Licence Appeal Tribunal File Number: 24-001343/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:
Christine Dimaano
Applicant
and
Wawanesa Mutual Insurance Company
Respondent
DECISION
ADJUDICATOR: Rasha El Sissi
APPEARANCES:
For the Applicant: Bianca Marinescu, Paralegal
For the Respondent: Morgan A. MacDonald, Counsel
HEARD: By way of written submissions
OVERVIEW
1Christine Dimaano, the applicant, was involved in an automobile accident on May 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, Wawanesa Mutual 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 $4,987.56 for Psychological Services, proposed by HM Medical Network Inc. in a treatment plan/OCF-18 (“plan”) dated January 30, 2023?
iii. Is the applicant entitled to $2,460.00 for a Psychological Assessment, proposed by HM Medical Network Inc. in a treatment plan dated November 24, 2022?
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 subject to treatment within the $3,500.00 limit of the MIG;
ii. The applicant is not entitled to the treatment plans in dispute; and
iii. The applicant is not entitled to interest.
ANALYSIS
The MIG
4Section 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.”
5The applicant may be removed from the MIG if she can establish his accident-related injuries fall outside of the MIG or, under section 18(2), that she has a documented pre-existing condition combined with compelling medical evidence stating that the condition precludes maximal recovery if she is kept within 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.
6The applicant submits that she should be removed from the MIG on the basis that she has suffered psychological impairments as a result of the accident.
Removal from the MIG due to a psychological condition
7I find that the applicant has not established, on a balance of probabilities, that she has a psychological condition that warrants her removal from the MIG.
8The applicant submits that she has been diagnosed with Adjustment Disorder, with mixed anxiety and depressed mood, and shows evidence for Specific Phobia, automobile fear.
9She submits that these psychological impairments do not fall within the definition of a “minor injury” and therefore, that she should be eligible for treatment in excess of the MIG limits.
10The respondent submits that the applicant has led insufficient evidence that she ought to be found outside the MIG.
11The applicant points to the clinical notes and records (“CNR”) of her treating physician, Dr. Eli Alegado on two dates: May 27, 2022, three days after the accident; and on July 4, 2022, approximately six weeks after the accident.
12She also points to her psychological assessment on January 30, 2023 performed by Ms. Viktoria Tolmatshov, Psychotherapist, registered with the Ontario College of Social Workers and Social Service Workers, acting under the supervision of Dr. Julie Gosselin, Psychologist.
13The applicant also submitted an OCF-3 Disability Certificate of Dr. Andrea Nalli, Chiropractor, diagnosing the applicant with whiplash, sprains and strains, insomnia and anxiety.
14The respondent did not provide any evidence.
15I am not persuaded by the applicant’s evidence that she should be treated outside of the MIG because of a psychological condition for the following reasons.
16Initially after the accident, Dr. Alegado assessed the applicant with “whiplash, upper back pain musculoskeletal strain post MVA, insomnia/ reactive anxiety”. He noted her anxiety occurred “when rides in a car”. The plan was to continue physiotherapy. She was advised to call back if her insomnia persists. Dr. Alegado stated that he “explained that this is a natural reaction post accident”.
17The applicant also submitted the CNR of Scarborough Health and Wellness Centre containing the SOAP [subjective, objective, assessment and plan] notes of Dr. Nalli, her treating chiropractor from May to October, 2022. Dr. Nalli’s intake assessment with the applicant on May 27, 2022 describes her anxiety when “travelling in vehicle”. It notes that the applicant has trouble falling asleep and waking up at night due to “LBP” [lower back pain] but has no nightmares.
18Six weeks after the accident, Dr. Alegado again assessed the applicant with “reactive anxiety” and noted, “occasionally specially when a truck is close to her vehicle”. There is no mention of ongoing insomnia in this CNR.
19There are no further encounter notes with Dr. Alegado in the evidence before me.
20There are no further mentions of insomnia and anxiety in the CNR of Scarborough Health and Wellness Centre.
21From the CNR of Dr. Alegado, I find that the applicant was continuing to complain of “reactive anxiety” when in a car, six weeks after the accident, but was not continuing to complain of insomnia.
22I note that the applicant did not request treatment for her anxiety, nor did Dr. Alegado record any recommendations or plan to address it in the CNR.
23I also note that there is no mention in the CNR of Dr. Alegado of the applicant suffering from depression or anxiety more broadly, either before or after the accident.
24Eight months after the accident, the applicant was psychologically assessed by Ms. Tolmatshov under the supervision of Dr. Gosselin (January 30, 2023). Ms. Tolmatshov conducted psychometric testing and a clinical interview of the applicant. She reviewed the OCF-3 of Dr. Nalli and the CNR of Dr. Alegado. The applicant was diagnosed with Adjustment Disorder, with mixed anxiety and depressed mood, with evidence of Specific Phobia related to fear of automobiles.
25The results of the psychometric tests of anxiety and depression showed no psychological impairment. The following test results are notable:
i. Beck Anxiety Inventory (BAI) – the applicant’s score of 1 fell in the Low Anxiety Range; she reported subjectively being nervous;
ii. Beck Depression Inventory – Second Edition (BDI-II) – the applicant endorsed items to receive a score of 5, which is within the minimal range; and
iii. Anxiety Inventory – the applicant’s score of 5 and fell into Low Anxiety Range; the applicant reported that she feels anxious or worried and that she is bothered by these feelings only a little bit.
26With respect to automobile anxiety, the applicant endorsed some items related to and to post-traumatic stress; however, these were found to be “inconsistent with PTSD” by the author of the psychological assessment report.
27Ms. Tolmatshov states in the assessment that despite the low scores on the psychometric testing, “it was evident that” the applicant’s symptoms are consistent with Adjustment Disorder with mixed anxiety and depressed mood.
28I do not find that this assessment is persuasive for the following reasons.
29Although the applicant submits that Dr. Gosselin diagnosed the applicant with Adjustment Disorder, mixed anxiety and depressed mood, it is not clear from the report that Dr. Gosselin participated in the clinical interview, which was essential to the conclusion given the psychometric test results. The report itself says that Dr. Gosselin “reviewed and endorsed” the assessment. It does not say that she assessed the applicant.
30There is a lack of medical evidence that the applicant was suffering from accident-related depressed mood. The anxiety the applicant complained of was specifically related to being in a car. The applicant’s treating physician noted that this was natural and did not recommend treatment. Therefore, the diagnosis of Adjustment Disorder, mixed anxiety and depressed mood is somewhat inconsistent with the medical evidence.
31I find that the applicant continued to complain of anxiety when in car as late as January 30, 2022. However, I am not persuaded that this amounts to a psychological condition that warrants removal from the MIG for the following reasons.
32The CNR encounter note of Dr. Alegado of May 27, 2022 indicates that the applicant continued to drive because she has to, for example, to her physiotherapy appointment, showing she continued to function as a driver.
33The clinical interview with Ms. Tolmatshov shows that the applicant prefers if her husband drives, showing that she continued to function as a passenger.
34The psychometric test results showed some indication of automobile phobia, but did not rise to a level of a disorder and there was no diagnosis of Specific Phobia, automobile fear or PTSD.
35For these reasons, I do not find that the applicant should be removed from the MIG for a psychological condition.
The plans in dispute (OCF-18s)
36As the applicant remains within the MIG and its $3,500.00 limit, it is not necessary for me to consider whether the treatment plans in dispute are reasonable and necessary.
Interest
37Interest applies on the payment of any overdue benefits pursuant to section 51 of the Schedule. Given that no benefits are overdue, the applicant is not entitled to any interest.
ORDER
38I find that:
i. The applicant’s injuries are predominantly minor and therefore subject to treatment within the $3,500.00 limit of the MIG;
ii. The applicant is not entitled to the treatment plans in dispute; and
iii. The applicant is not entitled to interest.
Released: December 9, 2025
Rasha El Sissi
Adjudicator