Licence Appeal Tribunal File Number: 24-007122/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:
Sheriffa Hammond
Applicant
and
Definity Insurance Company
Respondent
DECISION
VICE-CHAIR: Robert Maich
APPEARANCES:
For the Applicant: Joel McCoy, Counsel
For the Respondent: Maryam Aziz, Counsel
HEARD: In Writing
OVERVIEW
1Sheriffa Hammond, the applicant, was involved in an automobile accident on November 17, 2021, 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, Definity Insurance Company, 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 (“MIG”) limit?
ii. Is the applicant entitled to $4,201.42 for psychological services, proposed by Critical Trauma Therapy in a treatment plan/OCF-18 (“plan”) dated January 25, 2024?
iii. Is the applicant entitled to $2,486.00 for a physiatry/chronic pain assessment, proposed by Stuart Jollife in a treatment plan dated January 5, 2024.?
iv. Is the applicant entitled to $2,200.00 for a psychological assessment, proposed by Dr. Mandel in a treatment plan dated January 22, 2024?
v. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
vi. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3I find the respondent has removed the applicant from the MIG and approved the treatment plans described in paragraphs [2] ii. and iv. Therefore, they are no longer in dispute.
4I find the applicant is entitled to $2,486.00 for a physiatry/chronic assessment, proposed by Stuart Jollife in a treatment plan dated January 5, 2024 and interest.
5I find the applicant is not entitled to an award under s. 10 of Reg. 664.
ANALYSIS
6I find the respondent removed the applicant from the MIG and approved the treatment plans described in paragraphs [2] ii. and iv.; the respondent informed the applicant and the Tribunal by way of its written submissions; these issues are no longer in dispute and no longer before the Tribunal.
Is the applicant entitled to $2,486.00 for a physiatry/chromic pain assessment, proposed by Stuart Jollife in a treatment plan dated January 5, 2024.
7I find the applicant is entitled to $2,486.00 for a physiatry/chronic pain assessment, proposed by Stuart Jollife in a treatment plan dated January 5, 2024.
8Pursuant to section 15 of the Schedule, the respondent is liable to pay for all reasonable and necessary expenses incurred by or on behalf of the insured persons a result of an accident. It is the applicant’s responsibility to prove the medical benefits claimed are reasonable and necessary on a balance of probabilities.
9The purpose of an assessment is to determine whether a condition exists. For an insured, they bear the onus to demonstrate that there are grounds on which to believe that a condition exists that would warrant further investigation by way of an assessment.
10The applicant submitted she is suffering from chronic pain from the accident and has been receiving chronic pain treatment including injections and a nerve ablation, but her pain persists despite treatment. The applicant further submitted she had complained of lower and upper back pain, neck pain and right should pain consistently since the accident as documented by her family physician, Dr. Graham in his clinical notes and records. Approximately one year after the accident the applicant submitted she was referred to a pain clinic, NeuPath Centre for Pain and Spine (“NeuPath”), where she was diagnosed with chronic pain. The applicant submitted she began receiving pain injections from NeuPath and was eventually referred for a nerve ablation due to injuries caused by the accident. The applicant relies upon the clinical notes and records of NeuPath as evidence of her diagnosis, treatment and procedures.
11The applicant submitted the respondent denied the treatment plan because her injuries were assessed to be minor and subject to treatment under the MIG, as disclosed in the insurer’s notice of denial letter dated January 23, 2024. Further the applicant submitted that the respondent’s assessor, Dr. Nair, psychiatrist, in his report of April 16, 2025 confirmed the applicant was suffering from chronic pain. The applicant also relies upon the respondent’s assessments of Dr. Waseem, physiatrist, assessed January 24, 2024 and dated February 8, 2024 who opined the applicant’s condition was chronic and required further treatment, and Dr. Nair, psychiatrist, dated April 16, 2025 who opined the applicant was suffering from chronic pain.
12The respondent submitted that the applicant’s injuries did not warrant a physiatry assessment and relies upon Dr. Marchie, physiatry assessment dated March 16, 2024. Further the respondent submitted the applicant’s post-accident treatment demonstrates the assessment is not reasonable and necessary. In particular, the respondent points to unexplained gaps in approved physiotherapy.
13I find the applicant has demonstrated a need for a physiatry/chronic pain assessment through her ongoing and documented pain complaints to her family physicians, Dr. Graham and later Dr. Attalla, as well as the assessments of Dr. Waseem and Dr. Nair, are sufficient to discharge the applicant’s burden of proof.
14I find the applicant is entitled to $2,486.00 for a physiatry/chronic pain assessment.
Interest
15Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Interest applies to the applicant’s entitlement to $2,486 for a physiatry/chronic pain assessment.
Award
16The 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.
17I note the applicant submitted that the respondent has not communicated clearly with the applicant and did not resolve the issues in dispute 3.5 years post-accident.
18The respondent submitted that its conduct did not meet the award test of being “excessive, imprudent, stubborn, inflexible, unyielding, or immoderate.’ Further, the respondent submitted it initially had medical reason to deny the psychology treatment plans, but it approved two psychology treatment plans in dispute shortly after receiving the report of Dr. Nair, and promptly removed the applicant from the MIG.
19I find the submissions of the respondent to be persuasive. I note the insurer’s communication with the applicant was imperfect and could have informed the applicant of its removal from the MIG prior to the written submissions herein. The respondent altered its position on the MIG and approved two of the three treatment plans in dispute once medical evidence supportive of the applicant’s injuries was received. I find this to be persuasive evidence of the respondent insurer’s execution of its duty to continually adjust the file.
20I find the insurer adjusted the file in alignment with evolving medical evidence over the 3.5 years since the accident; to punish an insurer with an award would be against the public interest and ignore the importance of the insurer’s continuing duty to adjust a file as medical evidence evolves.
ORDER
21The Tribunal’s final Orders:
i. The respondent has agreed that the applicant’s injuries are out of the MIG and has approved the treatment plans outlined in paragraph [2] ii and iv of this decision, therefore the aforementioned issues are no longer in dispute and are no longer before the Tribunal.
ii. The applicant is entitled to $2,486.00 for a chronic pain /physiatry assessment as outlined at paragraph [2] iii of this decision, plus interest.
Released: January 13, 2026
Robert Maich
Vice-Chair