Licence Appeal Tribunal File Number: 23-012814/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:
Qais Al-Smadi
Applicant
and
Allstate Insurance Company of Canada
Respondent
DECISION
ADJUDICATOR:
Harouna Saley Sidibé
APPEARANCES:
For the Applicant:
Kameliya Stancheva, Paralegal
For the Respondent:
Evan Argentino, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Qais Al-Smadi, the applicant, was involved in an automobile accident on May 28, 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, Allstate Insurance Company of Canada, 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 a minor injury as defined in section 3 of the Schedule and therefore subject to treatment within the Minor Injury Guideline (“MIG”) and the $3,500.00 funding limit?
ii. Is the applicant entitled to a medical benefit in the amount of $2,256.86 for physiotherapy proposed by Integral Health Group in a treatment plan/OCF-18 dated October 21, 2021?
iii. Is the respondent liable to pay an award under section 10 of Regulation 664 because it unreasonably withheld or delayed payments to the applicant?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3For the reasons that follow, I find:
The applicant’s injuries are predominantly minor, and thus, the MIG monetary limit applies.
As the applicant is in the MIG, it is not necessary for me to consider whether the disputed treatment plan is reasonable and necessary.
The applicant is not entitled to an interest or an award.
ANALYSIS
Applicability of the MIG
4I find that the applicant’s injuries are predominantly minor and that the MIG applies.
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.
7In his submissions, the applicant did not clearly indicate the basis on which he wishes to be considered outside the monetary limit of the MIG. However, he contended that he experienced several sprains and strains, headaches, and ongoing functional limitations, all accompanied by persistent pain, indicating that the injuries are significant. He also noted that the diagnostic imaging reveals pathologies that do not align with minor injuries. Moreover, when recovery stagnates, the Tribunal often removes applicants from the MIG.
8The respondent reported that objective imaging reveals only minor degenerative changes and no fractures. The family doctor notes that the back pain was associated with long-distance truck driving rather than the accident. The physiatry assessment on December 4, 2023, diagnosed simple musculoligamentous injuries and confirmed the MIG. The applicant carries the burden of proof but has not provided any compelling medical evidence.
9I find that the applicant’s injuries meet the MIG definition because the evidence presented supports a classification of sprain/strain.
10Firstly, the thoracic, lumbar, and cervical X-ray report from AppleMed, dated June 8, 2021, revealed no fractures or disc pathology; only noted was "mild restriction of flexion."
11Secondly, the Clinical Notes and Records (“CNRs”) from October 2021 to February 2022, provided by Dr. Nassr Zabib, the applicant’s family doctor, consistently indicate that the applicant appears well and shows no distress. They also note that the prescription of Lyrica is aiding the applicant with both back pain and sleep issues. Furthermore, the lower back pain is likely connected to the fact that the applicant is a long-distance truck driver.
12Moreover, the CNRs from Doctor Khalid Muhammed, a family doctor, from September to December 2023 indicate that the applicant recently broke his left foot and was seeking a prescription refill. This fracture is not linked to the accident, as it is noted to have occurred due to falling down the stairs.
13Additionally, the applicant underwent a s.44 physiatry examination conducted by Dr. Shariff Dessouki, a physiatrist. The report, dated December 18, 2023, found that the applicant had musculoligamentous injuries to the cervical, thoracic, and lumbar spine due to the accident. These injuries suggest that the applicant is experiencing strains, sprains, or other soft tissue injuries in the neck, upper and middle back, or lower back.
14Overall, the evidence presented did not indicate that the applicant sustained injuries that would place him outside of the MIG limit.
15Therefore, I conclude on a balance of probabilities that the applicant is not entitled to removal from the MIG.
The treatment plan for physiotherapy services
16Since I have determined that the applicant has not shown that his accident-related impairments require treatment beyond the MIG limits, it is unnecessary for me to assess the reasonableness and necessity of the disputed treatment plan.
Interest
17Interest applies to the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since no benefits are payable, interest does not apply.
Award
18The applicant sought an award under s. 10 of Reg. 664. Under s. 10, the Tribunal may grant an award of up to 50 per cent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits.
19The applicant bears the responsibility to demonstrate that the insurer unreasonably withheld or delayed the payment of benefits. However, in his submissions, the applicant did not address the request for the award.
20The respondent stated that it relied on timely insurer examination reports, issued section 33 requests, and delivered reasoned denials; no conduct exists that is excessive, imprudent, or unyielding.
21Consequently, I find that the applicant is not entitled to an award.
ORDER
22For the above reasons, it is ordered that:
The applicant’s injuries are predominantly minor, and thus, the MIG monetary limit applies.
As the applicant is in the MIG, it is not necessary for me to consider if the dispute treatment plan is reasonable and necessary.
The applicant is not entitled to an interest or an award.
Released: May 27, 2025
__________________________
Harouna Saley Sidibé
Adjudicator