Licence Appeal Tribunal File Number: 24-002144/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:
Romeo Augustus McRae
Applicant
and
Intact Insurance Company
Respondent
DECISION
ADJUDICATOR: Amanda Marshall
APPEARANCES:
For the Applicant: Kathy Noohi, Counsel
For the Respondent: Callum Micucci, Counsel
HEARD: By way of written submissions
OVERVIEW
1Romeo Augustus McRae, the applicant was involved in an automobile accident on March 18, 2019, and sought benefits from the respondent, Intact Insurance Company, pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (“Schedule”). The applicant was denied the treatment plans in dispute because the respondent determined that his accident-related impairments fell under the Minor Injury Guideline (“MIG”). The applicant disagreed and submitted an application to the Tribunal for resolution of the dispute.
ISSUES IN DISPUTE
2The following issues are in dispute:
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 agree $2,262.81 has been paid as of the date of the case conference.
Is the applicant entitled to the treatment plan/OCF-18 (“plan”) proposed by Revive Health Centres, as follows:
i. $1,000.71 for chiropractic services plan submitted on May 8, 2023; ii. $1,000.71 for chiropractic services plan submitted on January 20, 2024; iii. $1,085.32 for chiropractic services plan submitted on October 12, 2022; iv. $1,085.32 for chiropractic services plan submitted on April 11, 2022; and v. $1,000.71 for chiropractic services plan submitted on February 6, 2023.
Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant remains in the MIG. The applicant is entitled to treatment up to the MIG limits. He is not entitled to interest or an award.
ANALYSIS
Minor Injury Guidelines
4I find that the applicant has not demonstrated on a balance of probabilities that he suffers from accident-related injuries that warrants 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 in accordance with the MIG. 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. The Tribunal has also determined that chronic pain with functional impairment or a psychological impairment warrant removal from the MIG. In all cases, the burden of proof lies with the applicant.
7The applicant argues that he should be removed from the MIG based on the following:
i. A psychological impairment as a result of the accident ii. Chronic pain as a result of the accident
8The applicant relies on the clinical notes and records (“CNRs”) of Dr. Muhammad Mahboob and Dr. Sheldon Turner, family physicians, and Revive Health Centres, including the Disability Certificate (“OCF-3”) completed by Dr. Bradley Sugar, chiropractor.
9The respondent argues the applicant’s injuries are minor, and that the applicant’s issues with depression and anxiety pre-date the subject accident. The respondent relies on the Insurer Examination (“IE”) reports of Dr. Alan Kruger, general practitioner, and the applicant’s own treating orthopaedic surgeon, Dr. Stephen Halman.
Psychological impairment
10I find that the applicant does not have a psychological impairment as a result of the accident.
11To be removed from the MIG due to psychological impairments, the applicant must show that he has a psychological impairment and not just post-accident psychological sequelae. A psychological diagnosis requires the progression of ongoing, post-accident symptomatology, or clinically significant psychological impairments.
12The applicant submits that he suffers from depression, anxiety and sleep disturbances as a result of the accident.
13The clinical notes of Dr. Mahboob reflect that the applicant had been experiencing anxiety and depression since July 2018, primarily related to family and work stressors, with the most recent notation dated February 21, 2019.
14The applicant saw Dr. Mahboob on April 5, April 22, May 10, May 17, and May 27, 2019; none of these notes mention the accident. The April 5 entry references anxiety and depression, but only in relation to pre-accident stressors. There are no further CNRs from Dr. Mahboob beyond May 27, 2019.
15Dr. Turner’s records are largely illegible and difficult to interpret. However, from what can be discerned, the applicant saw Dr. Turner on April 18, 2019, where the motor vehicle accident was noted, but no psychological symptoms were documented. Subsequent visits on April 25 and May 23, 2019, also contain no mention of psychological issues. The records extend to January 24, 2022, and contain no entries referencing a psychological condition.
16The applicant relies on Dr. Bradley Sugar’s OCF-3 dated March 19, 2019, which lists anxiety disorders (fear of cars, driving, traffic) and sleep disorders as injuries. Limited weight is given to the OCF-3, as I find that Dr. Sugar is a chiropractor, and psychological conditions fall outside his scope of practice. Also, the reference to a sleep disorder is questionable, as the applicant visited Dr. Sugar one day after the accident. While he may have had trouble sleeping, this does not meet the threshold of a sleep disorder.
17Based on the evidence before me, I find that the applicant has not established on a balance of probabilities that he suffers a psychological impairment as a result of the accident warranting removal from the MIG.
Chronic pain
18I find that the applicant has not demonstrated on a balance of probabilities that he suffers from chronic pain that warrants removal from the MIG.
19An insured may be removed from the MIG if they suffer from chronic pain as a result of the accident. However, it is not enough for the insured to have pain over an extended duration of time – it must be accompanied by functional impairment.
20The applicant argues that he suffers from chronic pain to his left shoulder, back, neck and knees as a result of the accident which hinders his ability to carry on with normal activities of daily life. To support his position, he relies on the OCF-3 of Dr. Sugar, as well as the CNRs of Dr. Turner to show that he has made consistent complaints of pain since the accident. He also submits that he received physical treatment for his injuries at Revive Health Centres.
21The respondent contends that the applicant has failed to provide compelling medical evidence to support he should be removed from the MIG based on chronic pain or that he suffers a functional impairment that impacts his daily life. The respondent submits that based on the applicant’s own medical evidence as well as the IE report of Dr. Alan Kruger, the applicant does not have chronic pain that warrants removal from the MIG.
22I find that the applicant has not established that he suffers from a chronic pain condition arising from the accident, nor that he experiences any functional impairment due to pain. This conclusion is based on the following findings.
23First, the OCF-3, completed one day after the accident, identifies several physical injuries, including neck muscle and tendon injury, cervicothoracic and lumbosacral radiculopathy, thoracic spine pain, rib and sternum sprain/strain, left shoulder injury, lower back and pelvic injury, and a left knee injury. While these diagnoses confirm acute injuries, they do not establish chronic pain or any associated functional impairment.
24Second, subsequent clinical notes from Revive Health Centres indicate the applicant attended regular treatment over several years, consisting of stretching, electrotherapy, massage, and resistance band exercises. Although occasional pain was recorded, most entries describe the treatment as maintenance, and there is no documentation of functional impairment.
25Third, similarly, the clinical notes from Dr. Turner dated February 27, April 8 and November 12, 2020 referenced by the applicant, note complaints of shoulder, neck pain, and sleep issues, but contain no discussion of any functional limitations.
26Fourth, in December 2020, the applicant was assessed by Dr. Halman, an orthopedic surgeon, regarding his shoulder. Dr. Halman concluded that the applicant has a chronic left shoulder rotator cuff deficiency. He noted that while the applicant may have experienced some neck symptoms and possibly a shoulder sprain from the accident, imaging taken shortly after the accident showed acromion remodeling, which could not have resulted from the accident. Dr. Halman opined that this is a longstanding condition, developing over years, and unrelated to the motor vehicle accident.
27Fifth, I find the IE report of Dr. Kruger, dated January 3, 2023, identifies no functional impairments. The applicant is not taking medication, manages household chores and personal care, sleeps well, and returned to modified work duties involving light tasks in March 2019. Dr. Kruger concludes that, despite ongoing subjective complaints, the injuries are minor soft tissue in nature, with full recovery anticipated.
28The medical evidence does not establish a diagnosis of chronic pain or chronic pain syndrome, nor does it demonstrate chronic pain accompanied by functional impairment. Accordingly, I find that the applicant does not meet the criteria for removal from the MIG on the basis of chronic pain.
29As I have found the applicant’s injuries to be within the MIG, he is entitled to treatment within the MIG limits. It is not necessary to determine if the treatment plans for chiropractic services are reasonable and necessary.
Interest
30Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since I have not determined that any benefits are overdue, the applicant is not entitled to interest.
Award
31The applicant also sought an award under s. 10 of O. Regulation 664. Under s. 10, the Tribunal may award up to 50% of the total benefits payable if it determines that the insurer unreasonably withheld or delayed the payment of benefits. Since no benefits were unreasonably delayed or withheld by the insurer, the applicant is not entitled to an award.
ORDER
32For the reasons above, I find that:
i. The applicant remains in the MIG and entitled to treatment up to the MIG limits. ii. The applicant is not entitled to interest or an award.
Released: January 8, 2026
Amanda Marshall
Adjudicator