Licence Appeal Tribunal
Licence Appeal Tribunal File Number: 23-012851/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:
Ferrond Cox
Applicant
and
Belair Insurance Company Inc.
Respondent
DECISION
ADJUDICATOR: Caley Howard
APPEARANCES:
For the Applicant: Monica Gill, Paralegal
For the Respondent: Susana Cardoso, Counsel
HEARD: By way of written submissions
OVERVIEW
1Ferrond Cox, the applicant, was involved in an automobile accident on July 14, 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, Belair Insurance Company Inc., 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 $3,622.31 for physiotherapy services, proposed by Mackenzie Medical Rehab Centre in a treatment plan/OCF-18 (“plan”) dated July 25, 2022?
iii. Is the applicant entitled to $2,530.00 for a psychological assessment proposed by Complete Rehab in a plan dated February 17, 2023?
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
3I find that:
i. The applicant’s injuries are predominantly minor and are subject to treatment within the $3,500.00 MIG limit;
ii. As the applicant is subject to the MIG, it is not necessary to consider whether the treatment plans are reasonable and necessary;
iii. The respondent is not liable to pay an award under s. 10 of Reg. 664; and
iv. There are no overdue benefits, therefore, the applicant is not entitled to interest under s. 51 of the Schedule.
ANALYSIS
The applicant’s injuries are subject to the MIG
4I find that the applicant suffered predominantly minor injuries in the accident and he remains subject to the MIG.
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 person 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.
7The applicant submits that he sustained right shoulder, neck and back pain as a result of the accident as well as psychological injuries. He submits that while his physical injuries were limited to sprains and strains, his psychological injuries do not fall within the definition of a minor injury and so he should be removed from the MIG. In support, he relies on the pre-screen interview notes of Dr. Jacqueline Brunshaw, psychologist, from the treatment plan dated February 17, 2023 and the psychological assessment report of Dr. Brunshaw dated May 8, 2024.
8The respondent submits that the applicant did not sustain psychological injuries in the accident and sustained only sprains and strains that fall within the definition of minor injuries. In support of this position, the respondent relies on the following: the insurer examination (“IE”) psychological assessment reports of Dr. Marc Mandel, psychologist, dated May 4, 2023 and September 13, 2024; the Clinical Notes and Records (“CNRs”) of Dr. Clarence Clottey, the applicant’s family doctor; and the IE report of Dr. Charanjit Sandhu, physician, dated October 26, 2022.
9Dr. Brunshaw first performed a psychology pre-screen interview of the applicant on February 17, 2023. Dr. Brunshaw’s notes indicate that the applicant reported various psychological and emotional symptoms that were impairing his overall general functioning. Dr. Brunshaw recommended a complete psychological assessment. Dr. Brunshaw assessed the applicant on April 25, 2024 and diagnosed the applicant with adjustment disorder with anxiety, major depressive disorder, mild to moderate, single episode, and specific phobia, situational type (vehicular), moderate to severe.
10Dr. Mandel conducted psychological assessments of the applicant on two occasions. In his May 4, 2023 report, based on both the applicant’s interview and the results of the applicant’s psychometric tests, Dr. Mandel determined that the applicant did not suffer from any clinically significant symptoms of a psychological condition or disability as a result of the accident. Dr. Mandel opined that, from a psychological perspective, the applicant’s accident-related impairments fell within the MIG. In his report of September 13, 2024 Dr. Mandel provides an opinion on the reasonableness and necessity of a treatment plan. Dr. Mandel’s general findings were very similar in both reports. I find that Dr. Mandel’s May 4, 2023 report is more relevant to the question of whether the applicant’s injuries fall within the MIG because it directly addresses the issue. However, I considered both reports and I find that, taken together, they show no worsening of the applicant’s condition between May 2023 and September 2024.
11I prefer Dr. Mandel’s opinion over the opinion of Dr. Brunshaw because Dr. Mandel found that the objective results of his testing concurred with and confirmed the subjective reports of the applicant from the interview portion of the assessments, in which the applicant reported that he was feeling “good” and denied the symptoms of psychological conditions that were canvassed. Conversely, Dr. Brunshaw’s report states that the results of the applicant’s psychometric testing revealed that he was experiencing lower levels of symptoms of depression than he reported during the clinical interview. I find that Dr. Brunshaw’s diagnoses are, in this respect, not supported by the results of psychometric testing. Because of this discrepancy between Dr. Brunshaw’s objective test results and clinical interview findings, I give Dr. Mandel’s opinion more weight.
12In addition, I find that Dr. Mandel’s opinion aligns with the preponderance of medical evidence available to me because I was directed to no evidence of the applicant reporting any psychological symptoms to Dr. Clottey. The CNRs of Dr. Clottey reveal that the applicant reported the accident to Dr. Clottey on August 3, 2022. He reported that he was experiencing shoulder, neck and back pain, had been doing physiotherapy and needed insurance forms filed. Dr. Clottey diagnosed a likely shoulder sprain and prescribed medication. That is the only CNR that addresses the applicant’s accident-related injuries and it contains no mention of any psychological symptoms or complaints.
13The applicant attended an IE with Dr. Charanjit Sandhu, physician, on October 26, 2022. In Dr. Sandhu’s report dated November 9, 2022, Dr. Sandhu states that the applicant reported no depression, anxiety, nightmares or panic attacks. The applicant reported to Dr. Sandhu that he did not feel that a psychological assessment was needed at that time. I find that Dr. Sandhu’s opinion further corroborates the opinion of Dr. Mandel that the applicant did not sustain a psychological condition as a result of the accident that would warrant his removal from the MIG.
14Therefore, I find that the applicant has not proven, on a balance of probabilities, that he sustained a psychological condition as a result of the accident that would warrant his removal from the MIG. The applicant remains subject to the MIG.
15I have found that the applicant remains subject to the MIG, therefore it is not necessary to determine whether the disputed treatment plans are reasonable and necessary.
Interest
16Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As I have found that the applicant remains within the MIG, there are no overdue payments and there is no interest payable in accordance with s. 51.
Award
17The 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.
18As there are no benefits withheld or delayed, the respondent is not liable to pay an award.
ORDER
19I find that:
i. The applicant’s injuries are predominantly minor and are subject to treatment within the $3,500.00 MIG limit;
ii. As the applicant is subject to the MIG, it is not necessary to determine if the treatment plans in dispute are reasonable and necessary;
iii. The respondent is not liable to pay an award under s. 10 of Reg. 664; and
iv. There are no overdue benefits, therefore, the applicant is not entitled to interest under s. 51 of the Schedule.
Released: August 12, 2025
Caley Howard Adjudicator