Licence Appeal Tribunal File Number: 24-010125/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:
Shahzad Rana
Applicant
and
Certas Home and Auto Insurance Company
Respondent
DECISION
VICE-CHAIR: Julian DiBattista
APPEARANCES:
For the Applicant: Jeremy Magence, Counsel
For the Respondent: Angeline Pillay, Counsel
HEARD: In Writing
OVERVIEW
1Shahzad Rana, the applicant, was involved in an automobile accident on May 23, 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, Certas Home and Auto 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 $3,257.04 for chiropractic services, proposed by Whitby Physio and Sports Rehab in a treatment plan/OCF-18 (“plan”) dated November 30, 2022?
iii. Is the applicant entitled to $2,460.00 for psychological services, proposed by Whitby Physio and Sports Rehab in a treatment plan dated December 15, 2022?
iv. Is the applicant entitled to $2,425.00 for physiotherapy services, proposed by Whitby Physio and Sports Rehab in a treatment plan dated January 20, 2023?
v. Is the applicant entitled to $2,878.47 for chiropractic services, proposed by Whitby Physio and Sports Rehab in a treatment plan dated April 20, 2023?
vi. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant remains subject to the MIG.
4The applicant is not entitled to the disputed treatment plans.
5The applicant is not entitled to interest.
ANALYSIS
The applicant remains subject to 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.”
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 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.
8The applicant submits that he should be removed from the MIG as he has suffered a psychological impairment, chronic pain and has a pre-existing anxiety disorder.
The applicant has not proven a psychological impairment that would warrant removal from the MIG
9I find that the applicant did not suffer a psychological impairment that would warrant removal from the MIG.
10The applicant submits that two separate psychologists, Dr. Frank and Ms. Ladak, have conducted assessments of the applicant and provisionally diagnose him with an adjustment disorder.
11The respondent submits that it is important to distinguish that Dr. Frank and Ms. Ladak have made these comments as part of pre-screening reports.
12The respondent further submits that the opinion of both psychologists is based on the applicant’s self-reported claims of anxiety and his interest in psychological intervention without any psychometric testing.
13Ms. Ladak assessed the applicant on November 11, 2022. Ms. Ladak did not make a provisional diagnosis, however, but recommended that the applicant undergo a comprehensive psychological assessment to obtain a detailed understanding of the overall impact the accident has had on his functioning. There are no submissions made or evidence adduced that this assessment has taken place.
14Dr. Frank’s comments are contained in the notes of an OCF-18 submitted on June 21, 2023.
15Dr. Frank noted that based on the applicant’s reports during an interview on June 21, 2023 that it is likely he is experiencing anxious and depressive symptomology as a result of the accident.
16However, the applicant has submitted that he was involved in a prior accident in July of 2020 and as a result his family physician, Dr. Salam, noted a history of anxiety prior to the May 23, 2022 accident; most notably on May 18, 2021 and April 19, 2023.
17There is no indication from his report that Dr. Frank was made aware of the prior accident. In the OCF-18, Dr. Frank writes, “It appears based on Mr. Rana's reports on June 21, 2023 that he is likely experiencing anxious and depressive symptomology as result of his accident.”
18Dr. Frank made his provisional comments based on the applicant’s solely self-reports. I cannot extrapolate what Dr. Frank’s opinion would be if he had been made aware of the applicant’s psychological history and the previous accident.
19For this reason, I give no weight to the provisional diagnosis of Dr. Frank as he was not aware of the applicant’s pre-existing psychological issues.
20The burden of proof lies with the applicant to demonstrate on a balance of probabilities that they suffer from a psychological condition.
21I find that the applicant has not met their onus and on the balance of probabilities am not convinced the applicant suffered a psychological impairment as a result of the May 23, 2022 accident that warrants removal from the MIG on this basis.
The applicant has not proven a pre-existing condition which would prohibit maximal medical recovery within the MIG limits
22I find that the applicant has not proven a pre-existing condition that would prohibit maximal medical recovery within the MIG limits.
23The applicant submits that he had a prior history of clinical anxiety for which he had been prescribed anti-depressant medication. The applicant submits that the clinical notes and records of Dr. Salam note this on April 19, 2023, one month before the accident. I agree that the applicant has a documented pre-existing condition of anxiety.
24However, the test in s. 18(2) of the Schedule has two parts, and I find the applicant has not met the second part. He has not provided compelling medical evidence stating that the condition precludes recovery if he is kept within the confines of the MIG.
25The applicant’s submissions state at paragraph 21:
The clinical notes and records of Mr. Rana’s family doctor show that Mr. Rana continued to suffer from anxiety the month before the subject accident. It is submitted that Mr. Rana’s anxiety was a pre-existing medical condition documented by a health practitioner before the accident, that has and will continue to prevent maximal recovery if he is subject to the $3,500 limit on treatment costs under the MIG.
26Submissions are not evidence, and the applicant has not directed the Tribunal to any evidence that would demonstrate a medical opinion that maximal medical recovery is not possible within the limits of the MIG. This is a requirement of s. 18(2).
27The applicant has not met his onus of proving a pre-existing condition that would prevent his maximal recovery if he were kept in the MIG, under s. 18(2), and therefore he is not removed from the MIG on this basis.
The applicant has not proven chronic pain with a functional impairment
28I find that the applicant has not proven chronic pain with a functional impairment that warrants removal from the MIG.
29The applicant’s submissions on chronic pain are also contained within paragraph 21 of his submissions:
The medical records provide compelling evidence that the subject MVA caused injuries to his back which continue to cause him pain and impairment to the present time. The clinical notes and records of Whitby Physio show regular, ongoing and consistent reporting of pain and impairment since the MVA, as well as (1) withdrawal from social milieu, including work, recreation, or other social contacts, (2) failure to restore preinjury function after a period of disability, such that the physical capacity is insufficient to pursue work, family or recreational needs, and (3) development of psychosocial sequelae after the initial incident, including anxiety, fear-avoidance, depression, or nonorganic illness behaviours – which satisfies at least 3/6 criteria for the diagnosis of Chronic Pain Syndrome from the AMA Guides.
30The AMA Guides are not incorporated into the Schedule, but the Tribunal has found that they are a useful analytical tool in assessing chronic pain. However, while I acknowledge the applicant’s submissions that he meets three of the six criteria in the AMA Guides, I have not been directed to specific instances within these clinical notes and records that would support the applicant’s submissions.
31The applicant has submitted 36 pages of clinical notes and records from Whitby Physiotherapy. I have reviewed these clinical notes and records and am not able to identify the instances the applicant is referring to.
32It is not this Tribunal's role to search through the evidence and make the argument on behalf of the applicant see Dooman v TD Insurance, 2025 ONSC 184 at para 50 (Div Ct).
33It is the applicant’s burden to prove that he suffers from chronic pain and a resulting functional impairment, and he needs to direct the Tribunal to specific instances within the clinical notes and records that supports this position.
34For the reasons above, I find that the applicant has not met their burden to prove they suffer from chronic pain with a functional impairment that would remove them from the MIG.
35Having determined that the applicant remains within the MIG, an analysis of the reasonableness and necessity of the disputed treatment plans is not required.
36I will now turn to the applicant’s arguments under s. 38 of the Schedule.
The denial letters comply with s. 38(8) of the Schedule
37I find the denial letters are compliant with s.38(8)
38Section 38(8) requires an insurer to inform an insured person, within 10 business days after it receives the treatment plan, of the medical and other reasons why it considered the goods and services not to be reasonable and necessary if it denies a plan. Pursuant to s. 38(11), if an insurer fails to comply with its obligations under section 38(8), it must pay for the goods and services that relate to the period starting on the 11th business day after the insurer received the application and ending on the day the insurer gives a notice described in s. 38(8) and it is prohibited from taking the position that the insured person has a impairment to which the MIG applies.
39The applicant submits that the notices denying the treatment plans in dispute at this hearing did not provide medical reasons and are therefore not in compliance with s. 38(8) of the Schedule.
40The respondent submits that the denial letters provide proper medical reasons and are compliant with s. 38(8).
41All four denial letters use the same language as the reasons for denial:
I have reviewed your list of injuries and compared them to the criteria in the minor injury guideline. I have concluded your injuries are minor and fall within the guideline. I have reviewed your pre-existing conductions, but the information I have does not support that they would prevent you from recovering from your minor injury within the minor injury limit. The policy has a limit for minor injuries in the amount of $3,500.00.
42I find that standing within the MIG is a medical reason because it indicates that the applicant’s impairments are minor, which is a medical definition in the Schedule. Therefore, I find that the denial letters are compliant with s. 38(8) of the Schedule.
Interest
43Interest 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
44For the reasons above, I find that:
i. The applicant’s injuries do not warrant removal from the MIG;
ii. The applicant is not entitled to the disputed treatment plans; and
iii. The applicant is not entitled to interest.
45This application is dismissed.
Released: February 19, 2026
Julian DiBattista
Vice-Chair