Licence Appeal Tribunal File Number: 24-003708/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:
Bi Yuan Yu
Applicant
and
Co-operators General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Jeff Chatterton
APPEARANCES:
For the Applicant:
Rakesh Sharma, Counsel
For the Respondent:
Irene Tsui, Counsel
HEARD:
In Writing
OVERVIEW
1Bi Yuan Yu, the applicant, was involved in an automobile accident on March 25, 2023, 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, Co-operators General 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:
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?
Is the applicant entitled to $3,341.56 ($3749.56 less $408.00 approved) for physiotherapy services proposed by UHeal Rehab Centre in a treatment plan/OCF-18 (“plan”) dated July 15, 2023?
Is the applicant entitled to $4,028.56 for chiropractic services proposed by UHeal Rehab Centre in a plan dated October 5, 2023?
Is the applicant entitled to $2,200.00 for a psychological assessment proposed by Somatic Assessment & Treatment Clinic in a plan dated April 13, 2023?
Is the applicant entitled to $725.00 for replacement of damaged glasses, submitted on a claim form (OCF-6) dated April 10, 2023?
Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant is being held to the Minor Injury Guideline. The applicant is not entitled to the treatment plans in dispute, nor interest or an award.
4The application is dismissed.
ANALYSIS
Has the applicant proven they should be removed from the Minor Injury Guideline (“the MIG”) based on medical evidence?
5The applicant has not established that she should be removed from 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.
8It is well-settled that the onus is on the applicant to establish that the treatment plans in dispute are reasonable and necessary and that her injuries cannot be treated within the MIG. It is also well-settled that more than just the treatment plan itself is required to show that that the proposed goods, services, or assessments are reasonable and necessary. There must be compelling contemporaneous evidence in support of the treatment plan.
9The applicant has chosen not to enter any submissions regarding the issue of MIG determination, on which grounds she seeks removal from the MIG or whether or not her injuries fall outside of the MIG.
10In terms of the medical evidence submitted by the applicant, the applicant has submitted only the OCF-18’s for the treatment plans in dispute and has not included or directed me to any other supportive medical evidence. I do not find the OCF-18’s on their own sufficient to meet the onus to establish entitlement to be removed from the MIG.
11Given that the applicant has not provided any submissions or directed me to medical evidence to establish non-minor impairments, I find that the applicant has not, on a balance of probabilities, met her onus to prove she should be removed from the MIG.
12As I have found that the applicant has not established that her accident-related impairments warrant removal from the MIG, it is not necessary for me to assess whether the treatment plans in dispute are reasonable and necessary.
13For all of the treatment plans in dispute, the applicant has raised the argument that the respondent’s denial letters were not compliant with s. 38(8) of the Schedule.
14Sections 38(8) and 38(11) of the Schedule set out strict notice requirements for insurers responding to treatment plans and specific consequences if they fail to comply. Section 38(8) requires an insurer to inform an insured person within ten business days after it receives an OCF-18 which goods, services, assessments, and/or examinations it agrees to pay for, and which it does not, as well as the medical and other reasons why it considered any of the goods and services to not be reasonable and necessary.
15If an insurer fails to comply with s. 38(8), the Schedule sets out two consequences under s. 38(11). First, an insurer who fails to provide the insured with an adequate notice of the reasons for its denial is prohibited by s. 38(11)(1) from taking the position that the insured person has an impairment to which the MIG applies. Second, s. 38(11)(2) provides that if an insurer fails to provide proper notice of the reasons for its denial it must pay for all incurred goods, services, assessments and examinations described in the treatment and assessment plan that related to the period starting on the 11th business day after the day the insurer received the applicant and ending on the day the insurer gives notice as described in s. 38(8).
16The applicant argues the treatment plans are payable under s.38(11) because the EOB letters dated April 28, 2023 July 25, 2023 and October 18, 2023 denying the treatment plans in dispute do not comply with s.38(8) because they do not provide sufficient medical reasons for the denial. The applicant also argues that the letter of April 27, 2023 is not compliant because the insurer made an unreasonable request.
17The respondent argues that the denial letters are compliant with s.38(8).
April 27 letter denying the OCF-6 for $725 for replacement of damaged glasses
18This denial letter is compliant with s. 38(8) of the Schedule.
19The applicant submits that according to s. 24 of the Schedule, the insurer shall pay for all reasonable expenses replacing broken prescription eyewear.
20The letter stated “It is our understanding that you have extended health care coverage through People Corporation and Manulife, therefore the above noted expense is not payable in accordance with Section 47 of the Statutory Accident Benefits Schedule (SABS). In order for us to consider reimbursement of your incurred expenses, we require the Explanation of Benefits statements from People Corporation and Manulife for review. We also require the invoice or receipt for the previous pair of glasses that were damaged in the motor vehicle accident.”
21The applicant argues this statement is not in compliance with the Schedule because “it is common knowledge that the extended health care carriers do not provide coverage for replacement of damage to glasses caused by the MVA.”
22I do not find this statement to be universally understood, nor do I find the request from the insurer to review the EOB from the extended healthcare provider to be unreasonable. I further find a request to review the receipt for the glasses in question to be a reasonable request used in the adjustment of the file, and compliant with the Schedule.
23I further find the insurer has offered a clear denial letter, outlining, as per the Schedule, “the medical reasons and all of the other reasons why the insurer considers any goods, services, assessments and examinations, or the proposed costs of them, to be reasonable and necessary.
24For these reasons, I find the denial letter to be compliant with the Schedule.
April 28 letter, denying a Psychological Assessment / July 25 letter, denying Physiotherapy Services / October 18 letter, denying Chiropractic Services
25I find that the respondent’s denial letters are compliant with the Schedule.
26For all three denials, the applicant has argued that the denial letters are boilerplate, lack specific medical information and are not in compliance with the Schedule.
27The applicant argues that the respondent’s reason for the denials, i.e. that because the applicant’s injuries are considered minor, she is not eligible for further treatment outside of the $3,500 MIG limits, is not a sufficient medical reason.
28I find that for all three letters, the insurer has used plain, easy to understand language that states they have no objective medical evidence on file to suggest the applicant’s injuries fall outside the Minor Injury Guideline.
29The letter of April 28, 2023 says “We have no compelling medical evidence to suggest a psychological impairment(s) has been sustained as a result of the motor vehicle accident, or that you suffered a pre-existing psychological impairment which was exacerbated by the subject motor vehicle accident, and continues to impact your recovery. We are not satisfied that the proposed Treatment and Assessment Plan (OCF-18) provides enough information to medically support this type of assessment.”
30The applicant states “the applicable section 38 of the SABS is silent about the “objective medical evidence”. In the absence of statutory definition/ requirement of objective medical evidence, it appears to be a criterion of respondent, to which the applicant has no obligation to comply with.”
31Furthermore, the applicant states that when a regulated health professional checks the box on an OCF-18 which states the impairment is not predominantly a minor injury, the ‘criteria of compelling medical evidence do not apply to said OCF-18.”
32The respondent disagrees. It argues that the applicant’s interpretation of the Schedule is entirely inconsistent with prevailing case law. To support their claim, it refers to the Divisional Court ruling in Scarlett v Belair 2015 ONSC 3635, which states “the burden rests with the applicant to prove that their injuries fall outside of the MIG.”
33The respondent also points out that the applicant has not pointed to any legal authority supporting the position that this burden shifts to the insurer to prove that an applicant’s injuries are, in fact, minor, merely because a completed OCF-18 was submitted. The respondent also states the Tribunal has repeatedly determined that treatment plans are not evidence.
34I agree with the respondent. It is well-accepted that an OCF-18 is not, in and of itself, considered objective medical evidence establishing an impairment. Rather, medical evidence is required to substantiate a claim. A signed OCF-18 does not ‘automatically’ remove a candidate from the MIG simply because a proposed treatment provider claims the applicant’s injuries fall outside of the MIG.
35I further find the letters compliant with the Schedule. I find the language stating that the respondent has not received compelling medical evidence to be a valid medical reason. It is well accepted that referring to the MIG is an acceptable medical reason, because it essentially states that the applicant’s injuries are minor in nature, and have not risen in seriousness to the level where the applicant would be entitled for further treatments. I note the other letters contain similar language.
36For these reasons, I find the applicant has not, on the balance of probabilities, established that the insurance company has failed to comply with Section 38. I find the EOB letters are compliant with the Schedule.
Interest
37Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no benefits are overdue, no interest is payable.
Award
38The 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.
39I find the respondent has not unreasonably withheld or delayed benefits, and therefore, no award is payable.
ORDER
40The application is dismissed.
i. The applicant is being held to the Minor Injury Guideline.
ii. The applicant is not entitled to the treatment plans in dispute.
iii. Neither interest nor an award are payable.
Released: December 17, 2025
Jeff Chatterton
Adjudicator