Licence Appeal Tribunal File Number: 23-000225/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:
Sherveer Dhillon
Applicant
and
Certas Direct
Respondent
DECISION
ADJUDICATOR:
Brian Norris
APPEARANCES:
For the Applicant:
Joseph Sidiropoulos, Counsel
For the Respondent:
Madison McNerney, Counsel
HEARD: By way of written submissions
OVERVIEW
1Sherveer Singh Dhillon (“the Applicant”) was involved in an automobile accident on March 14, 2020, and sought benefits from Certas Direct (“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. The Applicant disagrees and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
3The issues to be decided in the hearing are:
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 (the “MIG”) and the $3,500.00 funding limit for a minor injury?
Is the Applicant entitled to a medical benefit in the amount of $1,300.00, less $1,100.00 approved by the Respondent, for chiropractic and massage therapy treatment, proposed by Dr. S. Greenspan in a treatment plan/OCF-18 (“plan”) dated December 2, 2020?
Is the Applicant entitled to a medical benefit in the amount of $2,086.65 for a chiropractic and massage therapy treatment, proposed by Dr. S. Greenspan in a plan dated December 18, 2020?
Is the Applicant entitled to interest on any overdue payment of benefits?
RESULT
4I find that the Applicant sustained a minor injury as a result of the accident. He is subject to the MIG and the $3,500.00 funding limit for a minor injury.
5The treatment and assessment plans in dispute are not reasonable and necessary because they propose treatment outside the MIG.
6No interest or award is payable.
BACKGROUND
7The Applicant was the driver of a vehicle which was struck on the passenger side while traversing a suburban intersection. He was examined by paramedics at the scene of the accident and opted to go home thereafter. He visited his family physician the following day due to neck pain and headaches. He was diagnosed with a whiplash disorder and referred for physiotherapy and massage therapy. After, he commenced treatment pursuant to the MIG.
8The Applicant claims that he suffered from pre-existing knee and back pain which precludes his recovery if subject to the MIG. Alternatively, he submits that he suffers from psychological conditions that were caused or exacerbated by the accident, suggesting that he sustained injuries that are not included in the minor injury definition.
ANALYSIS
Minor Injury Guideline (“MIG”)
9The 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.
10The 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.
11For the following reasons, I find that the Applicant sustained a minor injury as a result of the accident.
Pre-existing condition does not impair recovery
12I find that the Applicant has not demonstrated that his pre-existing conditions preclude his recovery within the MIG.
13The MRI report of the Applicant’s lumbar spine is not compelling evidence of a pre-existing condition which would preclude the Applicant’s recovery if subject to the MIG and the $3,500.00 funding limit for a minor injury. The MRI report states a finding of a small broad-based posterior disc bulge without thecal sac or root compression. The report is undated and unclear if it is related to the Applicant as the name of the patient associated with the MRI report is smudged and illegible. Dr. S. Greenspan, chiropractor, indicates in the December 18, 2020, treatment plan that the Applicant’s disc bulge is a barrier to recovery, but there is no information indicating why or how the alleged disc bulge will impact the Applicant’s recovery. Further, the clinical notes and records from Dr. Greenspan do not clarify how or why the disc bulge is a barrier to recovery from uncomplicated soft-tissue injuries.
14My conclusion that the disc bulge is not a pre-existing condition which precludes the Applicant’s recovery is supported by the Applicant’s family physician and walk-in clinic CNRs. The Applicant was assessed at the walk-in clinic the day after the accident and there is no mention of or reference to a pre-existing issue which would impact his recovery. The following visit, about two months later, refers to the accident but, again, does not mention any pre-existing injuries or issues that would impact the Applicant’s recovery. Further, although the Applicant visited the walk-in clinic numerous times after the accident, the accident is not mentioned at all in those CNRs for any period after May 2021. This suggests that the Applicant recovered from his accident-related injuries and that his pre-existing disc bulge is not a barrier to recovery.
15Accordingly, I find no compelling evidence of a pre-existing health condition which would preclude the Applicant’s recovery if subject to the MIG.
No evidence of an accident-related psychological condition
16I find that the Applicant has not demonstrated an accident-related psychological condition.
17There is no evidence before me indicating that the Applicant suffers from an accident-related psychological condition. The Applicant makes passing reference to attention deficit and hyperactivity disorder (“ADHD”) and submits that this was caused or exacerbated by the accident. Yet, he has not directed me to any evidence indicating that the Applicant’s ADHD is caused by or exacerbated by the accident. The walk-in clinic and family physician CNRs do not include any accident-related psychological complaints. ADHD is discussed during a visit on August 8, 2022, in which the Applicant reports that he dealt with the condition in childhood and that he would like to test for it. A follow-up visit, on October 4, 2022, led to the Applicant being prescribed medication for ADHD symptoms. At no point did the Applicant, or his treating healthcare providers, ever suggest that his ADHD was caused or exacerbated by the accident. Similarly, the Applicant consulted with Dr. M. Showraki, psychiatrist, on August 10, 2023, who concluded that the Applicant appears to suffer from attention deficit disorder and general anxiety disorder. However, in those records Dr. Showraki never attributes the Applicant’s psychological symptoms to the accident.
18Accordingly, I find no evidence of an accident-related psychological condition, nor evidence of an exacerbation of the Applicant’s ADHD, as a result of the accident. His injuries are rightfully characterized as a minor injury, and he is subject to the MIG and the $3,500.00 funding limit for a minor injury.
The Applicant is not entitled to the treatment plans in dispute
19The 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
20Interest applies on the payment of any overdue benefits pursuant to section 51 of the Schedule. Having found no benefits payable, it follows that no payments are overdue and no interest is payable.
CONCLUSION AND ORDER
21The 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.
22The treatment and assessment plans in dispute are not reasonable and necessary because they propose goods and services that are not included in the MIG.
23No interest is payable as no payments were withheld or delayed.
24The Application is dismissed.
Released: January 20, 2025
Brian Norris
Adjudicator