Licence Appeal Tribunal File Number: 23-007639/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:
Sameer Beyan
Applicant
and
Belair Insurance Company Inc.
Respondent
DECISION
ADJUDICATOR: Aric Bhargava
APPEARANCES:
For the Applicant: Dean Trinetti, Counsel
For the Respondent: Shivani Mehta, Counsel
HEARD: By way of written submissions
OVERVIEW
1Sameer Beyan, the applicant, was involved in an automobile accident on October 2, 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, 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 section 3 of the Schedule and therefore subject to treatment within the Minor Injury Guideline (“MIG”)?
ii. Is the applicant entitled to $3,795.50 for chiropractic services proposed by Mackenzie Medical Rehabilitation in a treatment plan/OCF-18 (“plan”) dated November 25, 2021?
iii. Is the applicant entitled to $2,851.68 for chiropractic services proposed by Mackenzie Medical Rehabilitation in a plan dated August 31, 2022?
iv. Is the applicant entitled to $1,417.70 for chiropractic services proposed by Mackenzie Medical Rehabilitation in a plan dated May 18, 2022?
v. Is the applicant entitled to $2,026.55 for chiropractic services proposed by Mackenzie Medical Rehabilitation in a plan dated March 30, 2022?
vi. Is the applicant entitled to $1,300.00 for chiropractic services proposed by Mackenzie Medical Rehabilitation in a plan dated February 15, 2022?
vii. Is the applicant entitled to $2,460.00 for a psychological assessment proposed by HydroHealth Evaluations Inc. in a plan dated October 26, 2022?
viii. Is the applicant entitled to $2,460.00 for a chronic pain assessment proposed by HydroHealth Evaluations Inc. in a plan dated October 18, 2022?
ix. Is the applicant entitled to interest on any overdue payment of benefits?
3In his submissions the applicant has withdrawn issue ii) for $3,795.00 for chiropractic services. As such, I have only made a finding with respect to the remaining issues.
RESULT
4I find that:
i. The applicant’s impairments are predominantly minor, and therefore subject to the treatment limits of the MIG.
ii. As the applicant is in the MIG, it is not necessary for me to consider if any of the disputed treatment plans are reasonable and necessary.
iii. As no benefits are owing, no interest is payable.
ANALYSIS
Application of the Minor Injury Guideline
5I find the applicant’s injuries are predominantly minor injuries subject to treatment within 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.”
7The applicant may be removed from the MIG if he can establish that his accident-related injuries fall outside of the MIG or, under section 18(2), that he has a documented pre-existing condition combined with compelling medical evidence stating that the condition precludes maximal recovery if he is kept within 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 submits he has sustained psychological injuries and chronic pain as a result of the accident that warrant removal from the MIG.
Does the applicant have psychological injuries that warrant removal from the MIG?
9I find the applicant has not met his burden of proof to demonstrate that he should be removed from the MIG based on a psychological impairment.
10The applicant summarized that his accident-related injuries are sprain/strain of acromioclavicular joint, muscle strain, headache, radiculopathy, sleep disorder, irritability/anger, stress, nightmares, anxiety disorder, and a depressive episode. The applicant relies on the OCF-3 dated August 31, 2022, prepared by Dr. Brett Dykstra, chiropractor, and the plan dated October 26, 2022, prepared by Dr. Peter Waxer, psychologist.
11The respondent submits the applicant has not met his onus and has not produced compelling evidence that he sustained a psychological injury as a result of the accident. The respondent relies on the section 44 psychological MIG assessment dated February 7, 2023, prepared by Dr. Fabio Salerno, psychiatrist, who found that the applicant did not exhibit symptoms warranting a DSM-5-TR psychological diagnosis and the applicant’s psychological prognosis is excellent.
12I place little weight on the psychological diagnosis in the OCF-3 because such a diagnosis is outside of scope for a chiropractor. Also, an OCF-18 itself is not evidence of a diagnosis and therefore does not establish that the applicant has a psychological condition warranting removal from the MIG. Further, the applicant has not directed me to any corroborating contemporaneous medical evidence to support his claim of a psychological concern relating to the accident. Dr. Salerno’s results are within his scope of practice as a psychologist and based on two in-person and comprehensive psychological examinations. Dr. Salerno states the applicant’s symptoms fall below a diagnostic threshold and he does not display significant functional limitations.
13I find the applicant has not met his burden of proof to establish on a balance of probabilities that he has a psychological impairment that warrants removal from the MIG.
Does the applicant have chronic pain that warrants removal from the MIG
14I find the applicant has not demonstrated that he suffers from a chronic pain condition that would warrant removal from the MIG.
15The applicant submits that he should be removed from the MIG because he suffers from ongoing physical injuries and summarized his chronic pain as “neck pain, shoulder pain, lower back pain, and headaches.” The applicant submits that he meets criteria ii), iv), v) and vi) of the 6th Edition of the American Medical Association’s Guides to Evaluation of Permanent Impairment, 6^th^ Edition (“AMA Guides”) and relies on the clinical notes and records (“CNRs”) of Dr. Mahshid Mohseni, family doctor.
16Dr. Mohseni’s CNRs note that the applicant met with the doctor two months after the accident on December 2, 2021 with complaints of right shoulder pain and neck pain. An ultrasound of December 21, 2021 revealed tendonitis. The next accident-related visit was May 19, 2022. During this visit, the applicant reported that the shoulder and neck pain was “getting better”. On August 30, 2022, the applicant returned with complaints of right shoulder pain and neck pain being “on and off”. Dr. Mohseni advised that the applicant attend physiotherapy in December 2021, May 2022, and August 2022. However, the CNRs make no note of the level of pain or whether the pain is affecting the applicant’s function. The applicant did not direct me to contemporaneous medical evidence in support of the pain affecting his function.
17The applicant submits that he meets four of the six criteria for chronic pain outlined in the American Medical Association (AMA) Guides. The six criteria are:
i. Use of prescription drugs beyond the recommended duration and/or abuse of, or dependence on, prescription drugs or other substances.
ii. Excessive dependence on health care providers, spouse, or family.
iii. Secondary physical deconditioning due to disuse and/or fear-avoidance of physical activity due to pain.
iv. Withdrawal from the social milieu, including work, recreation, or other social contacts.
v. Failure to restore to pre-injury function after a period of disability, such that the physical capacity is insufficient to pursue work, family, or recreational needs.
vi. Development of psychosocial sequelae after the initial incident, including anxiety, fear-avoidance, depression, or nonorganic illness behaviours.
18The applicant states he meets criteria ii), iv), v), and vi), however, he has not directed me to evidence in support of these claims, or that his chronic pain is the cause of a functional limitation. While the family doctor’s CNRs note the applicant’s complaints, I have not been directed to a corroborating report or contemporaneous medical evidence of the applicant meeting any of the AMA Guides criteria for chronic pain.
19The respondent states the applicant has not been diagnosed with chronic pain, was not prescribed medications as a result of the accident, and he has resumed his pre-accident activities of daily living.
20The respondent submits the applicant’s injuries are minor and relies on three s. 44 musculoskeletal reports prepared by Dr. Eric Silver, family physician. In the s. 44 report of March 2022, Dr. Silver notes the applicant is fully independent with his personal care tasks and normal life activities. In the s. 44 report of November 22, 2022, Dr. Silver notes there was no “objective evidence of accident-related musculoskeletal injury leading to functional or physical limitations”. Each of the s. 44 reports, including the paper review of December 2022, state the applicant’s injuries were minor and his soft tissue injuries have resolved.
21I was not directed to a diagnosis of chronic pain and the applicant has not led evidence on the level of pain or its effect on his functioning, which are required elements to support removal form the MIG on this ground.
22I find that the applicant has not met his onus to establish chronic pain with functional limitations warranting removal from the MIG. Considering the evidence before me and with respect to the applicant’s functioning, I find that he does not suffer from a chronic pain condition that supports removal from the MIG.
23I find on a balance of probabilities that the applicant has not met his onus and is subject to the MIG.
24I have found the applicant has failed to prove that his accident-related impairments warrant treatment beyond the MIG limit. As the applicant remains in the MIG, it is unnecessary for me to consider the reasonableness and necessity of the disputed treatment plans.
Interest
25Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As there are no benefits owing, no interest is payable.
ORDER
26For the reasons outlined above, I find that:
i. The applicant remains within the MIG and its $3,500.00 limit.
ii. As the applicant is in the MIG, it is not necessary for me to consider if the treatment plans in dispute are reasonable and necessary.
iii. As no benefits are payable, the applicant is not entitled to interest.
27The application is dismissed.
Released: September 17, 2025
Aric Bhargava
Adjudicator