Licence Appeal Tribunal File Number: 24-008981/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:
Sharmini Sentheilvelmurugan
Applicant
and
Co-operators General Insurance Company
Respondent
DECISION
ADJUDICATOR:
John Mazzilli
APPEARANCES:
For the Applicant:
Shen Subramaniam, Counsel
For the Respondent:
Sonya Reid, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Sharmini Sentheilvelmurugan, (“the applicant”), was involved in an automobile accident on October 19, 2022, 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 Co-operators General Insurance Company (“the respondent”) 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? Note: The parties agree the MIG limits have not been exhausted and there is $26.33 remaining on the day of the case conference.
ii. Is the applicant entitled to $199.29 for chiropractic services, proposed by Whitby Wellness Centre Ltd. in a treatment plan/OCF-18 (“plan”) dated December 28,2022?
iii. Is the applicant entitled to $3,297.82 for chiropractic services, proposed by Whitby Wellness Centre Ltd. in a treatment plan dated May 11, 2023?
iv. Is the applicant entitled to $3,016.20 for chiropractic services, proposed by Whitby Wellness Centre Ltd. in a treatment plan dated November 15, 2023?
v. Is the applicant entitled to $2,875.63 for chiropractic services, proposed by Whitby Wellness Centre Ltd. in a treatment plan dated April 23, 2024?
vi. Is the applicant $2,197.00 for psychological assessment, proposed by Whitby Wellness Centre Ltd. in a treatment plan dated November 30, 2023?
vii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
viii. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant remains in the MIG, therefore an analysis of the reasonableness and necessity of the treatment and assessment plans in dispute is not necessary.
4As no benefits are owing, interest is not payable.
5The applicant is not entitled to an award.
6The application is dismissed.
ANALYSIS
Minor injury guideline (“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 a functional impairment or a psychological condition may warrant removal from the MIG. In all cases, the burden of proof lies with the applicant.
The applicant has failed to establish that she suffers from chronic pain with a functional impairment that warrants removal form the MIG
9I find on a balance of probabilities that the applicant has failed to demonstrate that she suffers from chronic pain with a functional impairment that warrants funding beyond the MIG limits.
10The applicant submits that she suffers from chronic pain in her back, shoulders and neck as a result of the accident. She argues that her pain has persisted well over the three-to-six-month threshold to be considered chronic. She submits that she exhausted the MIG limits in pursuing treatment with the goal of improving her pain, strength and range of motion rather than using the funding under the MIG to obtain a chronic pain report to document her symptoms; she ought not be penalized for this decision. The applicant relies on the clinical notes and records (“CNRs”) of Lakeridge Hospital, the CNRs of One Health and the CNRs of Dr. Gundala, physician.
11The respondent argues that as a result of the accident the applicant suffered soft tissue injuries at most and that the applicant has not provided compelling medical evidence of chronic pain syndrome. It argues that the applicant has provided no evidence of severe and debilitating pain with associated functional limitations as a result of the accident. It argues the applicant has failed to adduce evidence that she meets any of the American Medical Association Guides (“AMA Guides”) Criteria that meets the diagnosis for chronic pain.
12I find that the contemporaneous medical evidence does not support a finding that the applicant’s accident-related injuries result in chronic pain with a functional impairment because the applicant has failed to provide the Tribunal with the associated functional impairments or limitations that she suffers from as a result of the accident.
13Of particular importance the applicant produced limited medical records to support her claim. The evidence shows that shortly after the accident the applicant attended three medical appointments either with her family physician, a walk-in clinic and the Hospital. These records show that the applicant suffered from muscle strains and the recommended treatment is Tylenol/Advil as needed, ice pads, massage and acupuncture.
14The CNRs of the applicant’s family physician dated October 25, 2022, advise the applicant to follow up as needed and on November 7, 2022, at a follow up appointment with her family physician, the applicant did not report any accident-related complaints to her family physician.
15In addition, by January 25, 2023, approximately 3 months post accident the applicant advised her family physician that she did not have any neck pain and Dr. Gundala noted that the applicant was doing well. I was not pointed to other accident-related injuries that are discussed at this appointment or subsequent appointments provided to the Tribunal, further supportive of a finding that the applicant does not suffer from chronic pain with a functional impairment as a result of the accident.
16I find on a balance of probabilities that the applicant has failed to demonstrate that she suffers from chronic pain with a functional impairment that warrants funding beyond the MIG limits.
The applicant has failed to establish that she suffers from a psychological injury that warrants removal from the MIG
17I find on a balance of probabilities that the applicant has failed to demonstrate that she suffers from a psychological injury that warrants removal from the MIG as a result of the accident.
18The applicant did not provide the Tribunal with submissions to support her claim of psychological injuries, but rather relies on an OCF-18 dated November 28, 2023, prepared by Dr. Steiner, psychologist, based on a pre-screen by Dr. Steiner. Dr. Steiner noted on the OCF-18 that the applicant’s injuries and sequelae to be adjustment disorder, mixed anxiety and depressive disorder, and specific isolated phobias. The goals identified are to return to her pre-accident level of psychological functioning, and to improve her activities of normal living and ability to return to work.
19The respondent argues that the applicant’s submissions do not argue that she should be removed from the MIG due to psychological impairments. It argues that the applicant has not suffered and does not suffer from an accident-related psychological impairment that justifies removal from the MIG.
20I agree with the respondent because the contemporaneous medical evidence does not support a finding that the applicant suffers from an accident-related psychological injury. The applicant’s family physician’s CNRs do not suggest that the applicant suffered psychological injuries as a result of the accident. In addition, the OCF-18 references a pre-screen report that was sent to the applicant by fax on November 28, 2023, to support the plan, however the fax/pre-screen report was not provided to the Tribunal as evidence.
21The burden of proof lies with the applicant to prove entitlement for removal from the MIG due to a psychological injury. In the absence of contemporaneous corroborating medical evidence, the applicant has not met her burden of proof to be removed from the MIG due to a psychological injury.
22I find on a balance of probabilities that the applicant has failed to demonstrate that she suffers from a psychological injury that warrants removal from the MIG as a result of the accident.
The OCF-18’s in dispute
23The applicant remains in the MIG, so an analysis of the reasonableness and necessity of the disputed treatment and assessment plans is not required.
Interest
24Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no benefits are owing, interest is not owing.
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.
26As no benefits are payable, it follows that the respondent did not unreasonably withhold or delay the payments of benefits. Accordingly, I find that the applicant is not entitled to an award from the respondent.
ORDER
27It is ordered that:
i. The applicant remains in the MIG.
ii. As the applicant is in the MIG, it is not necessary to consider whether the treatment and assessment plans in dispute are reasonable and necessary.
iii. Since no benefits are owing, interest is not payable.
iv. The applicant is not entitled to an award.
Released: February 24, 2026
John Mazzilli
Adjudicator