Licence Appeal Tribunal File Number: 23-010351/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:
Damneet Bassi
Applicant
and
Aviva General Insurance
Respondent
DECISION
ADJUDICATOR:
Patrick Molloy
APPEARANCES:
For the Applicant:
John Chui, Counsel
For the Respondent:
Sophia Chaudri, Counsel
HEARD:
By Way of Written Submissions
OVERVIEW
1Damneet Bassi, the applicant, was involved in an automobile accident on March 3, 2020, 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, Aviva, 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? Note: The parties agree the MIG limits have not been exhausted, with $55.11 remaining at the date of the case conference.
ii. Is the applicant entitled to $2,460.00 for a chronic pain assessment, proposed by Elite Specialist Group in a treatment plan dated December 20, 2021?
iii. Is the applicant entitled to $2,460.00 for a psychological assessment, proposed by Elite Specialist Group in a treatment plan dated November 22, 2022?
iv. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
v. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant’s accident-related injuries are not predominantly minor, and therefore, she is removed from the MIG.
4The applicant is entitled to the treatment plan for a chronic pain assessment plus interest.
5The applicant is not entitled to the treatment plan for a psychological assessment.
6The respondent is not liable to pay an award.
ANALYSIS
Application of the MIG
7Section 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."
8An 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.
9The applicant submits that she does not belong in the MIG as a result of chronic neck and back pain, as well as a psychological impairment, identified as Depression and Chronic Pain. The respondent disagrees, arguing that the Applicant has failed to demonstrate that the treatment plans are reasonable or necessary and the goals of the plans have not been demonstrated by the applicant.
10For the reasons below, I find that the applicant has proven on a balance of probabilities removal from the MIG is warranted based on chronic pain, Dr. Karmy diagnosed the applicant with Chronic pain Syndrome, Chronic post traumatic headache, Chronic mechanical neck pain, Chronic mechanical shoulder blade pain, Chronic lower back pain, causing sleep disorder and possible mood disorder attributed to the accident.
11Based on the treatment plan from Physiotherapist Avni Parmar of the Progressive Rehab Clinic and the Disability Certificate of Dr. Anmol Sidhu, Chiropractor, I find the applicant’s injuries have affected her ability to carry out her activities of normal life and indicate the applicant has multiple barriers to recovery, such as insomnia and stress, her ability to lift or pull objects, neck rotation and lifting heavy objects The applicant attended physiotherapy sessions from May 8, 2020 through to November 12, 2022, which I find reveals the necessity and reasonableness for the treatment prescribed.
Chronic pain assessment
12For the reasons below, I find the Chronic Pain Assessment is reasonable and necessary.
13Chronic Pain is defined as pain that last more than 3 months. Chronic Pain adversely affects activities of daily living, adverse events, analgesia, and aberrant drug taking behaviours. An assessment with a chronic pain specialist is to determine the exact nature of the patient’s syndrome and to arrange an appropriate multidisciplinary pain.
14Chronic Pain Syndrome, the symptom complex, which can be characterized by the following six criteria as per the American Medical Association (AMA) Guides 1. Use of prescription drugs beyond the recommended duration and/or abuse of, or dependence on, prescription drugs or other substances. 2. Excessive dependence on health care providers, spouse, or family. 3. Secondary physical deconditioning due to disuse and/or fear-avoidance of physical activity due to pain. 4. Withdrawal from the social milieu, including work, recreation, or other social contacts. 5. Failure to restore pre-injury function after a period of disability, such that the physical capacity is insufficient to pursue work, family, or recreational needs. 6. Development of psychosocial sequelae after the initial incident, including anxiety, fear avoidance, depression, or nonorganic illness behaviors. Dr Karmy submitted; the claimant meets five of the above six criteria 2 to 6. Therefore, she has suffered from Chronic Pain Syndrome as a result of the accident. On May 20, 2020, Dr. Anmol Sidhu (Chiropractor) completed a Disability Certificate and determined the applicant suffers from a number of conditions causing the applicant chronic pain, including headaches, a possible concussion, numerous sprains and strains of the spine, ribs, and sternum as a result of the accident.
15Avni Parmar, physiotherapist, from Progressive Rehab Clinic reported the applicant’s injuries have prevented her from carrying on a normal life and that she has multiple barriers to recovery. Dr. Sidhu opined the applicant suffers from a substantial inability to perform the essential tasks of her employment and certified that these impairments would initially last between 9 to 12 weeks. Her multi year treatment history from May 8, 2020, to November 12, 2022, indicates a long-term chronic pain injury.
16Based on the above, I find the chronic pain assessment reasonable and necessary.
Psychological assessment
17I find the psychological assessment is not reasonable and necessary because the applicant has not demonstrated that they sustained a psychological injury as a result of the accident.
18I also find the psychological assessment is not reasonable or necessary as there is little reference to any psychological injury. One year after the accident the family doctor makes reference to some anxiety, with no reference to the cause. The applicant indicated that she had not undergone a psychological assessment and did not receive any counselling and added that she no longer needed or wanted psychotherapy.
19I am not persuaded by the applicant’s submissions or limited evidence. Accordingly, I find that the applicant has not demonstrated that a psychological assessment is reasonable or necessary.
Interest
20Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule.
21Interest will apply on the chronic pain assessment only.
Award
22The 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.
23The applicant did not particulars to support the award as per the case conference order, therefore the applicant is not entitled to receive an award.
ORDER
24I find:
i. The applicant’s chronic pain impairment entitles her to be removed from the MIG.
ii. The chronic pain assessment is reasonable and necessary.
iii. The psychological assessment is denied.
iv. The respondent is not liable to pay an award.
v. Interest is payable on the chronic pain assessment for $2,460.00.
Released: July 25, 2025
Patrick Molloy
Adjudicator