Slepcikova v. Definity Insurance Company
Licence Appeal Tribunal File Number: 24-006299/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:
Rozalie Slepcikova
Applicant
and
Definity Insurance Company
Respondent
DECISION
ADJUDICATOR: Jeff Chatterton
APPEARANCES:
For the Applicant: Victoria Gorbenko, Paralegal
For the Respondent: Matthew Murphy, Counsel
HEARD: In Writing
OVERVIEW
1Rosalie Slepcikova, the applicant, was involved in an automobile accident on February 3, 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, Definity 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 (‘the MIG’) limit?
ii. Is the applicant entitled to $2,374.40 for chiropractic services, proposed by E Clinic United Healing in a treatment plan/OCF-18 (“plan”) dated August 19, 2022?
iii. Is the applicant entitled to $1,995.00 for a Psychological Assessment, proposed by E Clinic United Healing in a treatment plan dated June 22, 2022?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant is held to the MIG. As she has been held to the MIG and the $3,500 treatment limitation, she is not entitled to the treatment plans in dispute. No interest is granted.
ANALYSIS
Should the applicant be removed from the MIG due to Psychological Injury?
4The applicant has not met the onus to prove she should be removed from the MIG due to psychological injury.
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 submits they should be removed from the MIG on the basis of psychological injury. To support their claim, the applicant relies upon a s.25 Psychological Assessment, conducted by Psychological Associate Mr. Bruce Cook, dated September 14, 2022.
8Mr. Cook administered the Personality