Licence Appeal Tribunal File Number: 23-014610/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:
Yu Jie Ren
Applicant
and
Definity Insurance Company
Respondent
DECISION
ADJUDICATOR:
Aric Bhargava
APPEARANCES:
For the Applicant:
Anil Hampole, Counsel
For the Respondent:
Matthew Owen, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Yu Jie Ren, the applicant, was involved in an automobile accident on October 17, 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, Definity 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 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 $4,416.71 for chiropractic services, proposed by Total Recovery Rehab in a treatment plan/OCF-18 (“plan”) dated June 5, 2023?
iii. Is the applicant entitled to $4,383.90 for chiropractic services, proposed by Total Recovery Rehab in a plan dated September 11, 2023?
iv. Is the applicant entitled to $2,200.00 for a psychological assessment, proposed by Somatic Assessments & Treatment Clinic in a treatment plan dated July 4, 2023?
v. Is the applicant entitled to interest on any overdue payment of benefits?
vi. Is the respondent liable to pay an award under section 10 of Reg 664 because it unreasonably withheld or delayed payments to the applicant?
RESULT
3The applicant is subject to the MIG.
4As the applicant is subject to the MIG, it is not necessary to consider if the treatment plans in dispute are reasonable and necessary.
5As there are no overdue benefits, the applicant is not entitled to interest.
6The applicant is not entitled to an award under section 10 of Reg 664 because no payments were unreasonably withheld or delayed.
ANALYSIS
The applicant is subject to treatment within the MIG
7I find the applicant’s injuries are predominantly minor injuries subject to treatment within the MIG.
8Section 18(1) of the Schedule provide 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.”
9An insured may be removed from the MIG if they can establish that their accident-related injuries fall outside of the MIG or, under section 18(2), that they have a documented pre-existing condition combined with compelling medical evidence stating that the condition precludes 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.
10The applicant submits that he sustained injuries to his lower back with chronic pain radiating to his right thigh, and psychological injuries as a result of the accident. The respondent submits that the applicant suffered soft tissue injuries and has not met his onus to warrant removal from the MIG.
The applicant does not have chronic pain with functional impairment
11I find the applicant has not demonstrated chronic pain with a functional impairment that would remove him from the MIG.
12The applicant relies on the OCF-18s, dated September 11, 2023, and June 5, 2023, both prepared by Dr. Georgia Palantzas, chiropractor, and the clinical notes and records (“CNRs”) of Dr. Gerald Fung, physician.
13According to Dr. Fung’s records, the applicant first visited his family doctor 13 months after the accident on November 17, 2023, and then again 18 months post-accident on April 23, 2024. On both occasions Dr. Fung notes the applicant’s medical history includes “low back pain, mva 2022”.
14I find the CNRs do not support the applicant’s claim of chronic pain due to the accident because his visits with the family doctor were 18 months apart and the applicant did not provide any explanation for this gap. Also, according to the CNRs, no medication was prescribed, no diagnosis was noted, and no treatment or referrals were recommended by the family doctor.
15I am alive to the applicant’s ongoing pain; however, he has not directed me to evidence that he has chronic pain or that he has a resulting functional impairment.
16I find on a balance of probabilities that the applicant does not have chronic pain with a functional impairment that occurred as a result of the accident that warrants removal from the MIG.
The applicant does not have a psychological impairment that warrants removal from the MIG
17I find the applicant has not met his burden to prove that he suffers from a psychological impairment that would warrant removal from the MIG.
18The applicant submits he has concentration and memory issues, feelings of depression, frustration, irritation, worry and stress since the accident.
19The applicant relies on the OCF-18, dated July 4, 2023, prepared by Dr. Mehrdad Pojhan, psychologist, and the pre-screen report, dated June 22, 2023, prepared by Yuling Zhou, psychotherapist, supervised by Dr. Pojhan.
20I find the pre-screen report, dated June 22, 2023 provides limited insight into the applicant’s psychological impairments because the pre-screen report is eight months after the accident, the pre-screen report was based entirely on the applicant’s self-reporting, and no formal diagnosis was provided in the report. Furthermore, none of the complaints reported by the applicant in the pre-screen report were corroborated by the reporting of his family doctor, or any other independent practitioner.
21I find on a balance of probabilities that the applicant has not met his burden to establish that he has a psychological impairment that would warrant removal from the MIG.
22Having found that the applicant is subject to the MIG, I do not need to consider whether the treatment plans in dispute are reasonable and necessary.
Interest
23Interest applies on the payment of any overdue benefits pursuant to section 51 of the Schedule. As no benefits are owed, no interest is payable.
Award
24The applicant sought an award under s. 10 of Reg. 664. Under section 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. The Tribunal has determined that an award is justified where the delay or withholding of benefits by the insurer is unreasonable conduct, meaning “behaviour which is excessive, imprudent, stubborn, inflexible, unyielding or immoderate.” The onus is on the applicant to prove, on a balance of probabilities, that the respondent’s conduct meets this threshold.
25I find an award is not appropriate. The applicant did not submit an argument for an award in his submissions and no benefits have been unreasonably withheld or delayed. As a result, no award is payable.
ORDER
26The applicant is subject to the MIG.
27As the applicant is subject to the MIG, it is not necessary to consider if the treatment plans in dispute are reasonable and necessary.
28As there are no overdue benefits, the applicant is not entitled to interest.
29The applicant is not entitled to an award under section 10 or Reg 664 because no payments were unreasonably withheld or delayed.
30The application is dismissed.
Released: November 14, 2025
Aric Bhargava
Adjudicator