Licence Appeal Tribunal File Number: 24-010655/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:
Hong Guang Yu
Applicant
and
Allstate Insurance Company of Canada
Respondent
DECISION
ADJUDICATOR:
Roderick Walker
APPEARANCES:
For the Applicant:
Sareena Samra, Counsel
For the Respondent:
Emily Siu, Counsel
HEARD:
By Way of Written Submissions
OVERVIEW
1Hong Guang Yu, the applicant, was involved in an automobile accident on September 11, 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 Allstate Insurance Company of Canada, 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 (“MIG”) limit?
ii. Is the applicant entitled to $3,749.56 for physiotherapy services, proposed by Total Recovery Rehab Centre in a treatment plan/OCF-18 (“plan”) submitted January 4, 2024, and denied January 16, 2024?
iii. Is the applicant entitled to $2,144.93 for a psychological assessment, proposed by Somatic Assessments and Treatment Clinic in a plan submitted December 29, 2023, and denied January 16, 2024?
iv. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
v. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant’s injuries are predominately minor as defined by s.3 of the Schedule and therefore the applicant is subject to treatment within the MIG.
4The applicant is not entitled to the treatment plans in dispute.
5The denials letters are compliant with s. 38(8).
6There is no interest or award granted.
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 functional impairment or a psychological condition may warrant removal from the MIG. In all cases, the burden of proof lies with the applicant. In this case the applicant seeks removal from the MIG on the basis of a chronic pain impairment and a psychological condition.
9I find that applicant has not meet his onus, on a balance of probabilities, and is not removed from the MIG. A mere treatment plan is not sufficient evidence to establish non-minor impairments.
10The applicant relies on the disputed plan of $3,749.56 for physiotherapy services, proposed by Total Recovery Rehab Centre in a treatment plan submitted January 4, 2024.
11Also, the applicant relies on the disputed plan for $2,144.93 for a psychological assessment, proposed by Somatic Assessments and Treatment Clinic in a plan submitted December 29, 2023.
12Outside of the treatment plans, the applicant has not provided any clinical notes and records from his family doctor or any medical record or diagnostic imaging report from any hospital he attended to support his claim at this hearing.
13The applicant contends that by merely checking the box in Part 4 of the OCF-18’s indicating that his injuries in the accident were predominantly not a minor injury, he is exempt from providing any obligation to provide any compelling medical evidence of same.
14The applicant has not directed me to any medical evidence or provided specific submissions on why he should be removed from the MIG due to chronic pain or a physiological condition. The Divisional Court in Dooman v. TD Insurance Co., 2025 ONSC 184 states at paragraph 50, that it is inappropriate for adjudicators to go through a party’s evidence, to make their case for them. The burden of proof lies with the applicant to establish that he has suffered a chronic pain injury or a psychological condition, which in this case he has not. For this reason, I find on a balance of probabilities, he is not removed from the MIG.
15As the applicant remains subject to the MIG, it is not necessary for me to consider whether the treatment plans in dispute are reasonable and necessary.
Are the respondent’s denial letters non-compliant with s. 38(8) of the Schedule?
16I find that the applicant has not established that the respondent was non-compliant with s. 38(8). In terms of the sufficiency of the respondent’s denials, the applicant states that the respondent failed to provide the applicant with firm and clear “medical and all of the other reasons within 10 business days” why they refused to pay for the benefit and the proposed treatments/assessments, as required by s. 38(8) of the Schedule.
17The respondent asserts that all denials are complaint with the Schedule. The respondent argues that it is sufficient for the denial to say that the applicant’s injuries fall within the MIG, particularly because it had little medical documentation to refer to or base its reasons on. The respondent points out the fact that the applicant submitted the disputed OCF-18s without corroborating evidence to support his claim. As a result of the limited amount of medical documentation provided by the applicant, the respondent submits that its medical reasons were sufficient. I agree.
18The Tribunal has considered standing within the MIG to be a “medical reason” in certain circumstances. In the Tribunal decision Zeitoun v Royal & Sun Alliance, 2020 CanLII 103701 (ON LAT), at para 35 Vice Chair McGee states: I do not agree…that citing the MIG in a denial fails to provide “medical reasons and all of the other reasons” for the determination as required by s. 38(8). For each of the treatment plans in dispute, the respondent explained that it had determined that M.Z. had “sustained a minor injury to which the Minor Injury Guideline applies.” I find that this reason satisfies the requirement, well-established in the jurisprudence, that an insurer provide reasons capable of giving a claimant a principled rationale, based fairly on the claimant’s file, to which an insured person can respond. I further note that the applicant has not provided any detailed submissions as to how the respondent has not complied with s. 38(8). Rather, he simply provides a general statement that the respondent has not given 10 business days notice for their denials.
19I find that the physiotherapy treatment plan (issue #2) was submitted by the applicant and received by the respondent on January 5, 2024. The denial was delivered to the applicant on January 16, 2024. Thus, the plan was denied 3 business days prior to the deadline of 10 business days. Similarly, while the psychological assessment plan (issue #3) is dated December 29, 2023, it was submitted by the applicant and received by the respondent on January 11, 2024. The respondent’s denial of the plan, by way of explanation of benefits, was submitted on January 16, 2024. As indicated, the plan was denied within 3 business days of receipt, well within the 10-business-day timeline set out in section 38(8) of the Schedule. I find the notices are compliant with s. 38(8) of the Schedule.
Interest
20Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. No interest is awarded as no benefits are due.
Award
21The 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 that no award is payable because there is no evidence that the respondent withheld or delayed any benefits payable.
ORDER
22On the totality of the evidence, I find that:
i. The applicant’s injuries are predominately minor as defined by s.3 of the Schedule and therefore the applicant is subject to treatment within the MIG.
ii. The applicant is not entitled to the treatment plans in dispute.
iii. The denial letters both dated January 16, 2024, are compliant with s. 38(8) of the Schedule.
iv. There is no interest or award granted.
v. The application is dismissed.
Released: March 18, 2026
__________________________
Roderick Walker
Adjudicator