Citation: Ghowsi v. Unifund Assurance Company, 2025 ONLAT 24-004792/AABS

Licence Appeal Tribunal File Number: 24-004792/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:

Hadia Ghowsi

Applicant

and

Unifund Assurance Company

Respondent

DECISION

ADJUDICATOR:

Matthew Frontini

APPEARANCES:

For the Applicant:

Moninder Khattra, Counsel

For the Respondent:

Robbie Brar, Counsel

HEARD:

By way of written submissions

1Hadia Ghowski, the applicant, was involved in an automobile accident on December 7, 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, Insurer, 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 the treatment plans/OCF-18s proposed by Physio Fix, as follows:

$4,289.15 for physiotherapy services, in a treatment plan dated June 7, 2023; and
$4,451.94 for a physiotherapy services, in a treatment plan dated June 14, 2023?

iii. Is the applicant entitled to the assessments proposed by Physio Fix, as follows:

$2,200.00 for a psychological assessment, in a treatment plan dated June 7, 2023;
$2,200.00 for a psychological assessment, in a treatment plan dated July 7, 2023; and
$2,200.00 for a psychotherapy assessment, in a treatment plan dated May 24, 2023?

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

RESULT

3I find that:

i. The applicant’s injuries are predominantly minor and therefore the applicant is subject to treatment within the $3,500.00 limit of the MIG;

ii. As the applicant is in the MIG, it is not necessary to consider if the disputed treatment plans are reasonable and necessary;

iii. The applicant is not entitled to interest pursuant to s. 51 of the Schedule; and

iv. The application is dismissed.

ANALYSIS

The applicant is not removed from the MIG

4The applicant is not removed from the MIG. She has not established on a balance of probabilities that she has suffered more than a minor injury because of the accident.

5Section 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.”

6An 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 are kept within the confines of the MIG. The Tribunal has also determined that chronic pain with a functional impairment or a psychological condition may warrant removal from the MIG. In all cases, the burden of proof lies with the applicant.

7In this case, the applicant claims to suffer from chronic pain as the basis for removal from the MIG. As a result, the applicant claims entitlement to medical benefits beyond the MIG funding limit.

The applicant has not established that she suffers chronic pain with a functional impairment warranting removal from the MIG

8I find that the applicant has not established on a balance of probabilities that she suffers chronic pain with a functional impairment warranting removal from the MIG.

9The applicant relies on past Tribunal decisions which held that pain complaints persisting longer than three to six months post-accident constitute chronic pain warranting removal from the MIG and that a formal diagnosis of chronic pain syndrome is not required.

10While the applicant’s submissions refer to other Tribunal decisions, they do not explain how the applicant’s accident-related impairments, and any supporting medical evidence, fits within Tribunal’s analytical framework for chronic pain in this application. Referring to decision where the Tribunal has found that chronic pain warrants removal from the MIG without establishing how the evidence in this application establishes chronic pain is insufficient to meet the applicant’s burden.

11The applicant also makes frequent references in submissions to how much time has passed since the accident. She notes that she has been enduring physical pain and physical limitations for far longer than the three to six months post-accident standard that is typically required for a diagnosis of chronic pain. The applicant submits that this establishes chronic pain warranting removal from the MIG.

12As set out above, persistent complaints of pain over an extended period are insufficient to warrant removal from the MIG. Experiencing pain over a significant length of time is not the only criteria required to establish chronic pain. Medical evidence is also necessary, which the applicant has not identified in her submissions in support of her claims. That evidence must also establish the applicant suffers functional impairments to her applicant’s life. In this case, the applicant’s submissions do not reference any functional impairments, focusing instead on the complaints of pain and need for treatment to reduce her pain.

13Because of the absence of any reference to functional impairments, I find that the applicant’s submissions do not establish on a balance of probabilities that she suffers chronic pain with a functional impairment warranting removal from the MIG.

The applicant is not entitled to the treatment plans in dispute

14As I have found that the applicant is not removed from the MIG, I do not need to consider whether the disputed treatment plans are reasonable and necessary.

Interest

15As I have found that the applicant is not entitled to any overdue payments, she is not entitled to interest.

ORDER

1I find that: