mississauga Hospital on the day of the accident which note headache, abdominal pain, along with mild burning in the right arm. She claims that she informed the EMS that she was dizzy and had hit her head on the front and side airbag. She submits that the Disability Certificate (“OCF-3”), completed at Healthmax Etobicoke, dated October 16, 2021, supports that she sustained post-traumatic headaches as a result of the accident. The applicant also relies upon the CNR of her family physician, Dr. Saira Hussaini, dated September 8, 2021, where she was assessed with bilateral arm pain, neck strain and right-hand pain and the CNR dated October 8, 2021, where she is assessed with right-sided abdominal pain, possibly musculoskeletal in nature. She further relies on the CNR of Dr. Ishan Waraich, family physician, dated February 8, 2023 which notes she is experiencing headaches and nausea.
23The respondent submits that the applicant suffered minor injuries in the accident and that her injuries fall within the MIG. It relies upon the Insurer Examination (IE) report of Dr. Ijaz Chaudhry, general practitioner dated April 16, 2024, that concluded that the applicant suffered uncomplicated soft tissue injuries only without evidence of significant musculoskeletal or neurological sequela which would be consistent with ‘minor injuries’ as defined in the Schedule.
24The respondent submits that other than the CNR dated September 8, 2021, there is no further mention of the accident or accident-related complaints in Dr. Hussain’s records. In addition, while the applicant saw her family doctor, Dr. Waraich, on multiple occasions post-accident, there was no mention of the accident or any accident-related complaints in his records. The respondent submits that there were never any referrals made to specialists, nor any ongoing medications prescribed. The respondent argues that within the CNRs relied upon by the applicant, there is no statement or suggestion that the applicant’s injuries are beyond minor, and the applicant has not submitted any independent medical evidence to substantiate that her injuries are not minor.
25In reply, the applicant submits that her ongoing pain is chronic in nature based on her consistent complaints to the s. 44 assessors, over six months post-accident. The applicant criticizes the IE report of Dr. Chaudry because he failed to provide an explanation as to why she is still experiencing lumbar pain over two years after the accident and he failed to address whether the applicant’s pre-existing 2017 sledding injury is contributing to her current lumbar pain.
26I find that the applicant has not demonstrated that she suffers from a chronic pain condition as a result of the accident. The applicant has not demonstrated that she is functionally impaired by pain. My reasoning is based on the following findings.
27First, I agree with the respondent that other than the CNRs of Dr. Hussaini, dated September 8, 2021 and October 8, 2021, immediately following the accident, the applicant did not subsequently report any accident-related injuries to Dr. Hussaini. In addition, upon review of the CNRs of Dr. Waraich, the applicant was seen multiple times post-accident and there were no accident-related complaints noted within these records. Therefore, I find that the records of Dr. Hussaini and Dr. Waraich do not support the applicant’s submissions that she suffers from chronic pain.
28Second, I find that the applicant has provided insufficient evidence to support that she suffers an ongoing functional impairment as a result of the accident. I do not agree with the applicant’s submissions that just because she received IRBs post-accident, that this automatically removes her from the MIG because the test for entitlement to an IRB is substantially different from the test to remove oneself from the MIG. I find that the applicant has not directed the Tribunal to sufficient medical evidence supporting that her injuries affected her functional impairment on an ongoing basis or that they affected her ability to perform her work duties on an ongoing basis. I further find that IE report of Dr. Chaudhry, dated April 16, 2024, noted that she was off work for one-month post-accident, and she was able to return to work on modified duties. She described her work as sedentary and not physically demanding. I find that the applicant has not provided any particulars on what limitations she suffered in returning to work to support that she suffered ongoing functional impairments as a result of the accident.
29Finally, I find that there is no actual diagnosis of chronic pain or chronic pain syndrome in the CNRs, and the applicant’s submissions do not engage with any of the six criteria under the AMA Guides. Indeed, while the applicant may have ongoing pain, I do not find that her pain causes the type of functional impairment that would warrant removal from the MIG, as her accident-related prescription history has not been provided, she has not been referred to any specialists by her family physician, she has not identified any functional issues with her daily activities and she returned to work at her job post-accident. In his IE report, Dr. Chaudhry confirmed that the applicant sustained primarily soft tissue injuries that would not prevent maximal medical recovery under the MIG. On the evidence, I see no reason to interfere with Dr. Chaudhry’s opinion and it is not rebutted by any other medical opinion.
30For the reasons outlined above, I find that the applicant has not proven on a balance of probabilities she suffers from a chronic pain condition as a result of the accident and therefore she is not removed from the MIG on this basis.
c. The applicant is not removed from the MIG on the basis of a psychological condition
31I find that the applicant has not proven on a balance of probabilities that she suffers from a psychological condition that would warrant removal from the MIG.
32The applicant submits that she suffered a psychological impairment as a result of the accident, and she should therefore be removed from the MIG. She submits that she made psychological complaints of anxiety to Dr. Saghatoleslami in his IE psychological assessment dated February 7, 2023. She submits in reply that Dr. Saghatoleslami’s report dismissed the potential emotional impact the accident had on her and failed to delve into the annoyance she feels when talking about the accident.
33The respondent submits that the applicant did not suffer a psychological impairment as a result of the accident. It submits that the applicant has not provided any independent medical evidence to support that she suffers a psychological impairment and that there is no mention of any psychological or mental health symptoms in the records of the applicant’s family physician or treatment providers. It relies upon the IE psychological report of Dr. Saghatoleslami, dated February 7, 2024 which concludes that the applicant did not suffer any mental health disorders.
34I find that the applicant has provided insufficient medical evidence to support that she sustained an accident-related psychological condition that would remove her from the MIG. Other than the psychological pre-screening report submitted by Dr. Mohammed El-Saidi, psychiatrist, dated November 9, 2023, I find that the applicant has not directed me to any other medical evidence to support that she suffers from a psychological condition.
35I find that the psychological pre-screening report lacks evidentiary weight. The report is not based on a review of the applicant’s medical records or any psychometric objective testing. Instead, it relies solely on the applicant’s self-reports as to her clinical history and her symptoms. It is unclear what basis, other than the applicant’s self-reports, Dr. El-Saidi has for his recommendation that the applicant undergo a psychological assessment.
36I further find that upon review of the CNRs of Dr. Hussaini and Dr. Waraich, the applicant was seen multiple times following the accident, yet there is no mention of any psychological complaints throughout the CNRs. I therefore find that there is no support in these records that the applicant was suffering a psychological impairment.
37Finally, I find the IE report of Dr. Saghatoleslami persuasive and comprehensive. Dr. Saghatoleslami notes during the clinical interview that with the exception of feeling annoyed by talking about the accident and wanting to move on, she did not identify experiencing any psychological distress in relation to the accident. She stated that she did not report feeling sad or down or experiencing any fluctuation in her mood. She did not endorse any affective or physiological symptoms of anxiety and has resumed driving. Dr. Saghatoleslami concluded that the psychometric testing did not reveal any marked psychological distress and she did not suffer from a psychological impairment as a result of the accident that was significant enough to require psychiatric intervention.
38For the reasons outlined above, I find that the applicant has not proven on a balance of probabilities she suffers from a psychological condition as a result of the accident and therefore she is not removed from the MIG on this basis.
The applicant is not entitled to the treatment plans for a chronic pain assessment and a psychological assessment
39As I have found that the applicant remains in the MIG, it is unnecessary for me to consider the reasonableness and necessity of the disputed treatment plans for a chronic pain assessment and a psychological assessment.
40As an alternative argument, the applicant submits that the treatment plans in dispute are payable pursuant to s. 38(11) of the Schedule, as the respondent did not comply with the notice requirements of s. 38(8) of the Schedule.
41Section 38(8) of the Schedule requires an insurer to provide its medical and all other reasons for a denial within 10 business days after receipt of a treatment plan. If an insurer fails to provide the requisite denial, under s. 38(11)2 it is required to pay for all goods and services described in the treatment plan that relate to the period incurred from the 11th business day after the treatment plan was submitted until the proper denial is given.
a. The respondent’s denial notice in respect to the treatment plan for a chronic pain assessment was compliant with s. 38(8) of the Schedule
42The respondent denied the treatment plan for a chronic pain assessment submitted on December 8, 2023, by way of letter dated December 18, 2023. On February 13, 2024, the respondent sent a second letter denying the treatment plan and advised that it required the applicant to attend an IE. On February 14, 2024, the respondent sent a notice of examination indicating that an IE with Dr. Isa Mohammed, general practitioner, was scheduled for March 6, 2024.
43The applicant submits that the respondent’s denial letters are in direct violation of s. 38(8) of the Schedule as they fail to reference any medical documentation on file and rendered generic opaque responses. The applicant further submits that the respondent did not schedule an IE until 57 days after the initial denial letter was sent on December 18, 2023. The applicant argues that the respondent’s initial denial letter did not mention that an IE would be required.
44I find upon review of the December 18, 2023 denial letter, that the respondent provided a clear and unequivocal denial, complaint with s. 38(8) of the Schedule. I find that the correspondence contains straightforward and clear language, sufficient to allow an unsophisticated person to make an informed decision to either accept or dispute the decision at issue. I find that the respondent clearly identified the treatment plan in dispute and provided the medical and other reasons for the denial of the assessment. I find that the respondent advised the applicant that based on the information on file, her injuries fall under the MIG and therefore the treatment plan was not reasonable and necessary. It advised the applicant that it does not have compelling medical evidence to support that she sustained non-minor injuries as a result of her accident that occurred two years ago and requested medical records in support. It further confirms that the applicant has not actively participated in treatment since December 2021.
45I do not accept the applicant’s argument that the denial does not comply with s. 38(8) because the respondent did not schedule the IE until 57 days after the initial denial letter was sent on December 18, 2023. The applicant has not provided any authority for this position.
46For the reasons set out above, I find that the applicant has not demonstrated on a balance of probabilities that the treatment plan recommending a chronic pain assessment is payable due to non-compliance with s. 38(8) of the Schedule.
b. The respondent’s denial notice in respect to the treatment plan for a psychological assessment was compliant with s. 38(8) of the Schedule
47The respondent denied the treatment plan for a psychological assessment submitted on November 17, 2023, by way of letter dated November 29, 2023. On November 30, 2023, the respondent sent a notice of examination indicating that an IE with Dr. Marjan Saghatoleslami, psychologist, was scheduled for January 12, 2024.
48The applicant submits that the respondent’s denial letter was non-compliant with s. 38(8) of the Schedule. The applicant submits that the respondent failed to reference any of the applicant’s medical documentation instead stating, “there is insufficient compelling medical evidence provided by your health practitioner showing your prior medical condition will not allow for a full recovery under $3,500.00 limit”.
49I find upon review of the November 29, 2023 denial letter, that the respondent provided a clear and unequivocal denial, complaint with s. 38(8) of the Schedule. I find that the correspondence contains straightforward and clear language, sufficient to allow an unsophisticated person to make an informed decision to either accept or dispute the decision at issue. I find that the respondent clearly identified the treatment plan in dispute and provided the medical and other reasons for the denial of the assessment. I find that the respondent advised the applicant that it reviewed the treatment plan and the medical documentation provided and compared it to the criteria in the MIG. It determined that her impairment is predominantly a minor injury. It advised the applicant that it does not have compelling medical evidence to support that she sustained a psychological impairment as a result of her accident that occurred two years ago and requested that she attend an IE.
50For the reasons set out above, I find that the applicant has not demonstrated on a balance of probabilities that the treatment plan recommending a psychological assessment is payable due to non-compliance with s. 38(8) of the Schedule.
Entitlement to an Income Replacement Benefit
51I find that the applicant is not entitled to any additional payment of IRBs, interest or an award.
52The applicant in her submissions indicates that she is limiting her IRB claim from the date of loss to the stoppage date of June 15, 2022. The applicant submits that she was paid an IRB of $262.50 per week from September 12, 2021 to June 15, 2022. The respondent submits that she was paid IRBs up to June 28, 2022. Therefore, there is no dispute about the applicant’s eligibility to ongoing IRBs. However, the applicant then submits that she is seeking interest on IRBs owed from December 13, 2021, the date the OCF-2 was received, to June 1, 2022, the date the respondent paid her IRBs. She also is seeking a 50% award for the delayed payment of IRB payments.
53The applicant claims that she submitted her Application for Accident Benefits (“OCF-1”) to the respondent on October 21, 2021, her Employer’s Confirmation Form (“OCF-2”) on December 13, 2021, and her OCF-3 on November 11, 2021.
54The respondent submits that the OCF-3 was not received in its office until February 11, 2022. In response, the applicant submits that the Account Summary of Healthmax Etobicoke indicates that the OCF-3 was submitted to the respondent and invoiced on November 11, 2021. She submits that this is further confirmed by the adjuster log notes entry dated December 9, 2021, which indicates that Healthmax was paid $200.00 for the OCF-3.
55The respondent submits that it issued payment of IRBs as fast as it reasonably could, once all required information was received. It submits that by letter dated February 15, 2022, the respondent requested a completed Election of Weekly Benefit (“OCF-10”) in accordance with s. 36(4)(c) and s. 33 of the Schedule. The respondent followed up for the OCF-10 in letters dated March 11, 2022 and April 8, 2022. The OCF-10 was finally received on April 11, 2022. By letter dated April 12, 2022, the respondent enclosed the IRB cheque for the period of September 12, 2021 to April 19, 2022. The Adjuster Log Notes confirm that on May 30, 2022, counsel for the applicant advised that the applicant had not received her IRB cheque and requested that the cheque be re-issued. A cheque was re-issued on June 1, 2022 for payment of IRBs from September 12, 2021 to May 31, 2022.
56I find that there is no dispute about the applicant’s entitlement to IRBs as the applicant has limited her claim from September 5, 2021 to June 15, 2022. With respect to the applicant’s claim for interest and award due to the delay in receiving payment, I do not find that she is entitled to same.
57Interest applies on the payment of any overdue benefits pursuant to s. 51(2) of the Schedule. Under s. 10 of Regulation 664, the Tribunal may grant an award of up to 50 percent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits.
58I find that there is a discrepancy with the date that the applicant’s OCF-3 was received by the respondent. I find that while the applicant submits that the OCF-3 was submitted on November 11, 2021, the respondent maintains that it was not in receipt of the OCF-3 until February 11, 2022. While the applicant submits that the fact the respondent paid for the cost of the OCF-3 on December 9, 2021 implies that it was received on November 11, 2021, the Tribunal has not been provided with any additional documentation to support when the OCF-3 was submitted to the respondent. Therefore, with the onus on the applicant, on a balance of probabilities I am unable to determine the date that the OCF-3 was received.
59I find that the respondent requested an OCF-10 on February 15, 2022, and despite numerous follow up letters, the applicant did not provide a completed OCF-10 until April 11, 2022. Immediately upon receipt of the OCF-10, the respondent issued payment of IRBs to the applicant on April 12, 2022. While the applicant submits that she did not receive her cheque until June 1, 2022, the Adjuster Log Notes confirm that a cheque was issued and mailed to the applicant on April 12, 2022. I find that upon receiving notice that the applicant had not received her cheque, the respondent reissued the cheque on June 1, 2022.
60I do not find that the applicant has proven on a balance of probabilities that the delay in receiving her IRB cheque was intentional on the part of the respondent. The applicant has not proven that the respondent unreasonably withheld payment of her IRBs. I therefore do not find that she is entitled to interest or an award for the delay.
61For the reasons set out above, I do not find that the applicant has proven on a balance of probabilities that she is entitled to an additional payment of IRBs, interest or an award.
Repayment of Income Replacement Benefits
62The respondent is seeking repayment of IRBs totaling $1,227.49, paid between February 14, 2022 and June 28, 2022.
63Under s. 52(1) of the Schedule, a person is liable to repay to the insurer any benefit that is paid to the person in error on the part of the insurer, the insured person or any other person, or as a result of a willful misrepresentation. Sections 52(2) and (3) require an insurer to give the insured person notice of the amount that is required to be repaid within 12 months after the payment of the amount that is to be repaid, unless it was originally paid to the insured person as a result of willful misrepresentation or fraud.
64The respondent submits that on July 12, 2022, the respondent sent a letter to the applicant providing notice of the overpayment and requested repayment pursuant to s. 52(1)(c) of the Schedule. It advised the applicant that there was a possible discrepancy or misrepresentation of employment details. It notes that the applicant reported that she returned to work in February or March of 2022, however, the respondent had continued to pay an IRB up until June 28, 2022, as it had not been notified of her return to work. Section 33 requests were also outlined in order to determine the amount of the overpayment amount.
65On August 11, 2022, the respondent provided a follow-up letter. On October 11, 2022, the respondent sent a second follow-up letter advising the applicant that her legal representative had confirmed on September 30, 2022, that she had returned back to work on February 14, 2022. The letter confirms the repayment amount of $1,227.89 and its request for repayment in accordance with s. 52(1)(c). The respondent submits that it followed up a number of times for the overpayment amount and interest in letters dated May 9, 2023, November 8, 2023 and March 26, 2024 and no response was received from the applicant.
66The applicant submits that the respondent’s letter dated July 12, 2022 seeking repayment is non compliant with s. 52(2)(a) of the Schedule as it fails to outline the amount of the alleged overpayment. She submits that the respondent failed to notify the applicant of the overpayment amount until October 11, 2022, which is an unreasonable delay.
67I find that the applicant returned to work without notifying the respondent. As a result, she continued to be paid IRBs by the respondent in error. I find that the respondent’s letter dated July 12, 2022, properly notified the applicant of its concerns about a discrepancy with her return to work and advised the applicant that it was seeking repayment. The respondent then made s. 33 requests including a request for the exact date she returned to work. The applicant did not reply to this request until September 30, 2022, when her counsel advised the respondent that she returned to work on February 14, 2022. I find that the respondent then sent the applicant a letter on October 11, 2022, setting out the amount of the repayment.
68I do not agree with the applicant that the July 12, 2022 letter is non-compliant with s. 52(2)(a) of the Schedule because it did not state the amount of the alleged overpayment in this letter. I find that the respondent clearly requested further clarification of the date the applicant returned to work in order to determine the amount of the overpayment. It therefore could not advise the applicant what the amount of the repayment was until it received confirmation of the date she returned to work. Any delay in advising the applicant of the amount of the repayment was due to her own inaction of confirming the date she returned to work.
69The respondent also seeks interest on the repayment. Sections 52(5) and (6) of the Schedule provide guidance on when an insurer may recover interest when seeking repayment. The insurer may charge interest on the outstanding balance of the amount to be repaid for the period starting on the 15th day after the notice is given and ending on the day repayment is received in full, calculated at the bank rate in effect on the 15th day after the notice is given.
70For the reasons set out above, I find that the respondent is entitled to a repayment of IRB in the amount of $1,227.89, plus interest pursuant to s. 52(5).
Interest
71The applicant claims entitlement to interest on overdue benefits. Given that there are no benefits owed to the applicant, she is not entitled to interest pursuant to s. 51 of the Schedule.
Award
72The applicant seeks an award under s. 10 of Reg. 664 because she submits that the respondent unreasonably withheld or delayed the payment of benefits. As I have found that the respondent did not unreasonably withhold or delay payment of any benefit, no award is warranted.
ORDER
73For the reasons set out above, I find:
i. The applicant’s accident-related injuries are predominantly minor, and she is therefore subject to treatment within the $3,500.00 limit of the MIG;
ii. The applicant is not entitled to the treatment plans for a chronic pain assessment and a psychological assessment;
iii. The applicant is not entitled to any additional IRBs, interest or an award;
iv. The respondent is entitlement to repayment of $1,227.49, plus interest for overpayment of IRBS;
v. The respondent is not required to pay an award; and
vi. The applicant is not entitled to interest on any overdue payment of benefits.
Released: November 4, 2025
Melanie Malach
Adjudicator