Piracha v. Definity Insurance Company, 2026 CanLII 34313

Citation: Piracha v. Definity Insurance Company, 2026 ONLAT 24-012257/AABS

Licence Appeal Tribunal File Number: 24-012257/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:

Wali Piracha

Applicant

and

Definity Insurance Company

Respondent

DECISION

ADJUDICATOR: Kathleen Wells

APPEARANCES:

For the Applicant: Kameliya Stancheva, Paralegal

For the Respondent: Yuliya Yarema, Counsel

HEARD: By way of written submissions

OVERVIEW

1Wali Piracha, the applicant, was involved in an automobile accident on March 19, 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, Definity 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 $2,738.73 for chiropractic services, proposed by Toronto Medical Centre, in a treatment plan/OCF-18 (“treatment plan”) submitted on May 17, 2023 and denied on May 29, 2023?
3. Is the applicant entitled to $1,748.05 for a biopsychosocial assessment, proposed by Toronto Medical Centre, in a treatment plan submitted on May 17, 2023 and denied on May 29, 2023?
4. Is the applicant entitled to $1,995.32 for a psychological assessment, proposed by Toronto Medical Centre, in a plan submitted on May 9, 2023 and denied on May 15, 2023?
5. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
6. 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 he has sustained injuries as a result of the accident that warrant his 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.

Chronic Pain

7I find that the applicant has not established that he suffers from chronic pain with functional impairment that warrants his removal from the MIG.

8The applicant submits that he has suffered from back and abdominal pain since the accident and has been treated at a chronic pain clinic for his accident-related chronic pain. He relies on the March 30, 2023 Disability Certificate (“OCF-3”) of Dr. Shadi Jahandideh, chiropractor, and the clinical notes and records (“CNRs”) of the Willim Osler Health Centre – Etobicoke Hospital Campus, and the CNRs of the Golden Mile Walk-in Clinic dated as well as the applicant’s OHIP billing records.

9The respondent argues that the applicant has not met his onus to prove that he suffers from chronic pain with functional impairment as a result of the accident, because the applicant has not provided sufficient medical evidence to support his reports of accident-related pain, or provided any evidence of functional impairment.

10While I accept that the applicant has experienced ongoing back pain, I find that the evidence does not establish that the applicant suffers from chronic pain as a result of the March 19, 2023 accident.

11In his March 30, 2023 OCF-3, Dr. Jahandideh notes that the applicant sustained injuries to his head, neck, back, and shoulders in a previous accident in 2021 which were exacerbated by the March 19, 2023 accident. The previous accident is not mentioned in the applicant’s submissions, however the CNR’s of the Golden Mile Walk-in Clinic reveal that the applicant was seen by Dr. Saber Malouka on March 14, 2023, four days before the accident, for back pain. Dr. Malouka prescribed medication and noted the applicant’s November 2021 accident, and that the applicant chronic neck and lower back pain, and had been seen by a pain specialist, which is corroborated by the applicant’s OHIP summary.

12The evidence reveals that the applicant attended the William Osler Health Centre emergency department on March 19, 2023, after the accident. He complained of pain “all over,” and was sent for CT imaging of his spine, pelvis, chest, and head. The tests revealed no acute injuries, and the spinal imaging revealed slight disk bulging in his lumbar spine. The applicant was discharged, and was not prescribed any medication.

13The applicant next saw Dr. Malouka on April 11, 2023, three weeks after the accident. Dr, Malouka noted the applicant’s recent accident and emergency department visit, and that the applicant had CT scans. While the CNR does not reflect any new pain complaints from the March 19, 2023 accident, I find it more likely than not that the applicant complained of lower back pain, because Dr. Malouka again noted the applicant’s November 2021 accident, his history of lower back pain, that he had been seen by a pain specialist and was doing physiotherapy. However, the Golden Mile Walk-in Clinic CNRs reveal no further complaints of back pain until February 8, 2025, and no further mention of the March 19, 2023 accident.

14Finally, the applicant has not made submissions or directed me to evidence with respect to the applicant’s function to support a finding that the applicant has functional impairment as a result of the accident.

15For these reasons, I find that the applicant has not met his onus to prove on a balance of probabilities that he has chronic pain with functional impairment as a result of the accident.

Psychological impairment

16I find that the applicant has not established that he has a psychological impairment that warrants his removal from the MIG.

17The applicant submits that he should be removed from the MIG because he has suffers from anxiety which requires ongoing treatment as a result of the accident.

18The respondent argues that the applicant has not met his onus to prove that he has a psychological impairment as the applicant has not provided evidence that he was seen, diagnosed or treated by a medical practitioner as a result of his accident-related injuries.

19I find that the evidence does not establish on a balance of probabilities that the applicant has a psychological impairment as a result of the accident. The CNRs of the Golden Mile Walk-in Clinic reveal no complaints of psychological symptoms, and the sole mention of anxiety in the CNRs was a notation by Dr. Tran that the applicant “appears slightly anxious” at his May 13, 2024 appointment. While the OCF-3 recommends a referral to a psychologist to “treat psychological healing barriers,” as noted above, the OCF-3 does not contain a list of the applicant’s injuries, and no psychological symptoms or referrals are mentioned in the applicant’s contemporaneous medical records. The OHIP summary indicates that the applicant attended one half-hour session of therapy on July 8, 2023, but the applicant has not directed me to evidence that the session was related to the accident.

20For these reasons, I find that the applicant has not met his onus to prove, on a balance of probabilities that he has a psychological impairment as a result of the accident that warrants his removal from the MIG.

21Accordingly, the applicant remains subject to the MIG and its $3,500.00 funding limit.

22As 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.

Interest

23Interest 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

24The 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.

25The applicant has not made any submissions with respect to an award. As such, I find that the applicant has not met his onus to prove on a balance of probabilities that the respondent unreasonably withheld or delayed the payment of benefits.

26Accordingly, the applicant is not entitled to an award.

ORDER

27I 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.