Licence Appeal Tribunal File Number: 24-009525/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:
Zong Lin Zi
Applicant
and
Allstate Insurance Company of Canada
Respondent
DECISION
ADJUDICATOR:
Timothy Porter
APPEARANCES:
For the Applicant:
Sareena Samra, Counsel
For the Respondent:
Loretta De Thomasis, Counsel
HEARD: In Writing
OVERVIEW
1Zong Lin Zi, the applicant, was involved in an automobile accident on August 1, 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, Allstate Insurance Company of Canada, 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 limit? (“MIG”)
ii. Is the applicant entitled to $2,144.93 for a psychological assessment, proposed by Somatic Assessments and Treatment Clinic in a treatment plan/OCF-18 (“plan”) submitted May 28, 2024?
iii. Is the applicant entitled to interest on any overdue payment of benefits?
iv. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
RESULT
3The applicant has not met his onus and remains within the MIG.
i. Given that the applicant remains within the MIG and the MIG is exhausted there is no need to determine if the treatment plan is reasonable and necessary.
ii. No interest is payable.
iii. No award is payable.
ANALYSIS
Minor Injury Guideline, psychological
4The applicant has not met his onus to prove, on a balance of probabilities, that his injuries are not minor.
5Section 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.”
6An 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.
7The applicant submits that he suffers a psychological condition as a result of the subject accident and relies on the clinical notes and records (“CNRs”) of Dr. Chongen Liu and the assessment by Crystal Ka Wun Ng, registered social worker.
8The CNRs of family physician Dr. Chongen Liu are insufficient evidence of a psychological condition. The CNRs of Dr. Liu are largely focused on the management of a chronic disease the applicant discovered as a result of the subject accident. The majority of the CNRs that have a psychological component mentioned relate that there is no concern. For example, for a visit on August 4, 2023, the applicant’s mood is noted as normal; on August 21, 2023, psychosocial screening is noted as performed, there are no notations indicating an issue. On November 9, 2023, Dr. Lui performs a screening, and the applicant indicates he is not feeling down, depressed or hopeless, which followed 4 days in hospital for an unrelated chronic health condition.
9With regard to the applicant’s poor sleep, the applicant is also under the care of Dr. James Jeong. On December 18, 2023, the applicant reported to Dr Jeong, for a “history of presenting illness”, that he has poor sleep at baseline with delayed onset as well as waking frequently, there is no mention of the subject accident in relation to this sleep issue, it is specifically a history for his chronic health condition, and in my mind “baseline” is intended to mean normally. This appears to be an inconsistency with the applicant’s reporting. However, and in any event, in my mind, two mentions of sleep issues over 7 visits and a single prescription for a very limited number of sleep medication tablets is not suggestive of a functional limitation.
10I cannot accept the opinion of Crystal Ka Wun Ng, registered social worker because she states that the subject accident is the cause of the applicant’s reported symptoms but provides no analysis to suggest that this is an opinion rooted in evidence. Ms. Ng assessed the applicant on February 26, 2024; Ms. Ng does not indicate that any clinical notes and records have been reviewed from any other providers; in my mind the assessor is too reliant on the applicant’s self reports without the benefit of any clinical history review. For example Ms. Ng relates that the applicant has also experienced high blood pressure and a restricted diet, leading to reduced weight; as noted in the hospital records from the day of the accident, high blood pressure is a symptom of his unrelated chronic health condition and as noted in the CNRs of Dr. Lui a restricted diet is one of the recommendations to combat the health condition; any resultant weight loss would be the result Dr. Lui is seeking with his recommendations. Underpinning the opinion of Ms. Ng is the applicant’s self reported sleep issues and noted headaches. The sleep issue in my mind is not directly related to the subject accident as noted above, the suggestion by the applicant to Ms. Ng that he cannot sleep without the help of a sleeping pill is not supported by the evidence, for example, the applicant received 15 tablets of a sleeping pills on November 1, 2023; 118 days passed between the prescription for 15 pills and Ms. Ng’s assessment.
11The applicant has not met his onus to prove, on a balance of probabilities, that his injuries are not minor.
Psychological assessment
12Given that I have determined that the applicant remains within the MIG, he is entitled to treatment up to the MIG limits. As the MIG is exhausted it is not required that I assess the reasonableness or necessity of the disputed plan.
Interest
13As no benefits are overdue, no interest is due.
Award
14The 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.
15The applicant submits that he has been unreasonably held within the MIG and denied a psychological assessment.
16I disagree with the applicant. I was not pointed or directed to evidence that the respondent treated the applicant unreasonably, immoderately or in an unyielding manner.
17No award is payable
ORDER
18The applicant has not met his onus and remains within the MIG.
i. Given that the applicant remains within the MIG and the MIG is exhausted there is no need to determine if the treatment plan is reasonable and necessary.
ii. No interest is due.
iii. No award is due.
Released: February 20, 2026
__________________________
Timothy Porter
Adjudicator