Licence Appeal Tribunal
Licence Appeal Tribunal File Number: 23-011327/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:
Inder Jandoo
Applicant
and
Intact Insurance Company
Respondent
DECISION
ADJUDICATOR: Harouna Saley Sidibé
APPEARANCES:
For the Applicant: Naman Nanda, Counsel
For the Respondent: Jane Lo, Counsel
HEARD: By way of written submissions
OVERVIEW
1Inder Jandoo, the applicant, was involved in an automobile accident on October 7, 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, 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 a non-earner benefit of $185.00 per week from October 29, 2021, to October 7, 2023?
iii. Is the applicant entitled to $4,987.56 for psychological services, proposed by HM Medical Network Ltd in a treatment plan/OCF-18 (“plan”) dated June 21, 2023?
iv. Is the applicant entitled to $58.19 ($1,337.20 less $1,279.01 approved) for physiotherapy services, proposed by Yong-Spruce Chiropractic Clinic in a plan dated January 6, 2022?
v. Is the applicant entitled to $2,286.83 for physiotherapy services, proposed by Yong-Spruce Chiropractic Clinic in a plan dated February 24, 2023?
vi. Is the applicant entitled to $2,486.00 for a psychological assessment, proposed by HM Medical Network Ltd. in a plan dated March 2, 2023?
vii. Is the applicant entitled to $2,460.00 for a chronic pain assessment, proposed by HM Medical Network Ltd. in a plan dated June 22, 2023?
viii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
ix. Is the applicant entitled to interest on any overdue payment of benefits?
3The applicant withdrew the non-earner benefit issue in his submissions.
RESULT
4For the reasons below, I find that:
The applicant’s impairments are predominantly minor, and thus, the MIG limit applies.
As the applicant is subject to the MIG, it is not necessary to consider whether the disputed treatment plans are reasonable and necessary.
The applicant is not entitled to interest or an award.
ANALYSIS
Are the applicant’s injuries predominantly minor?
5I find that the applicant has not proven, on a balance of probabilities, that his impairments fall outside the MIG.
6Section 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.”
7An 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.
8The applicant argues that the grounds for exclusion from the MIG are based on the presence of both chronic pain and psychological impairment, which, in his opinion, are not conditions that align with the MIG.
a) Has the applicant sustained psychological impairments that justify removal from the MIG?
9I find that the applicant has not demonstrated that he suffers from psychological impairments justifying removal from the MIG.
10The applicant relies on Dr. Julie Gosselin, a psychologist, for her s. 25 psychological report dated April 28, 2023. Dr. Gosselin diagnosed the applicant with Somatic Symptom Disorder with Predominant Pain and recommends psychotherapy.
11The respondent relies on Dr. Rodney Day, a psychologist, for his s. 44 insurer examinations. Dr. Day found that the applicant did not meet the criteria for a DSM-5 diagnosis.
12I find that the applicant did not report any psychological impairments to his family doctor, Dr. Amin Mohamed Dhalla, during his visits following the accident. The clinical notes and records (“CNRs”) from November 2021 contain no accident-related complaints, and the applicant was found to be doing very well. The CNRs of March 21, March 24, April 21, and July 12, 2022, did not refer to psychological complaints or the accident. None of the CNRs from the applicant’s family doctor, Dr. Dhalla, or from Dr. Mike Bentley-Taylor, the applicant’s cardiologist, mentioned any accident-related complaints, including psychological complaints.
13The applicant underwent a psychological assessment with Dr. Gosselin. The report dated April 28, 2023, states that the applicant’s symptoms are consistent with Somatic Symptoms Disorder with Predominant Pain. The applicant underwent several assessments, including the Automobile Anxiety Inventory, the PCL-5, the Beck Anxiety Inventory (BAI), the Beck Depression Inventory (BDI-II), and the Outcome Questionnaire (OQ-45.2), among others. The scores are generally below average or at a low level.
14The applicant underwent a s.44 psychological assessment with Dr. Rodney Day. The report, dated July 28, 2023, applied psychometric testing including the Personality Assessment Inventory (PAI), Pain Patient Profile (P-3), Pain Catastrophizing Scale (PCS), and interview diagnostics. Dr. Day concludes that there is no accident-related psychological diagnosis and no psychological or functional impairments that can be attributed to the accident.
15I place greater emphasis on Dr. Day’s report, which included comprehensive psychometric testing and interviews, ultimately concluding that there was no accident-related psychological disorder. In contrast, I assign less weight to Dr. Gosselin’s s. 25 report because her clinical impressions were not supported by the objective test results, specifically, the applicant’s minimal scores on standardized assessments did not align with the severity of symptoms she described. This inconsistency raises concerns about the reliability of her conclusions.
16Consequently, I conclude that, based on a balance of probabilities, the applicant has not suffered psychological impairments that warrant removal from the MIG.
b) Has the applicant sustained chronic pain that justifies removal from the MIG?
17I find that the applicant did not demonstrate that he suffers from chronic pain that would justify removal from the MIG.
18The applicant relies on a chronic pain report by Dr. Igor Portnoi, a family physician, dated March 8, 2024. Dr. Portnoi diagnoses the applicant with chronic pain and states that the applicant now suffers from serious and permanent physical impairment. Additionally, the applicant refers to a letter from the respondent, dated November 8, 2023, which advised the applicant he was “out of MIG,” arguing that that representation should bind the respondent.
19The respondent relies on s. 44 insurer musculoskeletal examinations by Dr. Mark Goldstein, a chronic pain specialist, dated September 14, 2023, which diagnosed persistent myofascial pain but no functional deficit. The respondent notes that the letter dated November 8, 2023, contained an obvious clerical error, which was subsequently corrected by the letter dated March 21, 2024; therefore, it cannot prevent the proper application of the Schedule.
20I find that the CNRs from the applicant’s family doctor, Dr. Dhalla, reveal no accident-related complaints of pain and highlight the applicant’s ongoing gym activity and golfing. Additionally, the family doctor CNRs document no complaints of neck or back pain related to the accident and emphasize the importance of cardiovascular follow-up.
21On March 8, 2024, the applicant underwent a chronic pain assessment with Dr. Portnoi. Dr. Portnoi diagnosed the applicant with a sprain and strain of the lumbar spine, a right shoulder strain/sprain, a right gluteal strain/sprain, likely underlying right hip osteoarthritis, and sacroiliac joint dysfunction.
22Additionally, on September 5, 2023, the applicant underwent a musculoskeletal assessment with Dr. Goldstein, who diagnosed the applicant with persistent myofascial pain in the trapezius without any functional range of motion impairments.
23I give less weight to Dr. Portnoi’s report because the chronic pain diagnosis was made 28 months after the accident and is not supported by contemporaneous CNRs from the applicant’s family physicians or any documented prior complaints of ongoing pain. While Dr. Portnoi may have conducted a physical examination, the diagnosis appears to rely heavily on the applicant’s self-reporting without corroboration from earlier medical documentation. In contrast, I assign more weight to Dr. Goldstein’s report, which is supported by a detailed physical examination and aligns more closely with the documented medical history.
24Finally, the letter from the respondent, dated November 8, 2023, states, “We are also in receipt of new medical information which indicates your injuries fall outside of the [MIG].” The letter dated March 21, 2024, explains that: “Further to our letter dated November 8, 2023, please be advised there was a clerical error in sending this letter and your injuries do not fall outside the [MIG] Limits.”
25I find that the erroneous letter dated November 8, 2023, does not, on its own, establish substantive entitlement. The respondent rectified the error, and there is no evidence that the applicant relied to their detriment on the letter when seeking or incurring treatment.
26I conclude that, on a balance of probabilities, the applicant’s impairments are minor according to the Schedule and remain subject to the MIG monetary limit.
Is the applicant entitled to the disputed treatment and assessment plans?
27Since I have determined that the applicant has not established that his accident-related impairments require treatment beyond the MIG limits, it is unnecessary for me to evaluate the reasonableness and necessity of the disputed treatment plans.
Interest
28Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no benefits are payable, no interest is due.
Award
29The applicant seeks an award under section 10 of Regulation 664. Under section 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. As no benefits were withheld or delayed, the respondent is not liable to pay an award.
ORDER
30For the reasons above, I make the following orders:
i. The applicant’s impairments are predominantly minor, and thus, the MIG limit applies.
ii. As the applicant is subject to the MIG, it is not necessary to consider whether the disputed treatment plans are reasonable and necessary.
iii. The applicant is not entitled to interest or an award.
Released: July 11, 2025
Harouna Saley Sidibé
Adjudicator