Ahmad v. Economical Insurance Company, 2025 CanLII 31121

Citation: Ahmad v. Economical Insurance Company, 2025 CanLII 31121

Licence Appeal Tribunal File Number: 23-006722/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:

Iqbal Ahmad

Applicant

and

Economical Insurance Company

Respondent

DECISION

ADJUDICATOR: Brian Norris

APPEARANCES:

For the Applicant: Maria Bihnam, Paralegal

For the Respondent: Sunjay Mistry, Paralegal

HEARD: By way of written submissions

OVERVIEW

1Iqbal Ahmad (“the Applicant”) was involved in an automobile accident on October 21, 2021, and sought benefits from Economical Insurance Company (“the Respondent”) pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”).

2The Respondent characterized the Applicant’s injuries as falling within the “minor injury” definition as outlined in section 3 of the Schedule and denied funding for the treatment and assessment plans in dispute.

3The Applicant disagrees with these decisions by the Respondent and applied to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

ISSUES

4The issues in dispute are:

i. Are the Applicant’s injuries predominantly a minor injury as defined in section 3 of the Schedule and therefore subject to treatment within the Minor Injury Guideline and the $3,500.00 funding limit for a minor injury?

ii. Is the Applicant entitled to medical benefits proposed by Heartland Wellness Clinic in a treatment plan/OCF-18 (“plan”), as follows:

(a) $4,941.65 for a physiotherapy plan submitted December 7, 2021;

(b) $20.45 ($1,320.45 less $1,300.00 approved) for a physiotherapy plan submitted March 22, 2022; and

(c) $2,476.68 for a physiotherapy plan submitted May 3, 2022?

iii. Is the Applicant entitled to the assessments proposed by Tier 1 Assessment, as follows:

(a) $2,685.44 for an attendant care assessment proposed in a plan submitted January 4, 2022;

(b) $2,530.00 for a psychological assessment proposed in a plan submitted January 11, 2022;

(c) $2,778.68 for a function ability assessment proposed in a plan submitted January 13, 2022; and

(d) $2,460.00 for a chronic pain assessment proposed in a plan submitted May 8, 2022?

iv. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

5I find that the Applicant sustained a minor injury in the accident. He is subject to the MIG and the $3.500.00 funding limit for a minor injury.

6The Applicant is not entitled to the treatment and assessment plans because they propose goods and services which fall outside the MIG and the funding limit.

7No interest is payable.

BACKGROUND

8The Applicant was the driver of a vehicle which was struck on the side while attempting to merge into the left lane on an urban roadway. No police or ambulance attended at the scene of the accident, and the Applicant drove himself home thereafter.

9He had a telephone consultation with his family physician, Dr. M. Rahman, a month later and reported the accident. He advised that he had low back pain with no radiculopathy. Dr. Rahman referred the Applicant to physiotherapy and prescribed naproxen. The Applicant started treatment pursuant to the MIG thereafter.

10The Applicant claims that he developed psychological injuries following the accident and that he has since developed chronic pain syndrome and that these injuries are not included in the minor injury definition.

ANALYSIS

Minor Injury Guideline (“MIG”)

11The MIG establishes a treatment framework available to injured persons who sustain a minor injury as a result of an accident. A “minor injury” is defined in the Schedule and includes sprains, strains, whiplash associated disorder, contusion, abrasion, laceration or subluxation and any clinically associated sequelae. The MIG provides that a strain is an injury to one or more muscles and includes a partial tear. Under section 18 of the Schedule, injuries that are defined as minor are subject to a $3,500.00 funding limit on treatment.

12The onus is on the Applicant to demonstrate that he sustained an injury that is not included in the minor injury definition outlined in section 3 of the Schedule.

13For the following reasons, I find that the Applicant sustained a minor injury as a result of the accident.

Psychological impairment

14I find no evidence demonstrating that the Applicant sustained an accident-related psychological injury that would require treatment outside of the MIG and the $3,500.00 funding limit for a minor injury.

15The Applicant submits that he complained of anxiety and depression to Dr. Rahman and that a psychological pre-screen report concluded that he suffers from an Adjustment Disorder with Mixed Anxiety and Depressed Mood due to the accident. The Respondent submits that the Applicant has not provided evidence of an accident-related psychological injury as a result of the accident.

16The Respondent highlights that the Applicant never followed through with a referral for psychological care and submits that the Applicant’s psychological complaints were minor and do not support a diagnosis of a psychological injury. It further highlights that the Applicant’s sleep issues predate the accident, he never participated in any treatment or took psychotropic medication, and that no one has diagnosed the Applicant with a psychological disorder.

17I agree with the Respondent and find no evidence that the Applicant suffers from of an accident-related psychological impairment. The Applicant reported minimal psychological symptoms and never followed through on Dr. Rahman’s referral to a psychologist. This suggests that the Applicant’s symptoms never reached a level where they impaired him or warranted treatment. I give no weight to the pre-screen report conducted by an occupational therapist (“OT”) because the OT acted outside of their scope when opining that the Applicant’s psychological condition. Further, the insurer’s examination (“IE”) report of Dr. M. Mandel, psychologist, concluded that there was no evidence that the Applicant requires services outside of the MIG.

18Accordingly, I find that the Applicant has not demonstrated that he sustained a psychological injury as a result of the accident.

Chronic pain

19I find that the Applicant has not demonstrated that he suffers from a chronic pain condition as a result of the accident.

20The Applicant claims that he suffers from chronic pain as a result of the accident on the basis that his pain symptoms persisted longer than the usual hearing time, that he experiences a functional impairment due to pain, received pain injections, and that his treatment providers recommended a chronic pain assessment.

21The Respondent submits that the Applicant has not consistently reported substantial functional limitations related to pain and that his daily schedule has mostly remained the same since the accident. It submits that the Applicant’s primary complaints were ongoing headaches, and neck, shoulder, and back pain. It notes that the Applicant was referred by Dr. Rahman to Dr. J. Chen, a chronic pain specialist for these complaints. On August 8, 2022, Dr. Chen recommended some prescription pain medication and localized pain injections. The Respondent notes that by October 15, 2022, the Applicant reported increased functionality from Dr. Chen’s treatments, and those treatments ceased by May 2023.

22I find that the Applicant has not demonstrated that he suffers from a chronic pain condition as a result of the accident. The Applicant has not demonstrated that he is functionally impaired by pain. He continued to work seven days a week at a parcel delivery store following the accident, and his only reported restriction is that he stopped lifting heavy packages and now asks customers to lift their packages. During an examination with Dr. Chen on August 2, 2022, the Applicant demonstrated functional range of motion (“ROM”) throughout his body. An August 10, 2022 IE by Dr. M. Hannah also noted that the Applicant demonstrated functional ROM throughout his body. Full functional ROM is also noted in the IE report of Dr. A. Belfon, dated September 1, 2023. The level of functionality depicted in the reports is incompatible with a finding that the Applicant is impaired by ongoing pain and both Dr. Hannah and Dr. Belfon concluded that the Applicant sustained soft tissue injuries which fall squarely within the definition of a minor injury.

23I find that the Applicant does not meet the criteria for a chronic pain condition as outlined by the American Medical Association Guides to the Evaluation of Permanent Impairment (the “AMA Guides”). While it is not part of the Schedule, the Tribunal has generally accepted the AMA Guides when assessing whether a person suffers from a chronic pain condition. To meet the criteria, the person must demonstrate that they likely meet three of the following six criteria: withdrawal from social milieu (including work, recreation, or other social contracts); use of prescription drugs beyond the recommended duration and/or abuse of or dependence on prescription dugs or other substances; development of psycho-social sequalae after the initial incident; excessive dependence on healthcare providers, spouse, or family; secondary physical deconditioning due to disuse; and a failure to restore pre-injury function after a period of disability.

24The Applicant has not provided evidence that he has withdrawn from social milieu or failed to restore his pre-accident function. Instead, the evidence indicates that he returned to his pre-accident work on a full-time basis. The Applicant does not claim to use prescription medication or other substances. The Applicant does not regularly visit with healthcare practitioners. Thus, I find that he is not dependent on them. None of the medical information before me suggests that the Applicant has deconditioned due to disuse. At most, the Applicant developed psycho-social sequalae in the form of complaints of anxiety, but those psychological complaints are minimal, and he never engaged in treatment or medication for those symptoms.

25Overall, I find that the Applicant has not demonstrated that he suffers from a chronic pain condition as a result of the accident.

The Applicant is not entitled to the treatment and assessment plans

26The treatment and assessment plans in dispute propose goods and services that fall outside the MIG and the $3,500.00 funding limit for a minor injury. The Applicant is not entitled to these benefits because he sustained a minor injury and is limited to benefits within the MIG and the $3,500.00 funding limit.

Interest

27Interest applies on the payment of any overdue benefits pursuant to section 51 of the Schedule. Having found no benefits payable, it follows that no interest is payable.

CONCLUSION AND ORDER

28The Applicant sustained a minor injury as a result of the accident and is subject to the MIG and the $3,500.00 funding limit for a minor injury.

29The Applicant is not entitled to the treatment and assessment plans in dispute, nor interest.

30The application is dismissed.

Released: April 10, 2025

Brian Norris

Adjudicator```