Licence Appeal Tribunal File Number: 24-007271/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:
Manvir Singh Basi
Applicant
and
TD Insurance
Respondent
DECISION
ADJUDICATOR: Sarah Guergis
APPEARANCES:
For the Applicant: Dayana Soto Santana, Paralegal
For the Respondent: Allison Webster, Counsel
HEARD: In Writing
OVERVIEW
1Manvir Singh Basi, the Applicant, was involved in an automobile accident on January 8, 2024, 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, TD Insurance, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issues in dispute are:
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 the MIG limits have been exhausted.
Is the Applicant entitled to a non-earner benefit (“NEB”) in the amount of $185.00 per week from January 29, 2024, to date and ongoing?
Is the Applicant entitled to examination expenses and medical services proposed by 101 Assessments as follows:
a) $2,460.00 for a psychological assessment, in a treatment plan/OCF-18 (“plan”) submitted April 9, 2024; and
b) $3,790.70 for psychological services, in a plan submitted April 9, 2024; and
c) $2,296.00 for a mental health and addiction assessment, in a plan submitted February 16, 2024; and
d) $2,460.00 for a chronic pain assessment, in a plan submitted September 24, 2024?
- Is the Applicant entitled to medical services proposed by Mackenzie Medical Rehabilitation Centre as follows:
a) $1,525.84 for assistive devices proposed in a plan submitted August 30, 2024; and
b) $2,023.03 for chiropractic services, in a plan submitted May 27, 2024; and
c) $705.15 for unspecified services, submitted on an auto insurance standard invoice /OCF-21 submitted August 1, 2024?
Is the Applicant entitled to $2,460.00 for a psychiatric assessment, proposed by Dr. Hasan in a plan submitted August 14, 2024?
Is the Applicant entitled to $45.08 for prescription drugs, submitted on a claim form (OCF-6) dated April 3, 2024?
Is the Applicant entitled to interest on any overdue payment of benefits?
RESULT
3I find that the Applicant is not removed from the MIG.
4As the Applicant has not been removed from the MIG, no plans or claim forms are payable.
5I find that the Applicant is not entitled to NEBs.
6As no benefits are overdue, no interest is owing.
MIG
7Section 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.”
8An 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.
9The Applicant submits that they should be removed from the MIG as they have been diagnosed with post-traumatic stress disorder (“PTSD”) and suffer from an extensive and diverse litany of accompanying psychological afflictions and physical injuries and impairments that manifest as disruptive and prohibitive functional limitations in their daily life. Based on my review of the applicant’s submissions, it appears that they seek removal from the MIG based on a psychological impairment, non-minor physical impairment and chronic pain. It does not appear the applicant seeks removal on the basis of a pre-existing medical condition that would prevent their maximal recovery if they were kept in the MIG.
10To quote the Applicant’s submissions directly, they submit that the definition of MIG “does not include chronic pain” and “as evidenced by the CNRs of (the Applicant’s) treating practitioners, he has been formally diagnosed with PTSD and suffers from an extensive and diverse litany of accompanying psychological afflictions and physical injuries and impairments that manifest as disruptive and prohibitive functional limitations in his daily life.” These are the Applicant’s only submissions to outline their reasoning for MIG removal.
11For the reasons that follow, I find the applicant has not met their burden of proving they should be removed from the MIG on any of these bases.
Psychological impairment
12The Applicant directed me to CNRs from March 6, 2024, from Dr. Kyaw Shwe, a doctor from Golden Mile Walk-in Clinic. The Applicant described ongoing headaches, shortness of breath, dizziness while driving, and fear of being on the road. It was noted that there was no prior history of depression or anxiety.
13The Applicant submits that a formal diagnosis of PTSD was made here. Within Dr. Shwe’s CNRs are “SOAP notes” within which they wrote “A: PTSD.” I interpret the “A” to stand for assessment/diagnosis. They also wrote that the Applicant dressed appropriately, answered questions well, maintained good eye contact, good insight, had no suicidal thoughts, and their blood results were within normal limit. They prescribed an anti-depressant for 30 days.
14The Applicant relies on a virtual psychological assessment by Mr. Amin Mohammadi, psychotherapist, supervised by Konstantinos Papazoglou, psychologist, dated March 13, 2024, (roughly two months post accident). Mr. Mohammadi formally diagnosed Mavir with adjustment disorder with mixed anxiety and depressed mood.
15The Applicant further relies on case law which hold that the Applicant’s injuries are outside of the MIG based on the diagnosis of psychological injuries, and medical prescriptions.
16The Applicant submits in their reply submissions that the reason the Applicant has not sought ongoing psychological treatment is that he was denied funding for necessary care. Further, that as a result, the Applicant could not afford to continue therapy and now carries outstanding balances of $3,128.18 with Mackenzie Medical Rehabilitation and $3,860.00 with 101 Assessments.
17The Respondent submits that there is no evidence to conclude that the MIG does not apply to the Applicant's claim for benefits, not to establish that he is entitled to the items in dispute.
18The Respondent further submits that the Applicant has not complained of any accident-related psychological symptoms since March of 2024 (roughly two months post-accident). Further, as of March 6, 2024, when PTSD was diagnosed by Dr. Shwe, the Applicant's only psychological complaint was a fear of driving, and no counselling has been pursued.
19Further, since March of 2024, the Applicant attended the walk-in clinic on four additional occasions and there is no report of psychological symptoms.
20The Respondent submits that there is no evidence that the Applicant has received any prescriptions for medication for accident-related symptoms or injuries since March of 2024.
21The Respondent submits that the psychological assessment performed by Dr. Papazoglou on March 13, 2024, and the formal psychological diagnoses made at that time were based on a snapshot in time regarding the Applicant's condition, as a result of a virtual interview and that there is no evidence of ongoing psychological symptoms after March 2024.
22The Respondent relies on a s. 44 multidisciplinary assessment, by Dr. Sedigheh Naisi, psychologist, from May 10, 2024. Dr. Naisi confirmed that the Applicant had no history of psychological issues prior to the subject accident and that the Applicant should be able to recover within the scope of treatment and financial limits provided by the MIG.
23Dr. Naisi also completed a Psychology Paper Review dated July 2, 2024, following his review of additional OCF-18s from 101 Assessments. He confirmed his earlier findings that the Applicant's condition was a minor injury as there was no definitive psychological diagnosis and his case reflects a normal adjustment period after an accident.
24The Respondent further relies on another in-person Multidisciplinary Assessment by Dr. Eric Silver, MD, from April 25, 2024. He stated that the Applicant was not taking any prescription medication at the time, which is consistent with the records as noted above. Dr. Silver found that the Applicant had sustained myofascial pain in the neck, upper trapezii, and lumbar spine, and very mild right patellofemoral pain syndrome, that his injuries are minor and that in the absence of a pre-existing medical condition there was no reason to view the Applicant as being unable to achieve maximal recovery within the MIG.
25I find that I was not pointed to evidence which would establish the Applicant’s removal from the MIG on the basis of a psychological impairment.
26I agree with the Respondent that I was not pointed to evidence that the Applicant has complained of accident-related psychological symptoms since March of 2024, nor has he pursued counselling. I acknowledge the Applicant‘s diagnosis from Mr. Mohammadi, psychotherapist, of adjustment disorder with anxiousness and depression. However, this diagnosis is not within the scope of a psychotherapist. I also acknowledge Dr. Shwe’s apparent diagnosis of PTSD. However, I was not pointed to evidence of ongoing reporting of psychological impairments, or evidence of ongoing use of prescription medication. Further, as the Respondent points out, the Applicant’s psychological assessment was completed relatively shortly after the accident and was virtual compared to the Respondent’s more recent assessments which were in-person.
Non-minor physical impairment
27On March 20, 2024, Manvir visited Dr. Shwe. He reported that despite being on medication for two weeks, he continued to experience widespread physical pain affecting his upper and lower back and shoulders. Naproxen (an anti-inflammatory) and baclofen (a muscle relaxant) were formally added to his medication regimen. Counseling and physician follow-up were again formally recommended.
28The Applicant also reported knee pain on September 19th and 24th, 2024, and the Applicant underwent an ultrasound of the right knee at Golden Radiology. Imaging revealed infrapatellar bursitis. The bursitis aligned with ongoing mechanical irritation secondary to trauma. A finding of inflammation was documented. Naproxen was prescribed, and further follow-up was advised.
29The Respondent submits that that despite the Applicant's submissions that he currently attends physiotherapy sessions once weekly, no records of this treatment post-September 2024 have been produced and thus, there is no evidence of this before the Tribunal. Further, there is no evidence that the Applicant has received any active treatment for accident-related physical injuries since September 2024.
30While I acknowledge the Applicant‘s reporting of back pain, knee pain and ongoing use of prescription anti-inflammatories and muscle relaxants, I agree with the Respondent that there are no records of treatment or progress reports or goals of treatment. Further, I have not been pointed to evidence which would establish the Applicant‘s removal of the MIG based on physical injuries.
Chronic pain with functional impairment
31The Applicant submits that “he also demonstrated elevated pain catastrophizing scores, suggesting a high risk for chronic pain disorder. Notably, no malingering or symptom exaggeration was suspected.” However, it is not clear if he is submitting he should be removed from the MIG on these grounds. If so, I was not pointed to an official diagnosis of chronic pain, or other evidence to establish chronic pain.
32The Applicant relies on case law which highlight chronic pain being a reason for the Applicant’s removal from MIG. However, I was not pointed to how these cases apply directly to this case, or whether chronic pain was being submitted as the Applicant’s reason for MIG removal.
33The Respondent submits that there has been no diagnosis of chronic pain, nor is there evidence of ongoing pain complaints such that one could conclude that the Applicant's pain is chronic.
34The Respondent further submits that in the cases relied upon by the Applicant, there was clear evidence of chronic pain, in one case two years post-accident, as well as evidence that it was debilitating and that the pain manifested itself in physical symptoms, which is not the case here.
35I acknowledge there was a “high risk for chronic pain disorder” in the Applicant’s psychological assessment. However, this is not an official diagnosis of chronic pain.
36I find the Applicant has not directed me to evidence to establish their MIG removal based on chronic pain, physical, or psychological impairments.
37For the reasons stated above, I find the Applicant is not removed from the MIG.
NEB
38I find that the Applicant is not entitled to NEBs.
39Section 12(1) provides that an insurer shall pay an NEB to an insured person who sustains an impairment as a result of the accident, if the insured person suffers a complete inability to carry on a normal life as a result of and within 104 weeks after the accident. Section 3(7)(a) defines a “complete inability to carry on a normal life” as “an impairment that continuously prevents the person from engaging in substantially all of the activities in which the person ordinarily engaged before the accident.” The Court of Appeal set out the guiding principles for NEB entitlement in Heath v. Economical Mut. Ins. Co., 2009 ONCA 391, which, generally, focuses on a comparison of the Applicant’s pre- and post-accident activities.
40The Heath test provides that the applicant may identify their “valued” activities of daily living and submit how, as a result of the accident, their most valued activities have fundamentally changed due to pain, thus resulting in a complete inability to carry on a normal life. Activities identified by an applicant as being highly valued, attract more weight.
41The Applicant submits that he is entitled to NEBs as he suffers a complete inability to carry on a normal life. Further, that he suffers a substantial inability to perform the housekeeping and home maintenance services that he performed prior to the accident.
42The Applicant points me to an OCF-3, from Mahsa Gordanpour, chiropractor, dated January 30, 2024. This form checked off the box titled “yes” under the question of whether the Applicant has suffered a complete inability to carry on a normal life. They wrote, “Injuries suffered in this accident continuously prevent the patient from engaging in personal grooming, housekeeping, sleep and social activities.”
43The Respondent submits that the Applicant has not presented sufficient evidence to establish that he suffers a complete inability to carry on a normal life. Further, he has made no ongoing complaints of pain or psychological issues or received treatment since September 2024.
44The Respondent relies on a further Multidisciplinary Assessment Report dated July 2, 2024, from occupational therapist, Meghan Passmore. Ms. Passmore noted that the Applicant was well groomed, he engaged in fourteen minutes of range of motion and functional demonstration and demonstrated mild limitations in range of motion that was not maintained in functional demonstration. The report notes that he completed the majority of his personal care activities, but he reported not engaging in pre-accident housekeeping activities due to pain, although the Applicant did not do meal preparation pre-accident and shared household responsibilities.
45The Respondent notes that in his psychological assessment, Dr. Naisi, concluded that the Applicant did not indicate severe psychological disturbances that would impair his capacity to function normally or engage in daily activities over the long term. Further the Respondent submits that the Applicant’s employment status has not changed (he was not employed pre- or post-accident) and that he can communicate effectively and participate in daily activities within his current capabilities.
46The Respondent further relies again on the in-person Multidisciplinary Assessment by Dr. Eric Silver from April 25, 2024. Dr. Silver also concluded that the Applicant has not suffered a complete inability to carry on a normal life as he is fully independent with personal care tasks and while he no longer performs certain household tasks, there was no objective evidence of an accident-related impairment restricting him from doing so.
47I find that the Applicant has not established that he suffers a complete inability to carry on a normal life. I am unable to engage in the analysis required by Heath to determine if the Applicant suffers from a complete inability to carry on a normal life as the Applicant has not pointed me to details of their pre-accident activities or demonstrated how their participation in those activities has been limited as a result of the accident.
48There are no submissions on which activities were most important to the Applicant, how they were prevented from engaging in the activities they normally engaged in pre-accident or evidence of the frequency and time commitments of his pre-accident activities. In the absence of this information, it is challenging to compare the Applicant’s pre- and post-accident capabilities with respect to the activities he ordinarily engaged in or valued. I was not directed to any medical evidence, outside of the OCF-3, that the Applicant was prevented from engaging in his pre-accident activities.
49Therefore, I find the Applicant is not entitled to NEBs.
50As the Applicant is not removed from the MIG and the MIG limits have been exhausted, it is not necessary to consider the reasonableness or necessity of the treatment plans in dispute or the claim form.
Interest
51As no treatment plans are payable there is no interest.
ORDER
52I find that the Applicant is not removed from the MIG.
53As the Applicant has not been removed from the MIG, no plans or claim forms are payable.
54I find that the Applicant is not entitled to NEBs.
55As no benefits are owing, no interest is payable.
Released: February 25, 2026
Sarah Guergis
Adjudicator```