Licence Appeal Tribunal File Number: 24-011659/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:
Valarie Versailes-Bedard
Applicant
and
Wawanesa Mutual Insurance Company
Respondent
DECISION
ADJUDICATOR:
Jeff Chatterton
APPEARANCES:
For the Applicant:
Bianca Pirotta Iaccino, Paralegal
For the Respondent:
Gabrielle Nigro, Counsel
HEARD: In Writing
OVERVIEW
1Valarie Versailles-Bedard, the applicant, was involved in an automobile accident on June 3, 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, Wawanesa Mutual 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:
a) 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? Note: The parties agreed at the case conference that the MIG limits have not been exhausted.
b) Is the applicant entitled to $3,024.62 for Chiropractic Services, proposed by Humber Civic Care Centre in a treatment plan/OCF-18 (“plan”) dated October 3, 2022?
c) Is the applicant entitled to $2,629.85 for Chiropractic Services, proposed by Humber Civic Care Centre in a plan dated March 2, 2023?
d) Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant is being held to the Minor Injury Guideline and the $3,500 treatment limit.
4As the applicant is being held to the MIG, it is not necessary for me to determine of the treatment plans in dispute are reasonable and necessary.
5No interest is payable.
ANALYSIS
Is the applicant removed from the Minor Injury Guideline due to chronic pain with a functional impairment?
6The applicant is not being removed from the MIG due to chronic pain with a functional impairment.
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 argues she should be removed from the MIG on the basis of chronic pain with a functional impairment. The applicant submits that she has lived with chronic ongoing pain since the accident, and that chiropractic services relieve her pain. Furthermore, she relies on the Clinical Notes and Records of her family physician, Dr. Monique Martin, where on May 11, 2023, Dr. Martin noted a “history of lower back pain, chronic, not changing.”
10The respondent argues that the applicant has sustained a minor injury, and that Dr. Martin’s note does not indicate proof of chronic pain syndrome, but merely identifies a complaint regarding the complainant’s lower back. The respondent further relies upon a s.44 IE physiatry assessment conducted by Physiatrist Dr. M. Devlin, dated November 18, 2022. This assessment indicates that the applicant had full range of motion in the lumbar spine and only minimal decrease in range of motion in the cervical spine. Dr. Devlin recommended no further facility-based treatment for the applicant’s injuries.
11The respondent further argues that the applicant has not provided evidence that she meets three of the six criteria required for the diagnosis of chronic pain, according to the AMA Guides to the Evaluation of Permanent Impairment.
12I find that the evidence presented by the applicant does not meet the onus to establish that she has accident-related chronic pain with a functional impairment. I make this finding this for several reasons:
i. A single note of Dr. Martin indicating that the applicant has a history of ‘chronic lower back pain’ is not sufficient to establish she has accident-related chronic pain with a functional impairment.
ii. I have not been led to evidence that the lower back pain described in May 2023 is accident related. I note that an MRI in July 2023 indicated a diagnosis of osteoarthritis and neuroforaminal stenosis.
iii. There is a lack of visits to the applicant’s primary care physician to support a claim of chronic pain that warrants removal from the MIG. The applicant visited Dr Martin three weeks post accident, but did not make complaints about pain. Between June 2022 and May 2023, the applicant’s only visits to Dr. Martin were for non-accident related concerns. After the MRI in July 2023, the applicant did not visit Dr. Martin for a further 10 months.
iv. I have been led to no further medical evidence to support the applicant’s claim and the applicant has not made arguments with respect to the AMA Guides.
13For these reasons, I find the applicant has not met her onus to establish that she is suffering from accident-related chronic pain with a functional impairment.
14I find, on the balance of probabilities, that the applicant has not met her onus to establish she should be removed from the MIG on the basis of chronic pain with a functional limitation.
15As I have ruled that the applicant is being held to the MIG, it is not necessary for me to do a reasonable and necessary analysis on the treatment plans in dispute.
Interest
16Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no benefits are overdue, no interest is payable.
ORDER
17The application is dismissed.
i. The applicant is being held to the Minor Injury Guideline.
ii. As the applicant is being held to the MIG, it is not necessary to review the treatment plans in dispute to determine whether they are reasonable or necessary.
iii. No interest is awarded.
Released: March 24, 2026
Jeff Chatterton
Adjudicator