Licence Appeal Tribunal File Number: 24-005915/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:
Sogol Ganji Haghighi
Applicant
and
Unifund Assurance Company
Respondent
DECISION
ADJUDICATOR:
Timothy Porter
APPEARANCES:
For the Applicant:
Katayoun Noohi, Counsel
For the Respondent:
Anthea Chan, Counsel
HEARD: In Writing
OVERVIEW
1Sogol Ganji Haghighi, the applicant, was involved in an automobile accident on April 20, 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, Unifund Assurance 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? Note: The parties agree there is $1,265.05 remaining for treatment within the MIG limit as of the date of the case conference.
ii. Is the applicant entitled to $2,200.00 for a psychological assessment, proposed by Healthcare Management Group in a treatment plan/OCF-18 (“plan”) submitted November 30, 2022, and denied December 5, 2022?
iii. Is the applicant entitled to $3,020.32 for physiotherapy services, proposed by Healthcare Management Group in a plan submitted November 30, 2022, and denied December 5, 2022?
iv. Is the applicant entitled to $2,200.00 for a psychological assessment, proposed by Global Health Recovery in a plan submitted January 6, 2024, and denied February 13, 2024?
v. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
vi. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3I find that the applicant has not met her onus and remains within the MIG.
4As the applicant remains within the MIG, and the funds remaining within the MIG are insufficient to support any of the proposed treatment and assessment plans, there is no need to explore whether the plans are reasonable and necessary.
5As no benefits are owing, no interest is payable.
6No award is payable.
ANALYSIS
Minor Injury Guideline
7For the reasons below I find that the applicant has not met her onus and remains within the MIG.
8Section 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.”
9An 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.
10The applicant submits that her pre-existing condition, chronic pain, and psychological injury should remove her from the MIG and relies on the clinical notes and records (“CNRs”) of Dr. Kyanzadeh, family physician, Dr. Amani, physiatrist, Dr. Fazeli, psychiatrist.
Pre-Existing Condition
11I find that the applicant has not produced compelling evidence that her pre-existing condition precludes recovery if she is kept within the MIG.
12The applicant’s pre-existing history of lumbar pain is well documented. Neither of Dr. Kyanzadeh, family physician, or Dr. Amani, physiatrist opine that the applicant’s existing condition precludes recovery if she is kept within the MIG. The diagnosis by Dr. Amani is of injuries that are categorized as minor within the Schedule, and his recommendations are massage and icing with some changes in medications due to stomach irritation. The applicant has not adduced sufficient evidence that the pre-existing condition would preclude maximum medical recovery and therefore she has not met the test.
Chronic Pain
13I find that the applicant has not met her onus to establish that she has chronic pain with a functional limitation, as a result of the accident.
14The Tribunal has established that a diagnosis of chronic pain syndrome removes an injured person from the MIG because it is not a minor injury. A chronic pain diagnosis or ongoing pain by itself does not remove the applicant from the MIG. It must be accompanied by some functional impairment. A diagnosis without any discussion of the level of pain, its effect on the person’s function, or whether the pain is bearable without treatment will not meet the applicant’s burden to show that chronic pain is more than mere sequelae of a minor injury.
15The applicant submits that she meets at least three of the six American Medical Association (“AMA”) guide to rating permanent disabilities, sixth edition, chronic pain criteria and relies on her submissions.
16Although not binding on me and not incorporated into the Schedule, the Tribunal has found the AMA’s criteria to be a useful interpretative tool in determining whether the person has chronic pain. 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 social milieu, including work, recreation, or other social contacts;
(v) Failure to restore pre-injury function after a period of disability, such that the physical capacity is insufficient to pursue work, family or recreational need; and;
(vi) Development of psychosocial sequelae after the initial incident, including anxiety, fear-avoidance, depression, or nonorganic illness behaviors.
17The applicant submits that her regular use of prescribed medications for pain and mental health, failure to restore pre-injury function and reliance on healthcare providers are factors that support a diagnosis of chronic pain.
18I do not agree with the applicant that the three factors support a diagnosis of chronic pain. In my mind, the applicant’s regular use of prescribed medications is insufficient for consideration in meeting the AMA criteria for a diagnosis of chronic pain because the AMA’s interpretative tool relates that the use of prescription medication will be denoted by use beyond the recommended duration, abuse of the medication or dependence and the applicant has not suggested this level of medication use and not pointed to evidence that supports the contention. Further, the applicant submits that she has modified work and points to this as evidence of a failure to restore pre-accident function. In my mind the modification to duties noted by the employer do not meet the standard outlined in the AMA Guides which state “physical capacity is insufficient to pursue work, family or recreational need.” Whereas the employer states that with the modification the applicant is “contributing positively to the daily operations of the office”.
19I have not been pointed to evidence that the applicant has been diagnosed with chronic pain. The applicant notes the subject accident to her family physician 20 days after the accident on May 10, 2021; the applicant notes severe pain in her neck to family physician Dr. Kyanzadeh on May 27, 2021, and discusses MRI results July 10, 2021; then there is no mention of the accident, treatment or pain in following visits August 6, 2021, and August 31, 2021. I find this is not sufficient reliance on healthcare providers to meet criteria in the AMA chronic pain diagnosis regime; in addition, there is no diagnosis, no discussion of the level of pain or its affects on function. The applicant’s submission that she meets three of the six criteria for a diagnosis is not supported with contemporaneous or compelling evidence of the level of pain or the effect of the pain on the applicant’s function. Finally, the applicant has not adduced any evidence that what she is feeling is as a result of the subject accident.
20I find that the applicant has not met her onus and has not established chronic pain.
Psychological Injury
21The applicant has not met her onus to demonstrate a psychological injury as a result of the subject accident.
22The applicant submits that her psychological injuries should remove her from the MIG and relies on the CNRs of Dr. Fazeli and her submission regarding treatment in Iran.
23The applicant submits that her referral to Dr. Fazeli on November 14, 2022, and his subsequent diagnosis of persistent depressive disorder with anxious distress and cluster B personality traits should remove her from the MIG on the basis of psychological injuries.
24The applicant’s visits with Dr. Kyanzadeh, family physician, on January 11, 2022, January 16, 2022, May 25, 2022, July 21, 2022 and October 31, 2022 do not appear to be in reference to the subject accident as there is no mention of the subject accident and Dr. Kyanzadeh appears to relate the psychological issues the applicant is facing to two other documented factors which are not accident related.
25I assign the report of Dr. Fazeli no weight because the doctor categorically denies that his report is valid for any medical/legal or disability insurance purposes. Dr. Fazeli did not provide his CNRs from the original visits, but a synopsis written in 2025. In my mind, the categorical denial for use in medical/legal context across the top of the synopsis suggests that the Dr. Fazeli is concerned that his synopsis will be misinterpreted, misused or mischaracterized and is placing a limitation on his opinion. The limitation on his opinion is the reason for assigning no weight. Dr. Fazeli does not discuss the cause of the applicant’s psychological complaints. I find that Dr. Fazeli does not opine that the applicant’s psychological state is as a result of the subject accident.
26The applicant submits that she attended psychological treatment in Iran due to financial constraints. The applicant has pointed me to her self-reports to a s.44 assessor that she attended treatment in Iran.
27The applicant has not pointed me to any contemporaneous evidence of psychological injury or diagnoses, her self-report is not corroborated and therefore is not sufficient evidence to meet her onus. I find that the applicant has not met her onus to prove, on a balance of probabilities, that she suffered a psychological injury as a result of the subject accident.
28For the reasons above I find that the applicant has not met her onus and remains within the MIG.
2 Psychological & 1 Physiotherapy treatment plans
29Given that I have determined that the applicant remains within the MIG, she is entitled to treatment up to the MIG limits. At the time of submission there were some funds remaining with in the MIG; however, as the applicant remains within the MIG, and the funds remaining within the MIG are insufficient to support any of the proposed treatment and assessment plans, there is no need to explore whether the plans are reasonable and necessary.
Interest
30As no benefits are owing, no interest is payable.
Award
31The applicant sought an award under s. 10 of Reg. 664. Under s. 10, the Tribunal may grant an award of up to 50 per cent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits.
32The applicant submits that an award should be made because the respondent unreasonably withheld benefits payments. I have not been pointed to any compelling evidence that the respondent unreasonably withheld benefits payments.
33I find that no award is due.
ORDER
34I find that the applicant has not met her onus and remains within the MIG.
35As the applicant remains within the MIG, and the funds remaining within the MIG are insufficient to support any of the proposed treatment and assessment plans, there is no need to explore whether the plans are reasonable and necessary.
36As no benefits are owing, no interest is payable.
37No award is payable.
Released: February 20, 2026
Timothy Porter
Adjudicator