Licence Appeal Tribunal File Number: 23-009267/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:
Eric Lee
Applicant
and
Co-operators General Insurance Company
Respondent
DECISION
ADJUDICATOR: Robert Rock
APPEARANCES:
For the Applicant: Self-represented
For the Respondent: Julianne Brimfield, Counsel
HEARD: By way of written submissions
OVERVIEW
1Eric Lee, the applicant, was involved in an automobile accident on April 6, 2022, 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, Co-Operators General 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 $250.00 for a psychological assessment, proposed by Imperial Medical Assessment in a treatment plan/OCF-18 (“plan”) dated February 6, 2023?
iii. Is the applicant entitled to $2,200.00 for a psychological assessment proposed by Imperial Medical Assessment in a treatment plan dated February 6, 2023?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant remains within the MIG.
4The applicant is not entitled to the treatment plans in dispute.
5As there are no overdue benefit payments, there is no interest owing.
6The application is dismissed.
PROCEDURAL ISSUES
7The applicant did not submit substantive submissions or evidence for this written hearing.
8A case conference was held on January 23, 2024 that set this matter down for a written hearing scheduled for August 30, 2024.
9The applicant filed a Notice of Motion on September 11, 2023. The applicant requested an adjournment that was consented by the respondent. An adjournment order was released on August 29, 2024 that set the new date for the written hearing as November 1, 2024 and marked this date as peremptory on the parties to proceed.
10Notice of the new written hearing date was provided on September 11, 2024.
11The applicant’s new deadline for written submissions was October 2, 2024. On October 21, 2024, the applicant provided a one-page document to the Tribunal explaining that he has been unable to file written submissions, and requesting that the Tribunal consider the fact that he had difficulties securing legal representation. I interpret this to mean that the applicant was requesting an additional adjournment to the scheduled written hearing.
12The applicant has not filed an additional Notice of Motion to request an additional adjournment and has not followed Tribunal procedure for requesting an adjournment.
13As the Adjournment Order of August 29. 2024 was marked peremptory, I have decided to proceed with the hearing.
The Minor Injury Guideline
14Section 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.”
15An 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.
16The burden is on the applicant to demonstrate, on a balance of probabilities, that his injuries fall outside of the MIG.
17As the applicant has not provided any substantive submissions or evidence, he has not met his onus to demonstrate that he should be removed from the MIG.
18I find that the applicant remains within 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. The applicant further has not provided any submissions or evidence on the reasonableness and necessity of the treatment plans in dispute.
Interest
20Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As there are no overdue benefit payments, no interest is owing.
ORDER
21I find that:
i. The applicant remains in MIG.
ii. The applicant is not entitled to the treatment plans in dispute.
iii. No interest is owing.
iv. The application is dismissed.
Released: June 2, 2025
Robert Rock
Adjudicator