Licence Appeal Tribunal File Number: 24-012467/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:
Ronkee J Sopot
Applicant
and
Certas Home and Auto Insurance Company
Respondent
DECISION
ADJUDICATOR:
Nadia Mauro
SUBMISSIONS BY:
For the Applicant:
Dagmara Woznaik, Counsel
For the Respondent:
Solinne McKay (Nee Jung), Counsel
HEARD:
By way of written submissions
OVERVIEW
1Ronkee J Sopot, the applicant, was involved in an automobile accident on July 23, 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, Certas Home and Auto 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 limit ("MIG")?
ii. Is the applicant entitled to $2,819.75 for physiotherapy services, proposed by Seksek Chiropractic Professional Corporation in a treatment plan ("OCF-18") submitted February 6, 2023 and denied February 7, 2023?
iii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
v. Is the respondent liable to pay $1000.00 in costs?
3I have also added the applicant's request for costs to the issues in dispute. Rule 19.2 of the Licence Appeal Tribunal Rules, 2023 ("Rules"), provides that a party can make a request for costs "at any time before the decision or order is released."
RESULT
4The applicant's accident-related injuries are predominantly minor as defined by the Schedule.
5As the applicant is in the MIG, it is not necessary to consider if the treatment plans in dispute are reasonable and necessary. He is not entitled to interest, an award, or costs.
ANALYSIS
The applicant's injuries are predominantly minor
6I find that the applicant's injuries are predominantly minor.
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 submits that, as a result of his injuries from the accident, he suffers from chronic back pain, and resultantly, significant functional limitations in vocational and avocational endeavours. The applicant submits that despite consistent therapy, approximately one year later, he continued to suffer from severe, constant back pain and was unable to perform his employment duties. The applicant submits that as a result he was terminated from his employment as they could no longer accommodate the modified duties and schedule.
10The respondent submits that the evidence presented by the applicant is limited and shows nothing more than soft tissue injuries and clinically associate sequalae.
11It is well established by this Tribunal that chronic pain cannot be inferred solely based on the length of time elapsed since the injury. A diagnosis of chronic pain or chronic pain syndrome is not strictly required for removal from the MIG treatment limits. Rather, the applicant must demonstrate, on a balance of probabilities, that he suffers from accident-related pain that is chronic in nature and which causes functional impairment.
12In the present case, I am not satisfied the applicant has met his burden to prove that he has chronic pain which causes functional impairment.
13The applicant relies on the s. 25 physical medicine and rehabilitation report of physician Dr. Keith Sequeira, dated July 10, 2024, to support a diagnosis of chronic low back pain and functional impairments. I am unpersuaded by the report of Dr. Sequeira given that it is conducted largely on the basis of the applicant's self-reported pain complaints and functional limitations, and a lack of corroborating evidence. Dr. Sequeira notes that the applicant does not have a family physician and that the applicant has not seen any specialists, nor has he had any injections since the accident. Nonetheless, Dr. Sequeira concludes "there has been consistent documentation of [the applicant's] symptoms, impairments, and limitations from the time of this injury to the present to corroborate my opinion". While Dr. Sequeira highlights a few passages from clinical records dated July 23, 2022 to July 29, 2022, which are immediately after the accident, Dr. Sequeira does not reference any record beyond July 2022. Moreover, Dr. Sequeira notes "the documentation reviewed to prepare this report is listed in the Appendix", but the Appendix is not included with report, nor tendered in the applicant's submissions and evidence. As such, I find there is a lack of corroborating medical evidence that would allow me to put weight on the diagnosis and conclusions of Dr. Sequeira, especially in light of the fact that this report was conducted during a singular attendance.
14I am also unpersuaded by the handwritten progress report of Hands on Health Wellness, dated April 5, 2024, with respect to the applicant's alleged chronic pain and functional impairments because I find the progress report to be vague. The report indicates that the applicant's chief complaints are "L/s pain 10/10", however, the report also indicates "L/s pain occasional". The report lists aggravating factors as running and standing, and difficulty with basketball and sleeping in a single position. The report does not comment on chronic pain, nor does the report speak to how, and in what way, the aggravating factors or difficulties cause a functional impairment.
15The applicant has not tendered any other corroborating evidence that speaks to chronic pain with functional impairments. While the applicant submits that he was terminated from his employment as his employer could no longer accommodate the modified duties and schedule, the applicant has not directed me to any evidence, other than the reports he made to Dr. Sequeira, to support this assertion. The applicant has not provided employment records, or evidence to support the nature of his termination. I accept that the applicant was off work for some time after the accident. However, it is unclear from the available evidence how long he was off work and I find that there is also a lack of evidence to support that the applicant's alleged chronic pain with functional impairment was the cause of his 'termination'.
16Based on the foregoing, on a balance of probabilities, I find that the applicant is not removed from the MIG on the basis of his alleged chronic pain with functional impairments.
17Given that I have found the applicant to remain within the MIG, I find that it is not required to review the treatment plans in dispute to determine if they are reasonable and necessary. If there is funding left in the MIG, the applicant is entitled to treatment up to the MIG limit.
Interest
18As there are no overdue benefits the applicant is not entitled to interest pursuant to s. 51 of the Schedule.
Award
19The 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.
20As there are no overdue benefits, the applicant is not entitled to an award.
COSTS
21Rule 19.1 provides that a party may request costs of the proceeding if they believe that the other party has acted unreasonably, frivolously, vexatiously, or in bad faith during the proceedings. Rule 19.4 further sets out the requirements for that request, which must include the reasons for the request and the particulars of the alleged conduct.
22The applicant submits that the respondent has knowingly and unfairly denied payment of benefits, and improperly redacted log notes for litigation privilege in advance of the application. The applicant is seeking $1000.00 in costs plus interest.
23Rule 19.1 may award costs where a party's conduct falls below the standard of reasonableness expected in Tribunal proceedings. The applicant's allegation of the respondent's unfair and improper conduct is not related to the conduct of the respondent during the within proceedings. The applicant has also not directed me to evidence of such improper behaviour, nor has made submissions, with respect to the respondent's conduct during Tribunal proceedings.
24As such, I find that the applicant has not met the test set out in Rule 19 and is not entitled to costs.
ORDER
25I find that:
i. The applicant's injuries are predominantly minor as defined by the Schedule;
ii. The applicant is not entitled to the treatment plan for physiotherapy services;
iii. The applicant is not entitled to interest pursuant to s. 51 of the Schedule;
iv. The respondent is not liable to pay an award;
v. The respondent is not liable to pay costs; and
vi. The application is dismissed.
Released: March 24, 2026
Nadia Mauro
Adjudicator