[HAH] v. Co-operators General Insurance Company, 2026 CanLII 31464

Citation: [HAH] v. Co-operators General Insurance Company, 2026 ONLAT 24-010418/AABS

Licence Appeal Tribunal File Number: 24-010418/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:

[HAH] (A minor by their litigation guardian, [HAH])

Applicant

and

Co-operators General Insurance Company

Respondent

DECISION

ADJUDICATOR: Kathleen Wells

APPEARANCES:

For the Applicant: Mobina Khan, Counsel

For the Respondent: Julianne Brimfield, Counsel

HEARD: By way of written submissions

OVERVIEW

1[HAH], the applicant, was involved in an automobile accident on July 28, 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, Co-operators General 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:

1. 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?
2. Is the applicant entitled to $2,216.00 for chiropractic services, proposed by Jamal Alaloul in a treatment plan/OCF-18 (“treatment plan”) submitted September 13, 2022?
3. Is the applicant entitled to $1,250.00 for chiropractic services, proposed by Jamal Alaloul in a treatment plan submitted May 25, 2023?
4. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
5. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

3I find that:

1. The applicant is subject to the MIG and its $3,500.00 funding limit.
2. As I have found that the applicant is subject to the MIG, it is not necessary for me to consider whether the treatment plans are reasonable and necessary.
3. As no payments are owing, no interest is due.
4. The applicant is not entitled to an award.
5. The application is dismissed.

ANALYSIS

Applicability of the MIG

4I find that the applicant has not established on a balance of probabilities that she has sustained injuries as a result of the June 28, 2022 accident, that warrant her removal from the MIG.

5Section 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.”

6An 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.

Physical Injuries

7I find that the applicant has not established that she has physical injuries as a result of the accident that warrant her removal from the MIG.

8The applicant submits that she should be removed from the MIG because she sustained a concussion as a result of the accident. She relies on the September 13, 2022 OCF-18 of Dr. Jamal Alaloul, chiropractor, which identifies concussion and headaches among the list of the applicant’s accident-related injuries.

9The respondent argues that the applicant has not met her onus to prove on a balance of probabilities that she sustained an accident-related injury that would remove her from the MIG.

10I find that the evidence does not establish on a balance of probabilities that the applicant sustained a concussion as a result of the accident, which places her outside of the MIG. While the September 13, 2022 treatment plan identities a concussion in addition to soft tissue injuries and psychological symptoms as the applicant’s accident-related injuries, Dr. Alaloul is a chiropractor, and concussion diagnoses are outside his scope of practice. The applicant has not directed me to any other evidence to corroborate that she was diagnosed with, or treated for, a concussion.

11As a result, I find that the applicant has not met her onus to prove that she sustained physical injuries that warrant her removal from the MIG.

Psychological Impairment

12I find that the applicant has not established on a balance of probabilities that she suffered a psychological impairment as a result of the accident that warrants her removal from the MIG.

13The applicant submits that she should be removed from the MIG because she is experiencing symptoms of anxiety and sleep disturbances since the accident. She relies on Dr. Alaloul’s September 13, 2022 treatment plan, which identified anxiety disorder and sleeping problems among the applicant’s accident-related injuries. The applicant further relies on the clinical notes and records (“CNRs”) of [a doctor], which included reports from Dr. Asim Salim, pediatrician.

14The respondent submits that the applicant has not met her onus to prove that she suffered a psychological impairment as a result of the accident, as the applicant has not submitted evidence that corroborates the applicant’s submissions.

15I find that the evidence does not establish on a balance of probabilities that the applicant suffered a psychological impairment as a result of the accident. I place little weight on Dr. Alaloul’s September 13, 2022 treatment plan because Dr. Alaloul is a chiropractor, and psychological diagnoses are outside his scope of practice.

16The evidence reveals a sole mention of accident-related psychological symptoms in the CNRs of the applicant’s treating physicians. In the applicant’s November 17, 2023 autism assessment, her mother told Dr. Salim that the applicant did not want to travel by car at night since the accident. Dr. Salim noted that the applicant’s symptoms of autism began when she was 2 ½ - 3 years old, which predated the accident. He referred the applicant for a comprehensive autism assessment. Dr. Salim noted accident- related “post-traumatic symptoms” in his report to [a doctor], but did not recommend the applicant for psychological assessment or treatment. Further, he applicant did not direct me to evidence that a subsequent comprehensive autism assessment took place.

17In his report to [a doctor], after the applicant’s follow-up appointment with Dr. Salim on February 2, 2025, more than a year after her previous visit, Dr, Salim noted psychological symptoms, and opined that the applicant may be suffering from adjustment disorder. He attributed her symptoms including recent incontinence and behavioural issues to anxiety from a house fire and “significant changes to her home environment” due the applicant’s recent move to a new city, and recommended play therapy. There was no mention of the accident or fear of travelling by car in Dr. Salim’s February 2, 2025 report.

18As the applicant has not directed me to any other evidence to suggest that she experienced accident-related psychological symptoms. I find that the applicant has not met her onus to prove on a balance of probabilities that she suffered a psychological impairment as a result of the accident that warrants her removal from the MIG.

19Accordingly, the applicant remains subject to the MIG and its $3500.00 spending limit.

20As I have found that 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.

Interest

21Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no payments are owing, no interest is due.

Award

22The 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. The Tribunal has determined that an award is justified where the delay or withholding of benefits by the insurer is unreasonable conduct, meaning “behaviour which is excessive, imprudent, stubborn, inflexible, unyielding or immoderate.” The onus is on the applicant to prove, on a balance of probabilities, that the respondent’s conduct meets these criteria.

23The applicant submits that she is entitled to an award because the applicant did not approve the treatment plans in dispute. As no benefits were withheld or overdue, and as the applicant did not direct me to evidence that the respondent’s conduct rose to the level of excessive, imprudent, stubborn, inflexible, unyielding or immoderate, I find that the applicant has not met her onus to prove that she is entitled to an award.

ORDER

24I find that:

1. The applicant is subject to the MIG and its $3,500.00 funding limit.
2. As I have found that the applicant is subject to the MIG, it is not necessary for me to consider whether the treatment plans are reasonable and necessary.
3. As no payments are owing, no interest is due.
4. The applicant is not entitled to an award.
5. The application is dismissed.