Licence Appeal Tribunal File Number: 24-015148/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:
[SJ]
(A minor by their litigation guardian, [EJ])
Applicant
and
Intact Insurance Company
Respondent
DECISION
ADJUDICATOR:
Timothy Porter
APPEARANCES:
For the Applicant:
Jae Hyon Cho, Counsel
For the Respondent:
Raman Pandher, Counsel
HEARD by Videoconference:
October 7-10, 2025
OVERVIEW
1[SJ], the applicant, was involved in an automobile accident on November 10, 2015, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (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.
2The applicant was 6 years old at the time of the accident, is 16 years old at the time of the hearing, and was supported at the hearing by his litigation guardian/mother [EJ].
ISSUES
3The issues in dispute are:
i. Has the applicant sustained a catastrophic impairment as defined by the Schedule?
ii. Is the applicant entitled to $2,260.00 for a clinical coordinator assessment and report for catastrophic determination, proposed by Omega Medical Associates Ltd. in an OCF-18/treatment plan (“treatment plan”) submitted August 23, 2023?
iii. Is the applicant entitled to $200.00 for an invoice, submitted on a claim form (OCF-6) dated April 5, 2024?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
4I find that the applicant has sustained a class 4 marked impairment of his social function, as a result of the subject accident, and therefore find that he meets the test for catastrophic impairment according to criterion 8.
5I find that the applicant is not entitled to the assessment plan or the OCF-6 in dispute.
6As no benefits are owing, no interest is owing.
ANALYSIS
Catastrophic impairment
7For the reasons that follow, I find that the applicant has sustained a class 4 marked impairment of his social function, as a result of the subject accident, and therefore find that he meets the test for catastrophic impairment according to criterion 8.
8To determine whether an insured person is catastrophically impaired under Criterion 8, the Tribunal considers whether the accident caused a mental or behavioral disorder, the impact of the disorder to the person’s life, and the level of impairment as described in s.3.1(1) (“Criterion 8”) of the Schedule. The applicant bears the onus to prove on a balance of probabilities that he is catastrophically impaired. The test to determine whether the applicant has sustained a catastrophic impairment is a legal test and not a medical test (see Liu v. 1226071 Ontario Inc. (Canadian Zhorong Trading Ltd.), 2009 ONCA 571).
9Next, criterion 8 requires evidence of the insured person’s impairment levels due to a mental or behavioural disorder. Impairment levels are to be assessed in relation to four functional domains: (1) activities of daily living; (2) social functioning; (3) concentration, persistence, and pace and (4) adaptation (deterioration or decomposition in work or work-like settings). As the accident took place in 2015, to meet the Schedule’s threshold for a catastrophic impairment designation under Criterion 8, an individual must have one marked (class 4) or one extreme (class 5) impairment as a result of the accident due to a mental and behavioural disorder. These impairments are assessed under the 4th edition of the American Medical Association Guides “AMA Guides”. Mental and behavioural impairments are rated according to how seriously they affect a person’s useful daily functioning. The spheres of functioning and the levels of impairment are outlined in the chart below:
| Area or Aspect of Functioning | Class 1: NO Impairment | Class 2: MILD Impairment | Class 3: MODERATE Impairment | Class 4: MARKED Impairment | Class 5: EXTREME Impairment |
|---|---|---|---|---|---|
| Activities of Daily Living (“ADLs”) | No impairment is noted | Impairment levels are compatible with most useful functioning | Impairment levels are compatible with some, but not all useful functioning | Impairment Levels Significantly impede useful functioning | Impairment levels preclude useful functioning |
| Social Functioning | |||||
| Concentration, Persistence and Pace (“CPP”) | |||||
| Adaptation (In a work-like setting) |
10The applicant submits that he is catastrophically impaired as a result of the subject accident, suffering somatic symptom disorder, vehicular phobia, major depressive disorder, generalized anxiety disorder, with panic attacks, insomnia disorder and social anxiety disorder and relies on the reports and testimony by Talia Dick, occupational therapist (“OT”) and Dr. Anson Lui, psychiatrist.
11The respondent submits that the applicant’s injuries do not reach the standard for a finding of catastrophic impairment and relies on reports and testimony of Joan Saunders, OT, and Dr. Shrenik Parekh, psychiatrist.
12There is agreement between the parties that the applicant’s impairment of his concentration, persistence and pace sphere is moderate, and insufficient to meet the test outlined above; therefore, my analysis will focus on the disputed ratings in activities of daily living, adaptation and social function.
13The applicant underwent a s. 25 catastrophic impairment determination multidisciplinary assessment with Talia Dick, OT, on November 1-2, 2023, and with Dr. Anson Lui, psychiatrist, on November 6, 2023. The conclusions of Dr. Lui provided the following ratings of the applicant in the four spheres of functioning:
| Area or Aspect of Functioning | Class 1: NO Impairment | Class 2: MILD Impairment | Class 3: MODERATE Impairment | Class 4: MARKED Impairment | Class 5: EXTREME Impairment |
|---|---|---|---|---|---|
| Activities of Daily Living | Marked Impairment | ||||
| Social Functioning | Marked Impairment | ||||
| Concentration, Persistence and Pace | Moderate Impairment | ||||
| Adaption (In a work-like setting) | Marked Impairment |
14Dr. Lui diagnosed the applicant with somatic symptom disorder, with predominant pain, specific phobia (vehicular), major depressive disorder, recurrent, moderate, generalized anxiety disorder, with panic attacks, insomnia disorder and social anxiety disorder.
15The applicant also underwent a s. 44 catastrophic impairment determination multidisciplinary assessment with Joan Saunders, OT, on May 15 and 22, 2024, and with Dr. Shrenik Parekh, psychiatrist, on April 1, 2024. The conclusions of Dr. Parekh provided the following ratings of the applicant in the four spheres of functioning:
| Area or Aspect of Functioning | Class 1: NO Impairment | Class 2: MILD Impairment | Class 3: MODERATE Impairment | Class 4: MARKED Impairment | Class 5: EXTREME Impairment |
|---|---|---|---|---|---|
| Activities of Daily Living | Moderate Impairment | ||||
| Social Functioning | Moderate Impairment | ||||
| Concentration, Persistence and Pace | Moderate Impairment | ||||
| Adaption (In a work-like setting) | Moderate Impairment |
16Dr. Parekh diagnosed the applicant with somatic symptom disorder, with predominant pain, specific phobia (vehicular), and major depressive disorder, with anxious distress.
Activities of Daily Living (ADL)
17According to the Guides, ADL include such activities as self-care, personal hygiene, communication, ambulation, travel, sexual function, sleep, social and recreational activities in the context of the individual’s overall situation, the quality of these activities is judged by their independence, appropriateness, effectiveness and sustainability. It is necessary to define the extent to which the individual is capable or initiating and participating in these activities independent of supervision or direction. What is assessed is not simply the number of activities that are restricted, but the overall degree of restriction or combination of restrictions.
18For the reasons that follow I find that the applicant has a moderate impairment of his ADL sphere of functionality.
19I am not persuaded by Talia Dick, OT’s, observations in the area of ADLs because she provides observations of the applicant in comparison to a generic 14-year-old, assembled from her experience and review of literature on the subject, rather than the standard pre and post accident functionality observations. I provide the report of Ms. Dick less weight because her observations are through the lens of uncited, generic 14-year-old attributes and developmental milestones as the measure of what function is expected rather than the pre and post analysis outlined in the AMA Guides.
20I am not persuaded by Dr. Lui’s ADL analysis because Talia Dick, OT’s premise of the generic 14-year-old infiltrates this section of Dr. Lui’s analysis. Dr. Lui reports that the applicant independently showers, changes his clothing, feeds himself and toilets and highlights that the applicant was able pre-accident to walk for hours whereas post-accident he can only walk for 30 minutes before requiring rest. In my mind the above relates to at least some useful function and does not rise to the level of significantly impeded function.
21The frequency of the applicant’s performance of hygiene tasks is unclear. The applicant testified that he showers once a week when told to do so by his mother. In contrast he reported to Dr. Lui that he is obsessive about cleanliness and showers multiple times a day.
22The degree to which the applicant’s fear of vehicles is impeding useful function is also unclear. The applicant has received a diagnosis of specific phobia (vehicular) from both psychiatric assessors, and it is clear from his testimony that he will more often choose not to ride in a vehicle. However, it is also clear from his testimony that the applicant does travel in vehicles, riding the bus to go to church and occasionally to school; in addition, the applicant has taken vehicles to multiple assessments throughout this process.
23I am persuaded by Dr. Parekh’s analysis and opinion because he clearly identifies the ADL activities pre and post accident that the applicant can accomplish, and Dr. Parehk’s classifications of the activities the applicant can accomplish align with his assessment that the applicant’s functioning is compatible with some but not all useful function.
24For the reasons above I find that the applicant’s overall degree of restriction in the ADL sphere is a moderate impairment.
Adaptation
25With respect to the sphere of Adaptation, the AMA Guides provide that deterioration or decompensation in work or work-like settings refers to repeated failure to adapt to stressful circumstances. In the face of such circumstances the individual may withdraw from the situation or experience exacerbation signs and symptoms. He or she may decompensate and have difficulty maintaining activities of daily living, continuing social relationships and completing tasks. Stressors common to the environment include attendance, making decisions, scheduling, completing tasks and interacting with others.
26For the reasons below I find, on a balance of probabilities, that the applicant’s impairment level in the adaptation domain is moderate.
27Dr. Lui opines that the applicant has severe stress intolerance, that seems to cause withdrawal or worsening emotional symptoms; notable difficulties with short- and long-term memory recall and that he did not demonstrate the capacity to maintain school-appropriate engagement and emotional demeanour during the assessment.
28Dr. Parekh assesses the applicant in his ability to psychologically cope with school-like demands such as capacity to sustain attention, work activity pace, persistence, productivity, stamina, interpersonal functioning and school-like demeanour at a competitive level, over a full week without accommodation. In my mind this is the correct test. Dr. Parekh opines that the applicant did not display any odd behavioural issues during the assessment, demonstrated the ability to follow a multi-step command and that his gross cognitive function appeared to be intact.
29The applicant’s school records indicate that while he required support for English, reading, and oral/auditory memory he regularly showed strength in computational math and comprehension of word classes; formal cognitive testing by the school board placed the applicant in the average range; in grade 8 his final grades, with the exception of religious studies, were all in the 70’s upon graduation to high school in fall 2023 he no longer had an individual education plan. While the applicant is not leading the class in marks, he is by and large passing while in many circumstances only attending one third of the classes. In my mind this performance aligns with some, but not all, useful functioning.
30For the reasons above I find, on a balance of probabilities, that the applicant’s impairment level in the adaptation domain is moderate.
Social
31With respect to Social Functioning, the AMA Guides state, social functioning refers to an individual’s capacity to interact appropriately and communicate effectively with other individuals. Social functioning includes the ability to get along with others, such as family members, friends, neighbours, grocery clerks, landlords, or bus drivers.
32For the reasons below I find that the applicant has a marked impairment of his social sphere.
33I agree with Dr. Lui’s assessment that the applicant’s Social Function impairments are greater than moderate and attained the level whereby they significantly impede useful functioning. I make this finding because Dr. Lui links the psychological diagnosis with the symptoms and observable behaviour. For example, Dr. Lui opines that the applicant is prevented from socializing due to pain, depression and anxiety; as a result, the applicant is increasingly becoming distant from family and experiences emotional dysregulation towards family, friends and community members. Dr. Lui also relates that the applicant struggles with impatience.
34The evidence supports a finding that the applicant no longer engages in social activities he did pre-accident. The applicant’s mother reported to Talia Dick, OT, that the applicant previously enjoyed soccer and Tae Kwon Do, however, he no longer enjoys these activities as he is not confident and “doesn’t want to meet other people anymore”.
35I am not persuaded by Dr. Parekh’s report and testimony with regards to the domain of Social Function because he does not adequately account for his observations, or the reports he received, in the analysis that led to the finding of a moderate impairment. For example, he notes that following the accident the applicant did not want to see “anyone”, he reportedly “hates” being with other people, was restricted, dysphoric and anxious during the assessment and engaged for only 14 minutes in the community activity at Dollarama due to being overwhelmed. In contrast, I do not see any examples of normal social function identified by Dr. Parekh. In my mind his observations and assessments identify a situation where useful function is significantly impeded and he does not adequately explain his conclusion of moderate impairment.
36Key elements of the applicant’s impairment were also identified by Dr. Parekh. Dr. Parekh observed that the applicant established a limited rapport with the assessor, demonstrated a blunt affect, rarely maintained eye contact and displayed limitations with emotional control and commented that the applicant was observed to avoid eye contact and tap his leg on the floor and demonstrated signs of irritability as the assessment progressed.
37The applicant testified regarding his impaired social function stating that he does not have any friends, relating “I always played alone” and “I don’t remember talking to any other kids”; and has related to assessors that he prefers to be alone and sleeps often. Taken together, on a balance of probabilities, this is demonstrative of avoidance of interpersonal relationships and strangers.
38Taken together, I find that the evidence of the applicant’s accident-related impairments in the domain of Social Function are consistent with a finding that he has a marked impairment. I find that Dr. Lui’s assessment is internally consistent, adequately explained and is in keeping with the AMA Guides and the preponderance of evidence before me with respect to the applicant’s level of social functioning.
39For the reasons above, I find on a balance of probabilities that the applicant has a marked impairment of his social functioning sphere.
Catastrophic Assessment Report
40To 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.
41For the reasons that follow I find that the applicant is not entitled to the assessment report in dispute.
42The applicant did not point or direct me to the treatment plan or the denial.
43The applicant did not testify regarding this plan. The applicant did not make submissions in support of this plan.
44For the reasons above I find on a balance of probabilities that the applicant is not entitled to the assessment report in dispute.
OCF-6
45For the reasons that follow I find that the applicant is not entitled to the OCF-6.
46The applicant did not point or direct me to the OCF-6 or the denial.
47The applicant did not testify regarding the OCF-6. The applicant did not make submissions in support of the OCF-6.
48For the reasons above I find on a balance of probabilities that the applicant is not entitled to the OCF-6.
Interest
49Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As there are no benefits owing, no interest is due.
ORDER
50I find that the applicant has sustained a class 4 marked impairment of his social function, as a result of the subject accident, and find that he meets the test for catastrophic impairment according to criterion 8.
51I find that the applicant is not entitled to the assessment plan or the OCF-6 in dispute.
52As no benefits are owing, no interest is owing.
Released: December 24, 2025
__________________________
Timothy Porter
Adjudicator