Licence Appeal Tribunal File Number: 24-002968/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:
Ghazala Sheikh
Applicant
and
Intact Insurance Company
Respondent
DECISION
ADJUDICATOR: Harouna Saley Sidibé
APPEARANCES:
For the Applicant: Ilona Agivaeva, Counsel
For the Respondent: Kathy Conteh, Counsel
HEARD: By way of written submissions
OVERVIEW
1Ghazala Sheikh, the applicant, was involved in an automobile accident on September 24, 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, Intact 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?
ii. Is the applicant entitled to $1,696.25 for physiotherapy services, proposed by Centenary Physio and Rehab in a treatment plan/OCF-18 (“plan”) submitted on March 25, 2023?
iii. Is the applicant entitled to $2,592.33 for a psychological assessment, proposed by Medex Assessments Inc., in a plan submitted on February 21, 2024?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3For the reasons below, I find that:
The applicant’s impairments are predominantly minor, and thus, the MIG limit applies.
As the applicant is subject to the MIG, it is not necessary to consider whether the disputed treatment plans are reasonable and necessary.
The applicant is not entitled to interest.
ANALYSIS
Are the applicant’s injuries predominantly minor?
4I find that the applicant’s injuries are predominantly minor, and thus, the MIG monetary applies.
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 injury or 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.
7The applicant argues that she should be removed from the MIG because of documented pre-existing conditions that hinder her recovery within the MIG framework.
Pre-existing Condition
8The applicant relies on medical records from her family physician, Dr. Sheeja Bavakutty Mohammed, and specialists Drs. A. Kachooie (a physiatrist) and Kamini Manokaran (a rheumatologist). These records document diagnoses of cervical radiculopathy, carpal tunnel syndrome, and chronic pain prior to the accident. The applicant argues that these conditions were aggravated by the collision and hinder her recovery.
9The respondent argues that the applicant’s injuries are predominantly soft-tissue injuries, consistent with simple strains and sprains. It cites the insurer examination by Dr. Alisa Naiman (a physician), who concluded that the applicant sustained minor injuries with no objective signs of radiculopathy or myelopathy.
1) Documented Pre-existing Condition
10The medical evidence confirms that the applicant was diagnosed with cervical radiculopathy on December 5, 2020, by Dr. Mohammed and again by Dr. Manokaran on January 13, 2021. Imaging dated July 3, 2021, revealed degenerative changes in the thoracic spine.
11On June 13, 2022, Dr. Mohammed diagnosed the applicant with carpal tunnel syndrome, which was confirmed by Dr. Kachooie, and she was referred to a plastic surgeon, Dr. Sandra Voice.
12I accept that the applicant had documented pre-existing degenerative conditions prior to the accident. However, to warrant removal from the MIG under section 18(2), the evidence must demonstrate that these conditions would prevent maximal recovery from the minor injuries sustained in the accident.
2) Prevention from Maximal Recovery
13The applicant did not submit a medical opinion from a treating practitioner explicitly stating that her pre-existing conditions would prevent recovery within the MIG. While her records reference pain and degenerative findings, they do not contain a clinical opinion linking these conditions to impaired recovery if kept within the MIG.
14Dr. Naiman acknowledged the applicant’s underlying degenerative changes but did not relate the ongoing symptoms to those conditions. He opined that functional recovery should have occurred within 14 months post-accident and characterized the impairments as WAD II and lumbar sprain/strain, with no objective evidence of radiculopathy or myelopathy. He assessed the prognosis as fair and noted that the impairments should have resolved within 16 to 20 weeks. Notably, his opinion does not indicate that the applicant’s pre-existing conditions would prevent recovery within the MIG framework; instead, it suggests that recovery was anticipated regardless of those conditions. No medical evidence is provided that being kept within the MIG would preclude recovery due to pre-existing conditions.
15On a balance of probabilities, I find that the applicant has not established that her pre-existing conditions prevented her from achieving maximal recovery under the MIG.
16Accordingly, I find on a balance of probabilities that the applicant’s impairments are predominantly minor and subject to the MIG limits.
Is the applicant entitled to the disputed treatment plans?
17As the applicant remains within the MIG, I do not need to address the reasonableness or necessity of the disputed treatment plans.
Interest
18Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since no benefits are payable based on the findings above, there are no overdue amounts on which interest can accrue.
ORDER
19For the above reasons, it is ordered that:
i. The applicant’s impairments are predominantly minor, and thus, the MIG limit applies.
ii. As the applicant is subject to the MIG, it is not necessary to consider whether the disputed treatment plans are reasonable and necessary.
iii. The applicant is not entitled to interest.
Released: December 1, 2025
Harouna Saley Sidibé
Adjudicator