Licence Appeal Tribunal
Licence Appeal Tribunal File Number: 24-014419/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:
Arvind S Bhangoo
Applicant
and
Wawanesa Mutual Insurance Company
Respondent
DECISION
VICE-CHAIR: Julian DiBattista
APPEARANCES:
For the Applicant: Yalini Yogeswaran, Paralegal
For the Respondent: Lyrica Roche, Counsel
HEARD: In Writing
OVERVIEW
1Arvind Bhangoo, the applicant, was involved in an automobile accident on September 23, 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 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:
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 $3,807.20 for psychological services, proposed by E Clinic United Healing in a treatment plan/OCF-18 (“plan”) dated June 24, 2024?
iii. Is the applicant entitled to $3,512.56 for chiropractic services, proposed by Alma Rehab Inc. in a plan dated June 24, 2024?
iv. Is the applicant entitled to $1,920.53 for a psychological assessment, proposed by E Clinic United Healing in a plan dated February 9, 2024?
v. Is the applicant entitled to $2,486.00 for a chronic pain assessment, proposed by Q Medical in a plan dated September 23, 2024?
vi. Is the applicant entitled to $3,919.58 for chiropractic services, proposed by Alma Rehab Inc. in a plan dated February 5, 2024?
vii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
viii. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant remains subject to the MIG.
4As the applicant is in the MIG, it is not necessary to consider if the treatment plans in dispute are reasonable and necessary. The applicant is entitled to treatment within the MIG limits.
5The applicant is not entitled to interest or an award under s. 10 of Reg 664.
ANALYSIS
The applicant remains subject to the MIG
6Section 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.”
7An 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.
8Here, the applicant argues that they should be removed from the MIG on the basis of chronic pain and a psychological impairment.
The applicant has not proven a psychological impairment
9I find the applicant has not proven a psychological impairment that would warrant removal from the MIG.
10The applicant submits a s.25 psychological assessment of Dr. S. Gabidulina, psychologist. In her report, Dr. Gabidulina diagnosed the applicant with Post Traumatic Stress Disorder and Situational Phobias, moderate.
11Dr. Gabidulina assessed the applicant via WhatsApp on June 11, 2024. She administered the Beck Depression Inventory (“BDI-II”), Beck Anxiety Inventory (BAI), Multidimensional Pain Inventory (“MPI”), and the Travel Anxiety Questionnaire (“TAQ”).
12On the BDI-II, the applicant obtained a score which indicated a moderate level of depression. On the BAI, he obtained a score which indicated a mild level of general anxiety. On the MPI, his scores indicated that his pain severity and the interference of pain within his life are lower than average. On the TAQ, he scored 2.38 on the anxiety scale and 2.5 on the avoidance scale.
13I note that Dr. Gabidulina diagnosed what she described as anxiety-based disorders, despite the applicant scoring at the mild level of anxiety on the BAI. She also did not explain how the scores on the TAQ qualify the applicant’s condition. Without an explanation, Dr. Gabidulina’s assessment does not connect the result to the diagnosis.
14The applicant’s own comments as quoted in Dr. Gabidulina’s report are, “I’m okay to drive but I’m a little scared still”. The applicant’s own statements appear to minimize or downplay the fear. They do not corroborate the diagnosis of a moderate situational phobia.
15The respondent submits that Dr. Gabidulina’s diagnosis should be afforded little weight as it is not supported by the contemporaneous clinical history with the applicant’s family physician. The respondent further notes that Dr. Gabidulina did not review the applicant’s clinical history. The respondent also submits that the diagnosis is entirely based on self-reported measures with no validity testing being conducted.
16The applicant submits, in reply, that the BAI and BDI-II have continually been used to demonstrate psychological impairment and the absence of validity measures or the fact that there are self-reports of the applicant’s condition should have no bearing on their applicability in this case. I agree with this position. However, I note that the applicant did not point to any other contemporaneous clinical observations of the applicant’s psychological impairments, despite the opportunity to do so.
17The respondent further submits that in the time following the accident the applicant was seen on multiple occasions by Dr. H. Pandhi and Dr. V. Malhotra, physicians, and Dr. K Grover, rheumatologist. In the clinical history with these clinicians, the applicant does not once reference a psychological symptom.
18I put little weight on the applicant’s evidence. The diagnosis of Dr. Gabidulina is not supported by either the contemporaneous clinical history, which she did not review, or by the psychometric testing she administered. In addition, the applicant’s own comments in the psychological assessment downplay the existence of a phobia, yet Dr. Gabidulina diagnosed one, at a moderate level.
19The applicant has not adduced any further evidence of a psychological impairment.
20Therefore, I find that the applicant has not met his burden to prove a psychological impairment that would warrant removal from the MIG.
I find the applicant has not proven chronic pain with an associated functional impairment
21I find that the applicant has not proven chronic pain with a functional impairment which would warrant removal from the MIG.
22While not incorporated into the Schedule, the Tribunal has accepted that the AMA Guides of Evaluation of Permanent Impairment, 6th Edition (“AMA Guides”), are a useful analytical took in assessing chronic pain. According to the AMA Guides, at least three of the following six criteria must be present for a diagnosis of chronic pain syndrome to be established.
i. Use of prescription drugs beyond the recommended duration and/or abuse of 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 contacts;
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 need; and
vi. Development of psychosocial sequelae after the initial incident, including anxiety, fear-avoidance, depression, or nonorganic illness behaviors.
23The applicant submits that he meets 4 of the 6 criteria of the AMA Guides, specifically, withdrawal from social milieu, excessive dependence of health care providers or family, failure to restore pre-injury function and development of psychosocial sequalae.
24The respondent submits that the applicant has not provided an evidentiary backing to support he meets 4 of 6 criteria in the AMA guides. In fact, the respondent submits that the applicant does not meet any of the criteria within the AMA guides.
25I note that the applicant has simply listed the 4 criteria he claims to meet and has not made further submissions on why he meets the criteria or adduced evidence to support how he meets the criteria.
26There have been no submissions made on the applicant’s withdrawal from social milieu. In fact, quite the opposite, it is submitted that the applicant returned to work in the days following the accident and has continued working since the accident.
27I also note that the applicant has not provided evidence to show an excessive dependence on health care providers or family. The applicant submits that he regularly attended physiotherapy, however, there have been no submissions to show an excessive dependence. The clinical history shows he has visited his family physicians, Dr. Phandi and Dr. Malhotra, less than once per month for an accident-related reason during the 18-month post-accident period that clinical records were submitted as evidence. There have been no submissions made detailing the applicant’s reliance on family.
28It is not necessary to consider the remaining two factors in the AMA Guides as I find the applicant cannot reach the three out of six criteria required.
29The applicant has not otherwise made submissions on a diagnosis of chronic pain syndrome with associated functional limitations.
30As I have found the applicant does not meet three of the six criteria of the AMA Guides, the applicant falls short of the test for chronic pain with a functional impairment.
31I therefore find on a balance of probabilities that the applicant remains subject to the MIG.
32As I have found the applicant is entitled to treatment within the MIG, an analysis on the reasonableness and necessity of the disputed treatment plans is not required.
Interest
33Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule.
34As no benefits are overdue, there is no entitlement to interest.
Award
35The 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.
36As no benefits have been withheld, there is no entitlement to an award.
ORDER
37For the reasons above, I find that:
i. The applicant remains subject to the MIG;
ii. As the applicant is in the MIG, it is not necessary to consider if the treatment plans in dispute are reasonable and necessary. The applicant is entitlement to treatment within the MIG limits; and
iii. The applicant is not entitled to interest or an award under s. 10 of Reg 664.
38This application is dismissed.
Released: March 27, 2026
Julian DiBattista
Vice-Chair