Licence Appeal Tribunal File Number: 23-015169/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:
Inder Jeet Singh
Applicant
and
Economical Insurance Company
Respondent
DECISION
ADJUDICATOR: Harouna Saley Sidibé
APPEARANCES:
For the Applicant: Patrick D'Aloisio, Counsel
For the Respondent: Camilla Oblak, Counsel
HEARD: By way of written submissions
OVERVIEW
1Inder Jeet Singh, the applicant, was involved in an automobile accident on November 12, 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, Economical 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 (“MIG”) limit?
ii. Is the applicant entitled to $2,086.50 for physiotherapy services, proposed by Focus Physio in a treatment plan/OCF-18 (“plan”) dated March 21, 2023?
iii. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3For the reasons below, I find that:
The applicant’s injuries are not predominantly minor, and thus, the MIG limit does not apply.
The applicant is entitled to the disputed treatment plan, with interest pursuant to s.51 of the Schedule.
PROCEDURAL ISSUES
4The respondent raises three procedural issues:
(a) The applicant’s written submissions exceeded the seven-page limit set out in the Case Conference Report and Order (“CCRO”) dated May 9, 2024;
(b) The applicant failed to properly serve submissions on counsel of record by the ordered deadline; and
(c) The applicant failed to produce records as required by the CCRO.
The Length of the Applicant’s Written Submissions
5The CCRO states that the parties must submit their written submissions to the Tribunal and serve them as follows: 7 pages for the applicant, 7 pages for the respondent, and 3 pages for the applicant’s reply.
6The respondent states that the applicant’s submissions are eight pages long and have inconsistent formatting. The respondent requests that pages 4 to 8 be excluded from consideration, arguing that these pages mainly summarize case law and do not substantively address the applicant’s injuries. Additionally, the respondent argues that the applicant should have sought permission to exceed the page limit.
7In reply, the applicant acknowledges the minor excess but contends that the additional content consists only of a few lines and does not contain substantive material. He submits that the formatting, including subheadings and spacing, was intended to enhance readability. The applicant argues that excluding four pages would be unduly prejudicial and that the Tribunal should exercise discretion in accepting the complete submission.
8Upon review, I find that the applicant’s submissions begin substantively on page 4, with the preceding pages consisting of a cover page, index, and summary of authorities. The eighth page contains only a few lines summarizing case law.
9I am satisfied that the excess is minimal and does not prejudice the respondent. Accordingly, I exercise my discretion to accept the applicant’s full submissions.
The Failure to Serve the Written Submissions
10The respondent submits that the applicant failed to serve his written submissions on counsel of record by the January 2, 2025, deadline. Instead, the submissions were sent to an adjuster, despite a Declaration of Representative (“DOR”) having been filed and served on July 19, 2024, and updated on November 5, 2024. The respondent only became aware of the submissions after contacting the Tribunal on January 6, 2025. The respondent argues that this procedural misstep constitutes a breach of procedural fairness and warrants reduced weight being afforded to the applicant’s submissions.
11In reply, the applicant explains that the submissions were sent to the adjuster on December 20, 2024, eleven days before the deadline, based on the understanding that the adjuster retained carriage of the matter, as they had attended the case conference and were referenced in the CCRO. The applicant submits that the failure to serve counsel directly was unintentional and occurred during the insurer’s transition to legal representation. He argues that the early delivery provided sufficient time for the adjuster to forward the materials to counsel and that no prejudice was caused.
12The Tribunal received the applicant’s submissions on December 20, 2024. While the respondent was represented by an Accident Benefits Specialist at the case conference, the DOR filed on July 19, 2024, clearly indicated that legal counsel had been retained. The updated DOR served on November 5, 2024, further confirmed the change in counsel within the same firm.
13I do not accept the applicant’s explanation. By December 2024, the applicant was aware that counsel represented the respondent and should have served the submissions accordingly.
14However, I also note that the adjuster, having received the submissions, could have forwarded them to counsel. The respondent has not demonstrated how this procedural irregularity caused material prejudice.
15In light of the above, I find that excluding or assigning reduced weight to the applicant’s submissions would be disproportionate and prejudicial. I will therefore consider the submissions in full.
Failure to Provide Records to the Respondent
16The CCRO stated that the applicant shall provide the respondent with a decoded OHIP summary from November 12, 2021, to date; clinical notes and records from any treating specialist listed on the OHIP summary involved in accident-related injuries, upon request; prescription summaries from all pharmacies attended from November 12, 2021, to date; and confirmation in writing that the applicant has no access to collateral benefits.
17The respondent submits that the applicant failed to produce the records required by the CCRO, including OHIP summaries, clinical notes, records from treating specialists, prescription summaries, and confirmation of collateral benefits. The respondent argues that this non-compliance warrants an adverse inference, suggesting the applicant sustained only minor injuries.
18The applicant’s reply submissions do not address this issue. No explanation is provided for the failure to produce the required records, nor is there any indication of efforts made to obtain them. This omission is material, as the records are within the applicant’s control and relevant to the issues in dispute.
19While the applicant’s submissions mention four items—clinical notes from Dr. Kaur, an X-ray, a report from Dr. Lansang, and a disability certificate—the CCRO requested additional documents, including a decoded OHIP summary, pharmacy prescription summaries, and confirmation of collateral benefits. The respondent did not specify which of these were missing. Although the absence of certain records is noteworthy and limits the completeness of the evidentiary record, I am satisfied that the materials submitted provide a sufficient basis to assess the claim. Therefore, I will not draw an adverse inference.
20I do not condone non-compliance with Tribunal orders. The records in question were directly relevant to the issues in dispute, particularly the determination of whether the applicant falls outside the MIG. Their absence creates a gap in the evidentiary record that could reasonably be viewed as prejudicial to the respondent. However, I accept that the applicant filed some materials in advance of the deadline and that the procedural irregularity did not materially affect the Tribunal’s ability to consider the claim. I will therefore consider all submissions in full, but I emphasize that parties are expected to comply strictly with Tribunal orders.
ANALYSIS
Are the applicant’s injuries predominantly minor?
21I find that the applicant’s injuries fall outside the MIG.
22Section 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.”
23An 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.
24The applicant submits that he should be removed from the MIG on the basis that he suffers from chronic pain with functional impairment resulting from the accident.
Chronic Pain With Functional Impairment
25The applicant supports his case with medical evidence, including notes from his family doctor, Dr. Simit Kaur Khural, dated February 22, 2023, documenting ongoing low back pain affecting sleep; an X-ray from February 28, 2023, showing early degenerative changes at L2-3; a consultation report from Dr. Edward Lansang, a physician at Kennedy Medical Centre, on April 11, 2023, diagnosing mechanical low back pain and recommending trigger point injections, exercise, and physiotherapy; and a Disability Certificate completed by physiotherapist Rupanjeet Kaur Kler on May 19, 2023, listing spinal sprains, headaches, sleep issues, and nervousness. The applicant claims these symptoms, primarily pain and sleep disturbance, show his injuries are more than minor.
26The respondent argues that the applicant has not met the burden of proof to establish that his injuries fall outside the MIG. It notes that no physician has diagnosed chronic pain or a psychological condition and asserts that the Disability Certificate completed by a physiotherapist exceeds her scope of practice. The respondent relies on a section 44 insurer’s examination conducted by Dr. Mohamed Lamine, General Practitioner, on June 12, 2024, which concluded that the applicant sustained minor soft-tissue injuries consistent with the MIG. The respondent also contends that the applicant has not satisfied three of the six factors outlined in the AMA Guides for establishing chronic pain.
27I have reviewed the clinical notes and records (CNRs) from Dr. Khural dated March 6, 2023. These indicate that the applicant reported persistent lower back pain since the accident, which occasionally disrupted his sleep. He was attending physiotherapy and exhibited decreased range of motion in all planes. Dr. Khural prescribed ibuprofen and advised the applicant to avoid strenuous activity.
28On April 11, 2023, Dr. Lansang assessed the applicant and noted pain with spinal flexion and extension, as well as muscle tenderness and tightness in the right paralumbar region. He recommended non-operative management, including physiotherapy and exercise, and did not consider surgical intervention appropriate.
29The insurer’s examination by Dr. Lamine diagnosed mechanical back pain resulting from the accident. While Dr. Lamine classified the injuries as minor, his report does not address the ongoing symptoms documented by the applicant’s treating providers. As such, I find Dr. Lamine’s report less persuasive, as it fails to engage with the applicant’s persistent complaints and functional limitations.
30I find that the applicant is suffering from chronic pain resulting from the accident. This conclusion is supported by consistent documentation in the Clinical Notes and Records (“CNR”s) of ongoing symptoms, including sleep disturbances, reduced physical ability, and reliance on external support for daily activities. The Disability Certificate dated May 19, 2023, further outlines functional impairments such as difficulty with childcare, maintaining prolonged postures, bending, carrying, and lifting. It also notes that the applicant required assistance from family members and hired housekeeping support due to an inability to manage cooking and cleaning independently. Taken together, this evidence supports the presence of persistent, accident-related limitations.
31While the respondent argues that the applicant has not met at least three of six AMA factors, I note that the AMA Guides are not a mandatory legal standard for establishing chronic pain under the Schedule. Instead, I rely on the entirety of the medical evidence, including clinical notes from Dr. Khural and Dr. Lansang, which document ongoing pain and functional limitations over time.
32I find that the applicant has provided sufficient evidence of chronic pain and associated functional impairment. Although the Disability Certificate was completed by a physiotherapist, its contents are consistent with contemporaneous medical documentation and reflect the applicant’s ongoing limitations. The evidence demonstrates that the applicant’s symptoms extend beyond a simple strain and have had a sustained impact on his daily functioning.
33Based on all the evidence, I find that the applicant is suffering from chronic pain caused by the accident. This is supported by consistent reports of pain that interfere with sleep, daily activities, and physical function, as documented in the CNRs and the Disability Certificate. Although there is no formal diagnosis of chronic pain syndrome and the radiological findings indicate degenerative changes, the applicant has shown ongoing symptoms and functional limitations over a lengthy period. The clinical observations of Dr. Khural and Dr. Lansang, along with the reported need for help with childcare, housekeeping, and physical tasks, support a finding of impairment consistent with chronic pain. I acknowledge that the applicant did not submit all records requested by the CCRO, which limits the completeness of the evidence. However, I am not making an adverse inference and have considered all submissions.
34On a balance of probabilities, I find that the applicant’s injuries are outside the MIG.
Is the applicant entitled to the disputed treatment plan?
35I find that the applicant is entitled to funding for the physiotherapy treatment plan dated March 21, 2023, in the amount of $2,086.50.
36To receive payment for a treatment and assessment plan under s. 15 and 16 of the Schedule, the applicant bears the burden of demonstrating on a balance of probabilities that the benefit is reasonable and necessary as a result of the accident. To do so, the applicant should identify the goals of treatment, how the goals would be met to a reasonable degree and that the overall costs of achieving them are reasonable.
37The treatment plan dated March 21, 2023, is signed by physiotherapist Rupanjeet Kaur Kler. It proposes 10 sessions of physical rehabilitation, 10 sessions of multiple body site manipulation, and 6 sessions of multiple body site therapy. The stated goals include pain reduction, increased range of motion, improved strength, improved posture and function, and a return to pre-accident and modified work activities.
38The applicant submits that the treatment plan is reasonable and necessary to manage ongoing pain and restore function. He relies on the test set out in General Accident Assurance Co. v. Violi (FSCO Appeal P99-00047), which considers whether the treatment goals are reasonable, whether they are being met, and whether the costs are reasonable.
39The respondent opposes the plan, stating it is neither reasonable nor necessary because the applicant has not shown a link between the accident and the injuries for benefits. It cites Dr. Lamine’s examination on June 12, 2024, which dismissed the plan, noting the injury was minor. Additionally, the respondent asserts that the applicant has reached the $3,500 MIG limit.
40As discussed earlier in this decision, I have found that the applicant’s injuries fall outside the MIG. Therefore, the $3,500 cap on medical and rehabilitation benefits does not apply.
41I also note that the treatment plan is contemporaneous with medical recommendations. On March 6, 2023, Dr. Khural advised physiotherapy, and on April 11, 2023, Dr. Lansang made a similar recommendation. These recommendations support the reasonableness and necessity of the proposed services because they reflect a consistent clinical approach to managing the applicant’s reported symptoms and functional limitations. The timing and alignment between the treatment plan and medical advice suggest that the services were not speculative or excessive, but rather part of a medically endorsed strategy to address ongoing impairments.
42Based on the evidence, I find that the treatment plan dated March 21, 2023, is reasonable and necessary as a result of the accident. The goals are clearly stated, supported by medical recommendations, and the proposed services are consistent with those goals.
43Accordingly, I find, on a balance of probabilities, that the applicant is entitled to the treatment plan for physiotherapy in the amount of $2,086.50.
Interest
44Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. The applicant is entitled to interest on any overdue payment of benefits in accordance with s.51.
ORDER
45For the above reasons, it is ordered that:
i. The applicant’s injuries are not predominantly minor, and thus, the MIG limit does not apply.
ii. The applicant is entitled to the disputed treatment plan, with interest pursuant to s.51 of the Schedule.
Released: September 24, 2025
Harouna Saley Sidibé
Adjudicator