Licence Appeal Tribunal File Number: 24-003674/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:
Man Kit Jordon Wan
Applicant
and
Co-operators General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Dominique Setton
APPEARANCES:
For the Applicant:
Rakesh Sharma, Counsel
For the Respondent:
Irene Tsui, Counsel
HEARD: In Writing
February 24, 2026
OVERVIEW
1Man Kit Jordan Wan, the applicant, was involved in an automobile accident on March 25, 2023, 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 by section 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 $200.00 ($1,300.00 less $1,100.00 approved) for physiotherapy services proposed by Uheal Clinic in a treatment plan/OCF-18 dated May 23, 2023?
iii. Is the applicant entitled to $2,931.56 ($3,749.56 less $818.00 approved) for physiotherapy services proposed by Uheal Clinic in a treatment plan/OCF-18 dated July 12, 2023?
iv. Is the applicant entitled to $3,749.56 for physiotherapy services proposed by Uheal Clinic in a treatment plan/OCF-18 September 25, 2023?
v. Is the applicant entitled to $2,200.00 for psychological assessment, proposed by Somatic Assessments & Treatment Clinic in a treatment plan/OCF-18 dated April 14, 2023?
vi. Is the respondent liable to pay a special award under s. 10 of Reg. 664 because it unreasonable withheld or delated payments to the applicant?
vii. Is the applicant entitled to any interest on overdue payment of benefits?
RESULT
3I find that the applicant’s injuries are predominantly minor as defined by section 3 of the Schedule and therefore subject to treatment within the $3,500.00 Minor Injury Guideline (MIG) limit. The parties agreed the MIG limits have been exhausted.
4As the applicant is subject to the MIG, I do not need to consider whether any of the treatment plans, proposed are reasonable and necessary.
5The applicant is not entitled to interest or an award.
ANALYSIS
Are the applicant’s injuries predominantly minor?
6I find the applicant has failed to meet his onus and has failed to show that he should be removed from the MIG.
7Section 18 (1) of the Schedule provides that medical and rehabilitation benefits are limited to $3,500.00 if the applicant sustains impairments that are predominantly a minor injury. Section 3(1) defines a “minor injury” as “one or more sprain or strain, whiplash associated disorder, contusion, abrasion, laceration, or subluxation and includes any clinically associated sequelae to such an injury.”
8An insured can 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. In all cases, the burden of proof lies with the applicant.
9The applicant submits that they should be removed from the MIG because the applicant’s onus is “to disprove the reasons on the balance of probabilities to prove entitlement to the denied benefits.” The applicant submitted at paragraph 6, of his submissions, that he would “not be making submissions solely on the applicability of MIG but would dispute the MIG’s applicability with respect to the denied substantive issues.” The applicant’s position, as I understand it, is to validate the treatment plans, which are provided by regulated health professionals, and are therefore valid, unless the insurer shows that they are not. The applicant appears to reverse the onus by saying that the applicant argues that the insurer did not properly describe in detail the reasons for the denial of the treatment plans, and that therefore they are valid.
10The respondent submits that the applicant has abandoned his application because he did not provide any compelling medical evidence to prove his injuries fell outside the MIG. Therefore, the MIG applies, and the applicant is not entitled to any amounts outside the MIG. Furthermore, the respondent submits that the applicant has not proven that the treatment and assessments are reasonable and necessary.
11In reply, the applicant claims that the denials were flawed, arbitrary and or statutorily deficient of the requirements of the Schedule. The applicant’s position is that the denial is limited by s. 54 of the Schedule, which states that when the insurer reduces or limits a right the person is receiving the insurer is the one who has to provide the notice of his right to dispute the matter. To support this~~,~~ the applicant argues that the insurer’s response is generic, and the applicant has not made submissions on MIG, and as a result, it appears, from this reasoning, that the claim should be allowed. In other words, the treatment plans should be paid.
12I agree with the respondent. The applicant has failed to meet his onus and has failed to show that he should be removed from the MIG.
13The applicant is held to the maximum amount of $3,500.00 for medical and rehabilitation benefits when in the Minor Injury Guideline if his impairments are defined as minor injuries.
14To be removed, the applicant must show that the accident-related injuries fall outside the MIG, or that they have a documented pre-existing condition that together with compelling medical evidence which states that the documented pre-existing condition precludes recovery if they are kept in the MIG. In all cases it is the applicant that has the burden of proof.
15The applicant did not provide any medical evidence regarding a documented pre-existing condition, or a documented pre-existing condition with compelling medical evidence stating that that there is any pre- existing condition precluding recovery if left within the MIG.
16The applicant’s position, as I understand it, is that the only relevant issue is whether the OCF-18’s complied with the procedural requirements of s. 38 of the Schedule and as a result the treatment plans themselves would be sufficient evidence to establish entitlement without consideration of the MIG. The respondent submits that the applicant’s reasoning is inconsistent with the prevailing law, as cited in Scarlett vs Belair, 2015 ONSC 3635: that the burden rests with the insured to prove that his injuries fall outside the MIG. If they do, then the applicant must then show that the treatment plans are reasonable and necessary.
17The applicant believes that if the treatment plan is completed and submitted, it is in itself sufficient evidence that the treatment plan (OCF-18) is reasonable and necessary, warranting removal from the MIG in turn.
18In the case of Shahid v. Aviva General Insurance, 2021 CanLII 30756 (ON LAT) case cited by the parties, it was also argued that the insurer failed to provide proper notice in accordance with the Schedule, particularly in accordance with s. 38 because it “failed to provide adequate medical reasons for its denial of the treatment plan.” In that case the applicant did not provide submissions on why the treatment plans are reasonable and necessary or what the goals of the treatment were. Here, the applicant provided no discussion as to the merits of any medical evidence and why it would support the OCF-18s in dispute as being reasonable and necessary, which is their burden.
19The applicant submits that the s. 38 denials are not proper, because as an example for Issue 4, the regulated health professional checked the box stating the injuries sustained in the accident are predominantly not minor injuries, and no pre-existing injury was checked off. It appears, since the treatment plan provided some information about prior and concurrent conditions, activity limitations, plans, goals, evaluation methods, and barriers to recovery and cost of assessment, that it was sufficient. The applicant argues that the respondent’s denial says, that “your impairment meets the definition od minor injury and is subject to the $3500.00 limit, and that that is mere conjecture, as it doesn’t provide the reason why it meets the definition of minor injury, and that it ignored elements in the part 6, 7,8, and 9 under pre-screen report which provided the information, as described.
20In addition, since the respondent is not a regulated health professional, and not competent to render a medical opinion, and in the absence of meaningful reasons, the regulated health professional’s opinion should prevail.
21I disagree with this analysis, because in the denials submitted, all state under the title “Medical and other reasons”, “our file lacks objective medical evidence supporting that the injuries fall outside the minor injury guideline, or that you have a pre-existing condition that would prevent you from achieving maximal medical recovery from the minor injury if you are subjected to the $3500.00 limit”. They reiterate, “we have not received objective medical evidence to support the injury or sequelae, nor have we been provided with compelling evidence of a pre-exiting medical condition as evidence in writing by your health practitioner before the subject accident, and they reiterate that they have asked previously for the family physician’s clinical notes and records from 2020 to the day of the denial, as well as clinical notes and records from a treating physician after the accident, hospital records, and an ambulance record and emergency medical report, all of which were not provided. As a result, I find the denials are proper as they detail the relevant information required to remove the applicant from the MIG.
22I find that the applicant’s injuries are predominantly minor. The applicant has not provided any medical reports, or records, showing that the applicant’s injuries fall outside the MIG.
23As I find that the applicant’s injuries are predominantly minor and are subject to treatment within the MIG, it is not necessary for me to consider the reasonableness and necessity of the treatment plans and medical expenses.
Interest
24Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As there are no overdue benefits payable no interest is payable.
Award
25The 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. As there are no benefits payable, there have been no benefits unreasonably withheld, and there is therefore no award payable.
ORDER
26I find therefore:
i. The applicant’s injuries are predominantly minor and therefore subject to the Minor Injury Guideline.
ii. The treatment plans are not payable as the applicant’s injuries are predominantly minor and subject to the MIG limits.
iii. The applicant is therefore not entitled to any interest as no benefits are payable.
iv. There is no award payable.
v. The application is dismissed.
Released: February 26, 2026
Dominique Setton
Adjudicator