Harjinder Singh Bhambra v. Economical Insurance Company, 2026 CanLII 18336

Citation: Bhambra v. Economical Insurance Company, 2026 ONLAT 24-007959/AABS

Licence Appeal Tribunal File Number: 24-007959/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:

Harjinder Singh Bhambra

Applicant

and

Economical Insurance Company

Respondent

DECISION

ADJUDICATOR: Nadia Mauro

APPEARANCES:

For the Applicant: Mohbina Khan, Counsel

For the Respondent: Yuliya Yarema, Paralegal

HEARD: By way of written submissions

OVERVIEW

1Harjinder Bhambra, the applicant, was involved in an automobile accident on March 9, 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, Economical Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

2This decision is a rehearing as a result of the reconsideration decision dated February 9, 2026, that cancelled the initial decision pursuant to Rule 18.4 of the Licence Appeal Tribunal Rules, 2023. The matter was ordered to be reheard based on the parties’ submissions and evidence from the initial written hearing.

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?
2. Is the applicant entitled to $902.48 ($1,874.96 less $972.48 approved) for chiropractic services, proposed by Life Total Wellness Centre in a treatment plan (“OCF-18”) dated December 5, 2023?
3. Is the applicant entitled to $1,874.96 for chiropractic services, proposed by Dr. Daughterty Chiropractic Professional Corporation in an OCF-18 dated June 27, 2024?
4. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
5. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

4The applicant’s injuries are predominantly minor.

5The expenses incurred under the treatment plan for a chiropractic services, dated December 5, 2023, are payable pursuant to s. 38(11) of the Schedule, plus interest.

6The applicant is not entitled to the treatment plan for chiropractic services dated June 27, 2024, or an award.

ANALYSIS

The applicant’s injuries are predominantly minor

7I find that the applicant has not proven, on a balance of probabilities, that she suffers from an injury or impairment that would warrant removal from the MIG.

8Section 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.”

9An 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.

10The applicant submits that he has suffered physical and psychological injuries as a result of the accident. The applicant submits that the persistence of his “ongoing issues” ought to remove him from the MIG.

11The respondent submits that the applicant has failed to meet his evidentiary onus to establish that his accident-related impairments fall outside the scope of the MIG.

a) Physical Impairment

12I find that the applicant has not met his evidentiary onus to demonstrate that he suffers from physical injuries warranting removal from the confines of the MIG.

13As a result of the subject accident, the applicant submits that he has sustained physical injuries such as sprain and strain of joints and ligaments of other and unspecified parts of neck, sprain and strain of the lumbar spine, shoulder joint, and hip. The applicant also relies on an X-ray of the cervical spine, dated May 24, 2023.

14I have reviewed the evidence and find that the X-ray of the cervical spine, dated May 24, 2023, is not a medical record of the applicant.

15Other than soft-tissue sprains and strains which fall within the definition of a “minor injury”, the only other accident-related physical impairments the applicant has established is a left shoulder injury and hip pain. However, I am not satisfied that the applicant has established that the shoulder injury or hip pain is non-minor.

16I find that the ultrasound of the applicant’s left shoulder, dated March 15, 2023, revealed partial tear of the supraspinatus with bicipital tenosynovitis. I also find that the ultrasound of the applicant’s right hip, dated March 15, 2023, revealed greater trochanteric bursitis. The applicant has not directed me to evidence or medical opinion that supports that these findings are non-minor impairments.

17As such, I am not satisfied on a balance of probabilities that the applicant has sustained an accident-related physical injury that falls outside of the definition of a minor injury.

b) Psychological Impairment

18Despite indicating briefly in his submissions that he suffers from psychological injuries as a result of the accident, the applicant does not point me to any corroborating medical evidence that would support he suffered a psychological impairment as a result of the accident. The applicant does not specify in his submissions what psychological impairment he has suffered nor does the applicant direct me to evidence that would support he received psychological counselling/treatment or was prescribed any psychotropic medication as a result of the accident.

19In the medical evidence, the CNRs of Dr. Peter Nord, family doctor, report on August 22, 2024, “PTSD signs and symptoms noted… fearful of driving.” However, this CNR references an “MVA from 2 years ago” which predates the subject accident. There is no further psychological complaint in the CNRs of Dr. Nord, nor referral for psychological treatment or prescription for psychotropics.

20As such, I find that the applicant has not provided medical evidence of significance to demonstrate, on a balance of probabilities, that he suffers from a psychological impairment that would warrant removal from the MIG.

c) Chronic Pain

21I am not satisfied that the applicant suffers from chronic pain with a functional impairment that warrants removal from the MIG.

22Although the applicant didn’t specifically submit that he should be removed from the MIG due to chronic pain which limits his functionality, he argued that he suffers from persistent symptoms “such as ongoing issues, e.g. chronic pain, his age, limited range of motion.” Therefore, and keeping in mind the consumer protection mandate of the Schedule, I have considered whether the applicant should be removed from the MIG due to chronic pain with functional limitations.

23A diagnosis of chronic pain or chronic pain syndrome is not required for removal from the MIG treatment limits. However, the applicant must still demonstrate, on a balance of probabilities, that he suffers from accident-related chronic pain that causes functional impairment. In the present case, I find that the applicant has fallen short of meeting his onus in establishing he has accident-related chronic pain with a functional impairment.

24The applicant has not directed me to evidence that would support ongoing accident-related impairments or complaints that would support that he is suffering from chronic pain. The CNRs of Dr. Nord, report accident-related complaints of bilateral hip pain on April 13, 2023, and Dr. Nord reports “acute on [sic] chronic bursitis and tendinitis”. However, I am not pointed to any further complaint for hip pain after this attendance. Moreover, while the CRNs of Dr. Nord report residual upper arm pain on October 21, 2024, and that the applicant is “unstable at times on his feet since MVA” on December 31, 2024, the CNRs of Dr. Nord are silent with respect to functional impairment.

25Therefore, I find that the applicant has not established, on a balance of probabilities, that he has chronic pain with a functional impairment that warrants removal from the MIG.

Conclusion

26Given the above, I find that the applicant has not proven, on a balance of probabilities, that he suffers from an injury or impairment that would warrant removal from the MIG.

27As I have found the applicant remains within the MIG, I find that it is not required to review the treatment plan in dispute to determine if it is reasonable and necessary. The applicant is entitled to treatment up to the MIG limits.

28However, the applicant submits that the denial letters in this case do not include any meaningful discussion about the applicant’s injuries or symptoms, or their bearing on the proposed treatment. The applicant submits that the treatment plans should be approved, and he should be removed from the MIG by operation of s. 38(11) of the Schedule.

Section 38(8) and 38(11) of the Schedule

29Sections 38(8) and 38(11) of the Schedule set out strict notice requirements for insurers responding to treatment plans and specific consequences if they fail to comply. Section 38(8) requires an insurer to inform an insured person within ten business days after it receives an OCF-18 which goods, services, assessments, and/or examinations it agrees to pay for, and which it does not, as well the medical and other reasons why it considered any of the goods and services to not be reasonable and necessary.

30If an insurer fails to comply with its obligations under s. 38(8), the following consequences set out in s. 38(11) of the Schedule are triggered:

1. The insurer is prohibited from taking the position that the insured person has an impairment to which the Minor Injury Guideline applies.
2. The insurer shall pay for all goods, services, assessments, and examinations described in the treatment and assessment plan that relate to the period starting on the 11th business day after the day the insurer received the application and ending on the day the insurer gives a notice described in subsection (8).

31To begin, s. 38(8) and the consequences set out in s. 38(11) are only applicable to treatment plans completed pursuant to s. 38(1) to (4) of the Schedule. Section 38(8) and s. 38(11) do not apply to the classification of the applicant’s impairment (i.e. minor injury, non-catastrophic, and catastrophic). In other words, there is no recourse under s. 38 for the applicant’s placement in the MIG.

The Explanation of Benefits (“EOB”), dated December 6, 2023 for the treatment plan for chiropractic services, dated December 5, 2023

32I find that the EOB, dated December 6, 2023, is non-complaint with s. 38(8) of the Schedule.

33The EOB dated December 6, 2023, for the OCF-18 for chiropractic services, in the amount of $1,874.96, dated December 5, 2023, stated:

“Fee Exceeds remaining minor injury balance. Medical reason - see explanation of benefits statement or correspondence with claimant.

The injuries listed are predominantly minor in nature and we have not been provided with clinical records or rationale that the insured person has a pre-existing medical condition that was documented by a health practitioner before the accident and that will prevent the insured person from achieving maximal recovery from the minor injury if the insured person is subject to the limit or is limited to the goods and services authorized under the Minor Injury Guideline. If these records are available, please submit for our review and consideration.”

34The respondent submits that it noted the lack of medical documentation on file and indicated that the MIG limits apply.

35While I appreciate that the respondent indicated in its denial letter that the applicant’s injuries are considered to be within the MIG, some or partial compliance with the Schedule is not enough. I find that the respondent’s denial letter does not reference the specific CNRs or medical records that it would require, nor the specific injuries that are “minor” that it considered when rendering its decision.

36In my view, simply referring to the “clinical records” without providing a single reference, is not sufficient to allow an unsophisticated person to make an informed decision to either accept or dispute the decision at issue. This also does not serve the Schedule’s consumer protection goal.

37Given the foregoing, I find that the respondent’s denial letter is non-compliant with s. 38(8) of the Schedule. Consequently, pursuant to the provisions set out in s. 38(11), I find that the respondent is liable to pay all expenses that were incurred by the applicant under the treatment plan, dated December 5, 2026, for chiropractic services, between the 11th business day after the plan was submitted until the day the respondent cured its deficient notice. If the respondent did not cure its deficient notice prior to this hearing, the applicant may incur these expenses, and provided they are properly invoiced, the respondent is thereafter liable to pay these expenses. To be clear, it is no longer open to the respondent to cure the denials that I have found deficient: Aviva v Suarez, 2021 ONSC 6200 at paras. 35-36.

The EOB dated July 12, 2024

38I find that the EOB, dated July 12, 2024, is complaint with s. 38(8) of the Schedule.

39The EOB dated July 12, 2024, for the OCF-18 for chiropractic services, in the amount of $1,874.96, dated June 27, 2024, stated:

“We have reviewed this OCF-18 that states that you have sustained Sprain and strain of joints and ligaments of other and unspecified parts of neck, Sprain and strain of lumbar spine, Sprain and strain of shoulder joint and Sprain and strain of hip.

However, we have not received significant clinical notes and records from healthcare providers confirming the injuries listed on this OCF-18. We have not been provided with evidence that would support your injuries are not minor in nature, additionally, the injuries stated in this treatment plan are also minor injuries. At this time, we do not find this OCF-18 treatment plan to be reasonable and necessary.”

40Unlike my finding for the EOB dated December 6, 2023, I find that the EOB dated July 12, 2024, provides medical reasons for the denial by specifically addressing the applicant’s physical impairments. I also find that the letter is clear and sufficient enough to allow an unsophisticated person to make an informed decision to either accept or dispute the decision. The applicant may disagree with the stated reasons, however, that does not render a denial invalid.

41As such, I find that the EOB dated July 12, 2024, is complaint with s. 38(8) of the Schedule. Therefore, the treatment plan dated June 27, 2024, is not payable.

Interest

42The applicant is entitled to interest on any overdue benefits pursuant to s. 51 of the Schedule.

Award

43The 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.

44The applicant submits that the respondent’s actions in delaying or withholding payments were unjustified, causing unnecessary financial hardship to the applicant.

45The respondent submits that the applicant failed to provide particulars in support of the special award claim within 30 days of receipt of the adjuster log notes contrary to the Case Conference Report and Order, dated November 6, 2024, and as such, his award claim should be dismissed.

46Although I found that the respondent did not comply with s. 38(8) of the Schedule in issue 2, I do not find that its conduct rose to the level that would substantiate the applicant’s request for an award despite finding that the denial letter did not meet the standard of notice required by the Schedule. This is because I find that the respondent’s non-compliance with s. 38(8) to be a wrong adjusting decision, rather than conduct that was “excessive, imprudent, stubborn, inflexible, unyielding, or immoderate” that I would deem to warrant an award.

47The respondent is therefore not liable to pay an award.

ORDER

48I find that:

i. The applicant’s injuries are predominantly minor; ii. The expenses incurred under the treatment plan for a chiropractic services, dated December 5, 2023, are payable pursuant to s. 38(11) of the Schedule, plus interest; iii. The applicant is not entitled to the treatment plan for chiropractic services dated June 27, 2024; and iv. The respondent is not liable to pay an award.