Licence Appeal Tribunal
Licence Appeal Tribunal File Number: 24-000077/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:
Rui Hu
Applicant
and
Allstate Insurance Company of Canada
Respondent
DECISION
ADJUDICATOR: Harouna Saley Sidibé
APPEARANCES:
For the Applicant: Yan Li, Counsel
For the Respondent: No Submissions Filed
HEARD: By way of written submissions
OVERVIEW
1Rui Hu, the applicant, was involved in an automobile accident on January 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, Allstate Insurance Company Canada, and applied to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
2A case conference was held on June 27, 2024, and the Case Conference Report and Order (“CCRO”) dated July 3, 2024, outlined the disputed issues. A written hearing was scheduled for April 4, 2025. On July 11, 2024, the Tribunal sent a notice of the written hearing to the parties. The applicant submitted his written submissions on March 4, 2023. Although the Tribunal properly served its notice of a written hearing to the respondent, the respondent did not file any submissions. As a result, the hearing will proceed based on the applicant’s written submissions and evidence.
ISSUES
3The 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 limit (“MIG”)?
ii. Is the applicant entitled to $3,840.83 for chiropractic services, proposed by Prime + Care Health Centre in a treatment plan/OCF-18 (“plan”) submitted December 10, 2022?
iii. Is the applicant entitled to $2,200.00 for a psychological assessment, proposed by Perfect Choice Psychologist Services Inc. in a plan submitted May 6, 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?
RESULT
4For the reasons below, I find that:
The applicant’s injuries are not predominantly minor, and therefore, he is entitled to treatment beyond the monetary limit of the MIG.
The applicant is partially entitled to the plan for chiropractic services dated December 10, 2022 (four physiotherapy sessions, including an initial assessment, evaluation report, and the costs of completing the OCF-18) and the entirety of the plan for the psychological assessment dated May 6, 2022, plus interest.
The applicant is not entitled to the remainder of the plan for chiropractic services dated December 10, 2022 (chiropractic services, active therapy, acupuncture) or an award.
ANALYSIS
Are the applicant’s injuries predominantly minor?
5I find that the applicant is not subject to the 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.”
7An 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.
8The applicant asserts that his injuries go beyond the MIG due to psychological impairments caused by the accident, specifically Post-Traumatic Stress Disorder (PTSD), Major Depressive Disorder with mixed anxiety and depressed mood, and Specific Phobia.
Psychological Impairments
9The applicant relies on medical evidence from his family physician, Dr. Kim Lazare, and on a psychological assessment conducted by Jian Su, a registered psychotherapist, under the supervision of Dr. Olivera Bojic-Ognjenovic, a registered psychologist.
10On July 4, 2023, the applicant informed Dr. Lazare that he had been experiencing stress, difficulty concentrating while driving, flashbacks of the accident, nightmares, irritability, anxiety, sleep disturbances, and avoidance of long-distance driving. Dr. Lazare diagnosed partial PTSD and referred the applicant to a psychotherapist for psychoeducation.
11A psychological assessment on August 25, 2023, found the applicant experiencing significant distress since the accident. Before the accident, he was functioning well, but now he experiences symptoms like low mood, anxiety, sleep problems, cognitive issues, and social withdrawal, which have lasted over eighteen months and affect his work, parenting, and daily life. He has been diagnosed with Major Depressive Disorder with Mixed Anxiety and Depressed Mood, along with a Specific Phobia of travel and the outdoors. He also exhibits trauma symptoms such as nightmares, avoidance, hypervigilance, and emotional sensitivity. The report recommends urgent psychological support to aid his recovery and improve his prognosis.
12I find the applicant’s evidence to be credible and unchallenged. The clinical notes and psychological report offer clear and consistent diagnoses of psychological impairments that significantly hinder his recovery and daily functioning. The respondent has not submitted any independent examination or medical opinion that contests these findings.
13I am satisfied that the applicant’s psychological impairments fall outside the scope of the MIG. His symptoms are not predominantly minor and have resulted in significant functional limitations.
14Accordingly, I find on a balance of probabilities that the applicant’s injuries are not predominantly minor and that he is not subject to the MIG.
Is the applicant entitled to the disputed treatment plans?
15To receive payment for a treatment and assessment plan under s. 15 and 16 of the Schedule, the applicant bears the burden of demonstrating on a balance of probabilities that the benefit is reasonable and necessary as a result of the accident. To do so, the applicant should identify the goals of treatment, how the goals would be met to a reasonable degree and that the overall costs of achieving them are reasonable.
16The purpose of assessments is to determine whether a condition warrants further investigation. The applicant must show that there is a reasonable basis to believe that such a condition exists and that the assessment is necessary to clarify the diagnosis or guide treatment.
Chiropractic Services
17I find that the applicant is entitled to four sessions of physiotherapy services but not to chiropractic services.
18The treatment plan dated December 10, 2022, amounts to $3,840.83 and was signed by chiropractor Jill Pawan. The goals include pain relief, improved range of motion, increased strength and muscular endurance, reduced inflammation, and a return to normal daily activities, pre-accident exercise, and social routines. The plan details an initial assessment, 16 sessions of chiropractic treatment, 16 sessions of active therapy and acupuncture, a first evaluation report, completion of the OCF-18 form, and four sessions of physiotherapy.
19On March 28, 2022, the applicant’s family physician, Dr. Lazare, diagnosed right-sided neck pain with musculoskeletal and nerve-related referred pain. He recommended a heating pad and a course of physiotherapy for 6 to 8 weeks.
20Although Dr. Lazare specifically recommended physiotherapy, there is no supporting medical evidence that he endorsed chiropractic treatment, active therapy, or acupuncture. Therefore, I consider the four physiotherapy sessions to be reasonable and necessary, as they align with the physician’s recommendations. While the Applicant argued that chiropractic services were reasonable and necessary to manage pain and restore function, and cited Dr. Lazare’s notes documenting ongoing back pain, these submissions did not bridge the gap between the physician’s recommendation for physiotherapy and the proposed chiropractic, active therapy, and acupuncture treatments. In the absence of persuasive evidence linking these additional modalities to the physician’s recommendations or demonstrating their necessity, I find that the 16 chiropractic sessions and 16 sessions of active therapy and acupuncture are not reasonable or necessary
21Based on the balance of probabilities, I find that the applicant is entitled to four sessions of physiotherapy, including an initial assessment, evaluation report, and the cost of completing the OCF-18, but not to the sixteen sessions of chiropractic services or the sixteen sessions of active therapy and acupuncture outlined in the treatment plan.
Psychological Assessment
22I find that the applicant is entitled to the psychological assessment treatment plan dated May 6, 2022.
23The treatment plan, in the amount of $2,200.00, was signed by psychologist Sharleen McDowall. It proposes a psychological assessment, including documentation, note-taking, and submission of the OCF-18 form. The stated goals are to address pain, depression, anxiety, and flashbacks through cognitive behavioural therapy (CBT), and to support the applicant’s return to normal daily and pre-accident work activities.
24On July 4, 2023, the applicant’s family physician, Dr. Lazare, diagnosed the applicant with partial post-traumatic stress disorder (PTSD) and referred him to a psychotherapist. This referral supports the need for psychological intervention.
25A psychological assessment conducted on August 25, 2023, by Jian Su under the supervision of Dr. Bojic-Ognjenovic confirmed clinically significant psychological impairments related to the accident, including symptoms consistent with PTSD, anxiety, and depression. While this assessment occurred after the disputed treatment plan, its findings validate the applicant’s ongoing psychological difficulties and demonstrate that the concerns identified in May 2022 persisted. This continuity underscores the appropriateness of initiating psychological intervention earlier and supports the need for comprehensive evaluation and treatment as proposed in the May 2022 plan.
26I am satisfied that the treatment plan dated May 6, 2022, is reasonable and necessary. It is supported by the applicant’s diagnosis, the referral from his treating physician, and the subsequent psychological assessment, which confirms that the applicant’s impairments were not transient but clinically significant and enduring. The proposed services—focused on assessment and CBT—are consistent with the nature of these impairments and aimed at facilitating recovery and reintegration into daily life. The later assessment does not render the earlier plan redundant; instead, it reinforces that timely psychological intervention was warranted.
27Accordingly, I find that the applicant is entitled to the psychological assessment treatment plan dated May 6, 2022.
Interest
28Interest applies to the payment of any overdue benefits pursuant to s. 51 of the Schedule. The applicant is entitled to interest on any overdue benefits.
Award
29The 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.
30The applicant argues that the respondent acted unreasonably by upholding its position under the MIG, despite medical evidence showing psychological impairments.
31The respondent did not submit any arguments or evidence in reply. Therefore, I lack insight into its position or explanation.
32However, the threshold for granting an award under section 10 is high. It requires more than just a disagreement over entitlement; it must be shown that the insurer’s conduct was unreasonable given the circumstances. While the respondent did not respond to the applicant’s evidence, the applicant has not demonstrated that the respondent’s conduct reached the level of being unreasonable or involved a deliberate or unjustified delay or denial of benefits.
33Accordingly, I find that the applicant is not entitled to an award.
ORDER
34For the above reasons, it is ordered that:
i. The applicant’s injuries are not predominantly minor, and therefore, he is entitled to treatment beyond the monetary limit of the MIG.
ii. The applicant is partially entitled to the plan for chiropractic services dated December 10, 2022 (four physiotherapy sessions, including an initial assessment, evaluation report, and the costs of completing the OCF-18) and the entirety of the plan for the psychological assessment dated May 6, 2022, plus interest.
iii. The applicant is not entitled to the remainder of the plan for chiropractic services dated December 10, 2022 (chiropractic services, active therapy, acupuncture) or an award.
Released: December 8, 2025
Harouna Saley Sidibé
Adjudicator