Adam Abdulrahman v. Intact Insurance, 2025 CanLII 39289

Licence Appeal Tribunal

Citation: Adam Abdulrahman v. Intact Insurance, 2025 CanLII 39289

Licence Appeal Tribunal File Number: 23-006005/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:

Adam Abdulrahman

Applicant

and

Intact Insurance

Respondent

DECISION

ADJUDICATOR:

Rasha El Sissi

APPEARANCES:

For the Applicant:

Malcolm H. Zoraik, Counsel

For the Respondent:

Harkamal Hehar, Counsel

HEARD:

By way of written submissions

OVERVIEW

1Adam Abdulrahman, the applicant, was involved in an automobile accident on June 6, 2019, 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, Intact 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 (“MIG”) limit?

ii. Is the applicant entitled to $4,275.34 for chiropractic services, proposed by Joint & Health in a treatment plan/OCF-18 (“plan”) dated July 27, 2022?

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

RESULT

3The applicant has sustained a minor injury as a result of the accident, as defined in s. 3 of the Schedule. He is subject to the MIG and the $3,500.00 funding limit on treatment.

4The applicant is not entitled to the plan in dispute or interest.

ANALYSIS

MIG

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.”

6The applicant may be removed from the MIG if he can establish his accident-related injuries fall outside of the MIG or, under s. 18(2), that he has a documented pre-existing condition combined with compelling medical evidence stating that the condition precludes maximal recovery if he is kept within 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 that he should be removed from the MIG based on his pre-existing back condition.

8For the following reasons, I find that the applicant sustained a minor injury as a result of the accident, and he does not have a pre-existing condition that warrants MIG removal.

The applicant is not removed from the MIG under s. 18(2) of the Schedule.

9I find, on a balance of probabilities, that the applicant does not suffer from a pre-existing condition that would warrant his removal from the MIG.

10To be removed from the MIG based on a pre-existing condition, the applicant must satisfy both parts of a two-part test pursuant to s. 18(2) of the Schedule. He must provide documented evidence of a pre-existing medical condition by a health practitioner, and he must also provide evidence that the pre-existing condition will prevent him from achieving maximal medical recovery from the minor injury if he is subject to the MIG limits.

11The applicant submits that he has well-documented long-standing back pain that pre-exists the motor vehicle accident and relies on medical evidence. He submits that this prevents him from achieving maximum recovery from his injuries suffered in the accident. He also has chronic pain that interferes with his sleep and has impacted his mental health.

12The respondent submits the applicant has not submitted any medical evidence to support his contention that he would be prevented from reaching maximum medical recovery if treated within the MIG.

13The applicant relies on the clinical notes and records of his family doctor, Dr. Steven Chan, as well as the s. 44 insurer’s examination report of Dr. James Stewart (musculoskeletal assessor).

14I find that the applicant has a documented history of back pain, as outlined in Dr. Chan’s clinical notes and records and summarized by Dr. Stewart in his s. 44 report. Dr. Chan recorded the applicant’s complaints of back pain on April 4, 2017, May 29, 2017 and January 30, 2019. In addition, the applicant was seen in emergency for a variety of complaints, including back pain on April 25, 2018.

15To be removed from the MIG on the basis of s. 18(2), the applicant must also provide compelling medical evidence stating that his pre-existing condition precludes maximal recovery if he is kept within the MIG.

16However, there is no statement in the clinical notes and records relied upon by the applicant that the applicant’s pre-existing back pain precludes maximal recovery if he is kept within the MIG.

17Accordingly, the applicant has not met his onus to be removed from the MIG based on a pre-existing condition.

18I find that the applicant has not satisfied s. 18(2) of the Schedule and that his injuries are captured in the definition of a minor injury in s. 3. The applicant is entitled to treatment within the $3,500.00 MIG limit.

The plan in dispute

19As I find that the applicant’s injuries are predominantly minor and these injuries are subject to treatment within the $3,500.00 MIG limit, it is not necessary for me to consider whether the plan in dispute is reasonable and necessary.

Interest

20Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no payment of benefits are overdue, the applicant is not entitled to any interest.

ORDER

21For the above reasons, I find:

i. The applicant’s injuries are predominantly minor as defined in s. 3 of the Schedule and therefore subject to treatment within the $3,500.00 MIG limit. The applicant is not entitled to the plan in dispute or interest.

ii. The application is dismissed.