Licence Appeal Tribunal File Number: 23-011435/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:
Luidmila Koidze
Applicant
and
Economical Insurance
Respondent
DECISION
ADJUDICATOR: Greg Witt
APPEARANCES:
For the Applicant: Ahmadreza Bazyar, Counsel
For the Respondent: Sunjay Mistry, Counsel
HEARD: In Writing
OVERVIEW
1Luidmila Koidze, the applicant, was involved in an automobile accident on November 26, 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, Economical Insurance, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The following issues are to be decided:
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 $12,912.72 for a multi-disciplinary assessment and services, proposed by Essential Physio Inc. in an OCF-18/treatment plan (OCF-18) dated September 25, 2023?
iii. Is the applicant entitled to interest on any overdue payment of benefits?
3In its submissions, the respondent withdrew its preliminary issue seeking to bar the applicant from proceeding to a hearing for all benefits claimed in the application because the applicant failed to attend the respondent’s examination under s. 44 of the Schedule.
RESULT
4I find that:
i. The applicant’s injuries are predominately minor and are therefore subject to treatment within the $3500.00 limit of the MIG;
ii. Given the applicant is in the MIG, it is not necessary to consider if the OCF-18 in dispute is reasonable and necessary; and
iii. The applicant is not entitled to interest.
ANALYSIS
Applicability of the Minor Injury Guideline (“MIG”)
5The MIG establishes a framework available to injured persons who sustain a minor injury as a result of an accident. A “minor injury” is defined in s. 3(1) of the Schedule as, “one or more of a strain, sprain, whiplash associated disorder, contusion, abrasion, laceration or subluxation and includes any clinically associated sequelae to such an injury.”
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 MIG. An 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.
7An applicant may receive payment for treatment beyond the $3,500.00 limit if they can demonstrate that a pre-existing condition, documented by a medical practitioner, prevents maximal medical recovery of the minor injury sustained in the accident if they were kept in the MIG, or if they provide evidence of an injury sustained in the accident that is not included in the minor injury definition in s.3(1). The Tribunal has also determined that chronic pain with functional impairment or a psychological condition may warrant removal from the MIG.
8It is the applicant’s burden to establish entitlement to coverage beyond the $3,500.00 cap on a balance of probabilities.
The applicant is not removed from the MIG
9I find that the applicant has not met their onus to demonstrate that they should be removed from the MIG.
10The applicant’s submissions comprise of a point form list of initial and ongoing treatments, current symptoms and complaints, diagnostic impressions, and an addendum report dated October 8, 2024 of Dr. Steve Blitzer, physician. The addendum report is also point form and lists gynecological issues, mental health concerns, cognitive functional issues and physical health issues.
11I find that the applicant did not make any submissions or direct me to the evidence on which they appear to rely to be removed from the MIG. The applicant’s evidence includes the addendum report, the hospital records from Mackenzie Health Hospital on the date of the accident, which confirmed no fractures, the OCF-18, and the clinical notes and records (“CNR’s”) of Dr. Benjamin Milad, physician, and Dr. Steve Blitzer, physician. However, I find that the applicant did not connect her submissions to the evidence.
12Furthermore, while the applicant made general references to persistent pain and mood disturbances, the applicant did not tie these references or make it clear on what basis the applicant seeks to be removed from the MIG. As a result, I find the applicant has not met her onus. This is enough to dismiss the application without reference to the respondent’s evidence, though I still considered it as noted below.
13The Tribunal does not have a duty to sift through evidence in order to make the case for the applicant, to do so risks the Tribunal inappropriately acting as an advocate for a party instead of a neutral arbitrator in a dispute. The submissions made by the applicant fail to prove on a balance of probabilities that her injuries should be treated outside of the MIG.
14In this case, in addition to finding that the applicant has not met her onus, I am persuaded by the respondent’s submissions.
15The respondent submits that the applicant’s injuries are predominately minor and relies on the medical evidence from the emergency department at Mackenzie Hospital where the applicant was diagnosed with neck strain. Furthermore, the CNRs of Dr. Milad, dated January 19, 2021, recommend Advil or Tylenol as well as ordered an x-ray requisition, that revealed no fractures to the applicant’s skull or spine. The x-ray is dated January 26, 2021.
16The respondent also submits that the applicant does not suffer from chronic pain because of the accident. The respondent relies on the CNR’s of, Dr. Seyed Dastmalchian, family physician, from December 15, 2022 to January 19, 2024 which makes no refence to ongoing pain, and highlights that the applicant does not address the AMA Guides in her submissions. The AMA Guides are not binding on the Tribunal; although the applicant is not required to make an argument that is non-binding on the Tribunal, many of the Tribunal’s decisions have found the AMA Guides to be a useful interpretative tool for evaluating chronic pain claims.
17Based on the medical evidence before me, I find that the applicant’s injuries fall within the definition of minor injury, and therefore the applicant’s injuries do not warrant a removal from the MIG.
18Therefore, I find on a balance of probabilities that the applicant is subject to the $3,500 funding limit of the MIG.
19Given the aforementioned findings, it is not necessary to determine if the treatment plan in dispute is reasonable and necessary.
Interest
20Given that there are no benefits owing, the applicant is not entitled to interest pursuant to section 51.
ORDER
21I find that:
i. The applicant’s injuries are predominately minor and therefore subject to treatment within the $3500.00 limit of the MIG;
ii. As the applicant is in the MIG, it is not necessary to consider if the OCF-18 in dispute is reasonable and necessary; and
iii. The applicant is not entitled to interest.
Released: August 14, 2025
__________________________
Greg Witt
Adjudicator