Licence Appeal Tribunal File Number: 23-014947/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:
Yong Da He
Applicant
and
Co-operators General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Jeff Chatterton
APPEARANCES:
For the Applicant:
Sareena Samra, Counsel
For the Respondent:
Jessica Telfer, Counsel
HEARD:
In Writing
OVERVIEW
1Yong Da He, the applicant, was involved in an automobile accident on October 25, 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 limit? Note: The parties agree the MIG limits have been exhausted.
ii. Is the applicant entitled to $4,697.20 for chiropractic services, proposed by UHeal Rehab Centre in a treatment plan/OCF-18 (“treatment plan”) submitted January 20, 2023 and denied January 20, 2023?
iii. Is the applicant entitled to $2,200.00 for a psychological assessment, proposed by Somatic Assessments and Treatment Clinic in a treatment plan submitted December 28, 2022 and denied January 5, 2023?
iv. Is the applicant entitled to $8.76 for medication, submitted on a claim form (OCF-6) submitted January 31, 2023 and denied February 2, 2023?
v. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The application is denied. The applicant’s injuries are minor and are subject to the $3,500 limitation of the Minor Injury Guideline (MIG).
4Since the applicant remains within the MIG, he is not entitled to the treatment plans and claim form in dispute, nor is interest due on overdue payment of benefits.
ANALYSIS
Applicability of the MIG
5The applicant submits that he should be removed from the MIG due to chronic pain, specifically, chronic neck, shoulder and knee pain.
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 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 alleges that he should be removed from the MIG because he suffers from chronic pain as a result of the accident. In the alternative, the applicant submits that he has sustained a psychological injury outside the definition of a minor injury.
Chronic Pain
9To support his claim, the applicant has submitted the clinical notes and records (“CNRs”) from a visit to Dr. Heung Wing Li. Dr. Li is a GP at a walk-in clinic attended by the applicant on January 17, 2023.
10The applicant has also submitted the OCF-18 for chiropractic services proposed by chiropractor Dr. Richard Tavares on January 20, with stated goals of pain reduction, increased strength, and increased range of motion, in an effort to return to the activities of normal living and modified work activities.
11The applicant submits that he should be removed from the MIG based on chronic pain. It should be noted that reports of ongoing pain on its own do not merit removal from the MIG. Rather, it is well-settled that the applicant must establish chronic pain with a functional impairment.
12The CNRs from Dr. Li were limited to a single visit to the walk-in clinic, and make no reference to chronic pain. The evidence submitted by the applicant makes no reference to chronic pain, and I have not been directed to any further supporting medical evidence which indicates the applicant suffers from chronic pain, with (or without) a functional limitation.
13Therefore, I find that on the balance of probabilities, the applicant has not met his onus to establish that he is suffering from chronic pain.
Psychological Injury
14The applicant has submitted that he should be removed from the MIG on psychological grounds.
15To support his claim, the applicant has submitted the previously mentioned CNR’s from Dr. Li, as well as an OCF-18 requesting a psychological assessment from psychologist Dr. Sharleen McDowell. The applicant argues that he suffers from isolated phobias, headache, nightmares and sleep disorder.
16The purpose of an assessment is to determine whether a condition exists. For an insured, they bear the onus to demonstrate that there are grounds on which to believe that a condition exists that would warrant further investigation by way of an assessment.
17I have reviewed the CNRs from Dr. Li. I note that the initial diagnosis of PTSD was made based on a telephone interview on January 16, 2023. The diagnosis was not confirmed or otherwise referenced in the follow up notes from January 17, 2023, after an in-person visit.
18I further note that Dr. Li specifically recorded that the “Patient is clearly not sad” and “the patient admits to no suicidal thoughts.” While on its own such notes do not negate a preliminary diagnosis of PTSD, I note that Dr. Li did not recommend further treatment or refer the applicant to any specialists for psychological issues nor does the applicant direct me to CNR entries where he continued to report psychological symptoms.
19The respondent also submits that based on a prescription drug summary, the patient has not renewed his prescription for any pharmaceuticals to address either physical or psychological concerns. The respondent also points out that the only follow up visit to Dr. Li was several months later, for an issue unrelated to the accident in question.
20Based on the evidence, I find on a balance of probabilities that the applicant has not met the onus to establish a psychological condition exists which would warrant further investigation.
21For these reasons, I find on the balance of probabilities that the applicant has not met the onus to demonstrate he should be removed from the MIG.
22As the applicant has been held to the MIG, it is not necessary to review the disputed treatment plans and the OCF-6 to determine whether they are reasonable and necessary.
Interest
23Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no benefits are overdue, no interest is payable.
ORDER
24The application is dismissed.
i. The applicant is held to the MIG, and the $3,500.00 treatment limit applies.
ii. The applicant is not entitled to treatment plans for a psychological assessment, chiropractic services, or reimbursement for pharmaceuticals.
iii. No interest is payable.
Released: August 28, 2025
Jeff Chatterton
Adjudicator