Citation: Kumar v. Co-operators General Insurance Company, 2026 ONLAT 24-008392/AABS

Licence Appeal Tribunal File Number: 24-008392/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:

Sanjay Kumar

Applicant

and

Co-operators General Insurance Company

Respondent

DECISION

VICE-CHAIR: Robert Maich

APPEARANCES:

For the Applicant: Seema Passi, Paralegal

For the Respondent: Emily Schatzker, Counsel

HEARD: In Writing

OVERVIEW

1Sanjay Kumar, the applicant, was involved in an automobile accident on February 3, 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.

2The applicant was operating his 2023 Tesla at the Winston Churchill and Emerald intersection in Brampton. He was in a stopped position waiting to make a left turn on a green light when his car was struck by an oncoming vehicle on the left front side. Two days later the applicant experienced pain on the left shoulder, left arm, and left hand; the following day he attended Mississauga Credit Valley Hospital (“MCVH”) emergency room where he received diagnostic imaging.

ISSUES

3The issues in dispute are:

1. 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.

2. Is the applicant entitled to the services, proposed by Alliance Diagnostic and Treatment Inc. in a treatment plan/OCF-18 (“plan”) as follows:

i. $4,239.44 for a psychological services, in a treatment plan submitted March 13, 2024; and

ii. $8,694.67 for a chronic pain assessment, in a treatment plan submitted March 28, 2024?

3. Is the applicant entitled to the assessments proposed by Alliance Diagnostic and Treatment Inc., as follows:

i. $2,200.00 for a chronic pain assessment, in a treatment plan submitted October 10, 2023;

ii. $2,200.00 for a neurology assessment, in a treatment plan submitted August 2, 2023;

iii. $2,200.00 for orthopaedic assessment, in a treatment plan submitted August 2, 2023;

iv. $2,175.91 for driving anxiety assessment, in a treatment plan submitted December 15, 2023; and

v. $2,200.00 for psychology assessment, in a treatment plan September 15, 2023;

4. Is the applicant entitled to $2,425.62 for functional ability evaluation, proposed by Alliance Diagnostics and Treatment Inc, submitted on March 13, 2024?

5. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?

6. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

4I find the applicant’s injuries are predominantly minor as defined in s. 3 of the Schedule and therefore subject to treatment within the MIG.

5I find that as the parties have agreed the MIG is exhausted, it is not necessary to consider whether the treatment plans herein are reasonable and necessary.

ANALYSIS

Are the applicant’s injuries predominantly minor as defined in s. 3 of the Schedule and therefore subject to treatment within the MIG?

6I find the applicant has not discharged his onus and find his injuries are predominantly minor as defined in the Schedule and subject to treatment within the MIG limits.

7The MIG establishes a treatment framework available to injured persons who sustain a minor injury as a result of an accident. A “minor injury” is defined in the Schedule and includes sprains, strains, whiplash associated disorder, contusion, abrasion, laceration or subluxation and any clinically associated sequelae. The MIG provides that a strain is an injury to one or more muscles and includes a partial tear. Under section 18 of the Schedule, injuries that are defined as minor are subject to a $3,500.00 funding limit on treatment.

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 onus is on the applicant to demonstrate that he sustained an injury that is not included in the minor injury definition outlined in section 3 of the Schedule.

10The applicant submitted that on March 20, 2023 he was prescribed gabapentin for nerve injury and has continuous pain in his left shoulder. On October 28, 2023, he was referred to a psychologist for general anxiety and has subsequently reported worsening anxiety and panic attacks. On March 21, 2024, he was prescribed braces for back and knee pain. The applicant submitted he attended and physiotherapy subsequent to the accident; he was also referred to Wasser Pain Management Centre for Chronic neck pain. The applicant is prescribed the following medications since the accident Ativan, Cipralex, Lyrica and Apo-Lorazepam.

11The applicant submitted that prior to the accident he was healthy and did not have any physical or psychological pre-existing conditions. The applicant also submitted that he suffers from headache which has affected his memory and his ability to focus, as well as sleep deprivation after the accident along with periodic nightmares; nor has he been able to perform any household duties preformed before the accident. Further the applicant submitted his medical record demonstrates he is suffering from anxiety, depression and PTSD which removes him from the MIG. The applicant relies upon the clinical notes and records from an unnamed family doctor, and the various intake screening reports contained within the treatment plans in dispute.

12I note the applicant has not directed the Tribunal to pinpointed evidentiary records to support his position in regard to the MIG, nor were the applicant’s submissions tabbed, indexed or paginated had he chosen to direct the Tribunal to any specific records. I further note in the applicant’s submissions under the identified issue heading of MIG is limited to one paragraph outlining complaints of the applicant, without specific evidentiary references.

13The respondent submitted the applicant has not explained why his accident-related impairments warrant removal form the MIG. Further, the applicant refers to his medical records indicating he is suffering from anxiety depression and PTSD without specifying the records. The respondent submitted the applicant appears to rely upon the psychology assessment of Dr. Sadeghi, psychologist, dated February 20, 2024, however, the respondent noted the complaints made to Dr. Sadeghi were inconsistent with his reports to Dr. Sandhu, physician, where he indicated his anxiety issues were related to his employment and did not report accident related symptoms of PTSD. The respondent submitted Dr. Sadeghi did not corroborate the applicant’s the self-reports in the assessment with the self-reports documented by Dr. Sandhu.

14Further, the respondent submitted the psychological assessment dated May 7, 2024 by Dr. West, psychologist and neuropsychologist, reported the applicant’s testing results indicated high levels of depression, anxiety, and somatic, pain and functional complaints, which is contrary to his lack of prior complaints. Dr. West opined the applicant endorsed a high frequency of symptoms atypical of a psychiatric disorder, suggesting exaggeration or over-reporting. Dr. West also opined the applicant did not provide evidence of any clinically significant accident-related mental health symptomatology, sequelae, or impairment meeting the criteria for any mental health diagnosis.

15The respondent submitted that little weight should be assigned to Dr. Sadeghi’s report because it is based upon self-reporting without a review of medical documentation, including the records of Dr. Sandhu.

16Further, the respondent submitted the applicant cannot be removed from the MIG based upon only ongoing pain, and there is no evidence to support a diagnosis of chronic pain syndrome and a causal connection to the accident.

17I find the submissions of the respondent to be persuasive and prefer the evidence of Dr. West over the evidence of Dr. Sadeghi due to Dr. Sadeghi’s omission to review and relate the contradictory notes of Dr. Sandhu in regard to the applicant’s condition. I note the absence any submissions in chief or reply by the applicant in respect to the evidentiary issue raised by the respondent regarding the methodology of Dr. Sadeghi’s assessment. I also note the applicant did not specifically refer to the opinion of Dr. Sadeghi to support its submissions. I find that Dr. Sadeghi did not conduct a thorough review of the applicant’s records; particularly Dr. Sadeghi listed Dr. Sandhu’s notes in his appendix as having been reviewed, but Dr. Sadeghi did not comment on Dr, Sandhu’s contradictions with his findings, and I therefore give his opinion less weight.

18The onus lies upon the applicant to prove his case on a balance of probabilities. The applicant did not direct the Tribunal to any specific medical record or medical evidence supporting its submissions with only a non-specific reference to Dr. Sadeghi’s report, which I previously assigned less weight.

19I find the applicant has not discharged his onus for the above stated reasons and find his injuries are predominantly minor and subject to treatment within the MIG.

20As the applicant is in the MIG, it is not necessary to consider if the treatment plans in dispute are reasonable and necessary.

Interest

21Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. I find there are no overdue benefits owed to the applicant; I find interest does not apply.

Award

22The 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. I find the respondent did not unreasonably withheld or delayed any payment of benefits.

ORDER

23The Tribunal’s final Orders:

i. I find the applicant has not discharged his onus and find his injuries are predominantly minor and subject to treatment within the MIG.

ii. As the applicant is in the MIG, it is not necessary to consider if the treatment plans in dispute are reasonable and necessary.

iii. I find the applicant is not entitled to interest or award.