Licence Appeal Tribunal File Number: 23-008768/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:
Kaela Pryce
Applicant
and
Economical Insurance
Respondent
DECISION
ADJUDICATOR:
Robert Rock
APPEARANCES:
For the Applicant:
Laya Witty, Counsel
For the Respondent:
Mirsa Duka, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Kaela Pryce, the applicant, was involved in an automobile accident on November 13, 2021, 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, Economical 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 the OCF-18/treatment plans (“treatment plan”) proposed by Mind by Design, as follows:
(i) $2,200.00 for a psychological assessment, in a treatment plan dated September 5, 2023; and
(ii) $3,615.65 for a virtual vehicle anxiety assessment, in a treatment plan dated September 19, 2023?
RESULT
3The applicant remains in MIG.
4As the applicant remains in MIG, it is not necessary to consider if the treatment plans in dispute are reasonable and necessary.
ANALYSIS
The Minor Injury Guideline
5Section 18(1) of the Schedule provides that medical and rehabilitation benefits are limited to $3,500.00 if the insured person sustains impairments that are predominantly minor injuries. 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 person may be removed from the MIG if it can be established that accident-related injuries fall outside of the MIG, or if there is documentation of a pre-existing condition combined with compelling medical evidence stating that the condition precludes recovery from any accident-related minor injury if they are kept within the MIG, pursuant to s. 18(2) of the Schedule. The Tribunal has determined that chronic pain with a functional impairment or a psychological condition may warrant MIG removal.
7The burden is on the applicant to demonstrate, on a balance of probabilities, that his injuries fall outside of the MIG.
a) The applicant does not suffer from chronic pain with a functional impairment.
8The applicant has not proven on a balance of probabilities that she has chronic pain with a functional impairment that warrants removal from the MIG.
9The applicant argues that he suffers from chronic pain as a result of the subject accident. The applicant relies on the clinical notes and records (CNRs) of Dr. Jalayer, her family doctor.
10I find that the CNRs of Dr. Jalayer do not support the applicant’s claim of chronic pain with a functional impairment. The CNRs continually note the applicant reporting physical improvement, and unremarkable physical examinations. A note in the CNRs on September 18, 2022, reads “history of chronic intermittent left shoulder and knee pain,” but the rest of the note includes, “no pain at this point, no limitation of range of movement, able to walk and bear weight.” The CNRs note, on February 23, 2023, discomfort with lifting, pulling and pushing and a history of left wrist injury from a few months ago. This note does not tie these issues to the subject accident, which occurred more than a year before. The CNRs lack any reporting of functional impairment associated with the subject accident.
11I find that the applicant has not proven on a balance of probabilities that she suffers from chronic pain with a functional impairment. The CNRs of Dr. Jalayer do not present medical evidence to substantiate that the applicant suffers chronic pain or an associated functional impairment that warrants removal from the MIG.
b) The applicant does not suffer from psychological condition.
12The applicant has not proven on a balance of probabilities that she suffered from a psychological condition that warrants removal from the MIG.
13The applicant argues that she sustained a psychological impairment as a result of the subject accident. The applicant relies on a pre-screening report by Dr. Sharifzadeh from August 25, 2023.
14I placed little weight on the pre-screening report by Dr. Sharifzadeh. The determination made by Dr. Sharifzadeh is not corroborated by other medical evidence before me. The applicant did not report any psychological issues to her family doctor, nor did any of the other treatment facilities that the applicant attended note psychological issues.
15The respondent argues that the applicant has not provided objective medical evidence to indicate any psychological condition as a result of the subject accident. The respondent relies on the CNRs of Dr. Jalayer, and a psychological assessment by Dr. Manel, psychologist, from November 16. 2023.
16I find that the CNRs of Dr. Jalayer do not support the applicant’s claim of a psychological condition as a result of the subject accident. The CNRs do not show that the applicant reported any psychological issues regarding the subject accident. The CNRs note on September 18, 2022, “no manic symptoms.” On February 16, 2023, the CNRs note the applicant reporting work related stress, but “denies any depressed mood or anxiety attack”.
17I place significant weight on the psychological assessment by Dr. Mandel. This assessment does not support the applicant’s claim of a psychological condition. The clinical interview and psychometric testing does not support a diagnosis of a psychological condition. The applicant notes during the clinical interview that she still drives, and that her loss of work was through a resignation not associated with the subject accident. The findings of this assessment are corroborated with the CNRs of Dr. Jalayer, specifically that the reported stress was work related and not associated with the subject accident.
18I find that the applicant has not proven on a balance of probabilities that she suffers from a psychological condition as a result of the subject accident that warrants removal from the MIG.
19As the applicant has been found to remain in the MIG, there is no need to conduct the reasonable and necessary analysis of the disputed treatment plans.
ORDER
20I find that:
i. The applicant remains in MIG.
ii. As the applicant remains in MIG, it is not necessary to consider if the treatment plans in dispute are reasonable and necessary.
iii. The application is dismissed.
Released: May 14, 2025
Robert Rock
Adjudicator