Citation: Ngu v. Economical Insurance, 2026 ONLAT 24-001776/AABS

Licence Appeal Tribunal File Number: 24-001776/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:

Paul Ngu

Applicant

and

Economical Insurance

Respondent

DECISION

ADJUDICATOR:

Robert Spiegel

APPEARANCES:

For the Applicant:

Dean Trinetti, Counsel

For the Respondent:

Yuliya Yarema, Paralegal

HEARD: In Writing

January 6, 2026

OVERVIEW

1Paul Ngu, the applicant, was involved in an automobile accident on September 30, 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 the respondent and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

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 been exhausted.

ii. Is the applicant entitled to $3,387.51 for chiropractic services proposed by Scarborough Health and Wellness Center Inc. in a treatment plan/OCF-18 (“plan”) dated March 1, 2023?

iii. Is the applicant entitled to $2,234.00 for a chronic pain assessment, proposed by Paramount Medical Assessments Ltd. in a treatment plan dated November 28, 2023?

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

RESULT

3I find, on the balance of probabilities, that the applicant has not met the onus to prove his impairments warrant removal from the MIG.

4As the applicant is subject to the MIG, it is not necessary to consider if the treatment plans in dispute are reasonable and necessary.

5No interest is payable.

Are the applicant’s injuries predominantly minor?

6I find that the applicant’s accident-related injuries are predominantly minor, and thus, the funding limit of the MIG applies.

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 made no submissions to establish they qualify for removal from the MIG under s. 3(1) or s. 18(2) of the Schedule.

10The applicant submits that they should be removed from the MIG due to chronic pain. To support their claim, the evidence applicant is relying on are the Clinical Notes and Records (“CNRs”) of the emergency department at Scarborough Health, Dr. Shweta Dhawan, a family doctor, and Dr. Sivananthan, a physiatrist, to demonstrate that the applicant meets at least three of the six criteria of the American Medical Association Guides to the Evaluation of Permanent Impairment, 6th Edition (“Guides”) for a diagnosis of chronic pain, listed below. While the Guides are not binding, the Tribunal has consistently held that they are a helpful evaluative tool for assessing chronic pain claims in the absence of a diagnosis.

11The applicant asserts they meet four of the six criteria, namely criteria (ii), (iii), (iv) and (v) as follows:

i. Use of prescription drugs beyond the recommended duration and/or abuse or dependence on prescription drugs or other substances;

ii. Excessive dependence on health care providers, spouse, or family;

iii. Secondary physical deconditioning due to disuse and or fear-avoidance of physical activity due to pain;

iv. Withdrawal from social milieu, including work, recreation, or other social contracts;

v. Failure to restore pre-injury function after a period of disability, such that the physical capacity is insufficient to pursue work, family, or recreational needs; and,

vi. Development of psychosocial sequelae after the initial incident, including anxiety, fear, avoidance, depression, or nonorganic illness behaviors.

12The applicant asserts that they meet the criterion of section (ii) of the Guides but provided no explanation as to how they do so, as they did not prove that they have an excessive dependence on health care providers, spouse, or family. The applicant provided no evidence of reliance on spouse or family. I have reviewed the frequency and nature of medical visits in the CNRs and have found insufficient evidence to support a finding of excessive dependence on health care providers. The CNRs show attendance at the emergency department at Scarborough Health on October 1, 2022, and clinic visits on January 10, 2023, October 3, 2023, and May 1, 2024. This does not suggest excessive dependence on health care providers, and section (ii) of the Guides has therefore not been met.

13The applicant submitted that they meet criterion (iii) of the Guides, without explaining how they do so, namely how the accident has led to secondary physical deconditioning due to disuse and or fear-avoidance of physical activity due to pain. At the medical appointment on January 10, 2023, a referral was made to a Dr. Sivananthan, a physiatrist, who examined applicant on January 17, 2023.

14In the physiatry report, Dr. Sivananthan notes that the consultation was for rehabilitation management following the accident and that the applicant was advised to do core and back exercises and advised against being sedentary, and to exercise and stretch daily to improve myofascial pain. The physical examination disclosed no concerns of inactivity and or fear avoidance due to pain, and no reference to chronic pain was made in that report.

15A follow up consultation with the physiatrist on July 29, 2024, had the same finding and recommendation regarding exercise.

16On August 26, 2024, the physiatrist met with applicant to review his spinal MRI and reported a finding of a congenitally narrow spinal canal and hypertrophy/degenerative changes, with no suggestion that their lower back pain was related to the motor vehicle accident. The physiatrist made a further recommendation of core strengthening and stretching exercises, and to vary the speed based on any discomfort experienced. I therefore find criterion (iii) has not been met.

17The applicant submitted that they meet criterion (iv) of the Guides, without explaining how they do so, such as withdrawal from social milieu, including work, recreation, or other social contacts because of the accident. The CNRs contained no such evidence to support this. Rather, in the s. 44 Report of Dr. Kahn, in taking note of their work history, the applicant stated that their lack of work was related to the absence of available work contracts. I find therefore that criterion (iv) is not met. The applicant’s statement that they meet criterion (iv) is not evidence.

18The applicant submitted that they meet criterion (v) of the Guides, being the failure to restore pre-injury function, after a period of disability, such that the physical capacity is insufficient to pursue work, family, or recreational needs. The applicant gave no explanation or evidence supporting this claim. The applicant’s statement that they meet criterion (v) is not evidence. I find therefore that criterion (v) is not met.

19I find that the applicant has not satisfied at least three of the criteria in the Guides supporting a diagnosis of chronic pain.

20The respondent submitted that there was no diagnosis of chronic pain, nor was there any consistent accident-related complaints beyond three months post-accident and it relied upon physiatrist Dr. Kahn’s s. 44 assessment report as further evidence that the applicant should not removed from the MIG on the basis of chronic pain.

21Dr. Kahn performed a physiatry assessment of the applicant on August 22, 2024, and noted that applicant was able to perform their activities of daily living without assistance, noted no impairments from the physical assessment, and that the applicant’s continuing low back pain since the accident was consistent with a strain/sprain injury. The applicant did not produce their own assessment report, and I found the respondent’s report persuasive in demonstrating that the applicant remains subject to the MIG.

22While the applicant reports continuing lower back pain since the motor vehicle accident, the applicant has not established that they have met the criteria of chronic pain with a functional impairment, that may warrant removal from the MIG. It is notable that the CNRs do not suggest follow up care is needed with a specialist for chronic pain or as a result of any functional impairment.

23In sum, I find that the CNRs of Dr. Dhawan and Dr. Sivananthan do not provide persuasive evidence that the applicant meets three out of six criteria to establish chronic pain under the Guides. No evidence was presented by the applicant to establish on a balance of probabilities, that they have chronic pain with a functional impairment that warrants removal from the MIG.

24As the applicant is in the MIG, it is not necessary to consider if the treatment plans in dispute are reasonable and necessary.

Interest

25As no benefits are payable, the applicant is not entitled to interest.

ORDER

26The applicant has not met the onus to prove his impairments warrant removal from the MIG.

27As the applicant is subject to the MIG, it is not necessary to consider if the treatment plans in dispute are reasonable and necessary.

28No interest is payable.