Bilehjani v. Sonnet Insurance Company

Citation: Bilehjani v. Sonnet Insurance Company, 2026 ONLAT 24-010885/AABS

Licence Appeal Tribunal File Number: 24-010885/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:

Bahman Bilehjani Applicant

and

Sonnet Insurance Company Respondent

DECISION

ADJUDICATOR: Amar Mohammed

APPEARANCES:

For the Applicant: Camille Ramrattan, Paralegal

For the Respondent: Yuliya Yarema, Paralegal

HEARD: By Way of Written Submissions

OVERVIEW

1Bahman Bilehjani, the applicant, was involved in an automobile accident on November 30, 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, Sonnet 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 (“MIG”) limit?

ii. Is the applicant entitled to a non-earner benefit (“NEB”) of $185.00 per week from December 28, 2022, to December 28, 2024?

iii. Is the applicant entitled to $3,622.73 for chiropractic services proposed by Mackenzie Medical Rehabilitation Centre in a treatment plan/OCF-18 dated December 19, 2022, and denied on January 10, 2023?

iv. Is the applicant entitled to $2,200.00 for an assistive device proposed by Mackenzie Medical Rehabilitation Centre on an OCF-23 treatment confirmation form dated February 12, 2024, and denied on February 16, 2024?

v. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?

vi. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

3The applicant’s injuries are predominantly minor as defined in s. 3 of the Schedule and therefore subject to treatment within the $3,500.00 MIG limit.

4The applicant is not entitled to a non-earner benefit of $185.00 per week from December 28, 2022, to December 28, 2024.

5Since the applicant is subject to the MIG, an analysis of whether the plans in dispute are reasonable and necessary is not warranted.

6The applicant is entitled to the portion of the plan proposing $3,622.73 for chiropractic services, which was incurred during the period between January 6, 2023 and January 10, 2023, if incurred, under s. 38(11) of the Schedule.

7The respondent is not liable to pay an award under s. 10 of Reg. 664.

8The applicant is entitled to interest, if there are any overdue payments.

PROCEDURAL ISSUES

9The respondent’s request to exclude the section 25 psychological assessment report dated August 19, 2025 is denied.

10The respondent argues that the report should be excluded because it was produced for the first time with the applicant’s initial submissions dated August 20, 2025. For context, the assessment took place on August 18, 2025, the report is dated August 19, 2025, and the applicant’s submissions are dated August 20, 2025, whereas the deadline for productions was on or about April 16, 2025.

11While the respondent argues that it is prejudiced because there was not sufficient time to get a medical opinion from an assessor who could have reviewed the report, the respondent’s submissions addressing the report are detailed and grounded in medical evidence. I find that the prejudice to the applicant, if I were to exclude the report under the specific circumstances of this case, outweighs any prejudice to the respondent for these reasons.

12For the reasons above, I am not granting the respondent’s request to exclude the report.

ANALYSIS

Minor Injury Guideline

13I find that the applicant has not established his injuries warrant removal from the MIG.

14Section 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.”

15An 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.

Documented pre-existing injury or condition

16The applicant submits that his injuries warrant removal from the MIG because he has a pre-existing psychological condition from 2016.

17In support of his position, the applicant relies on a section 25 psychological assessment report by Dr. Betty Kershner, psychologist, and Owen Giddens, registered social worker. I give this report no weight because it is based on unreliable information and is counter to contemporaneous records from the family doctor. The assessment was completed over Whatsapp, on August 18, 2025, producing a report on August 19, 2025 in time for the applicant’s submissions which are dated August 20, 2025. The report does not indicate any document review. Rather, the assessors indicated that the sources of information were the clinical interview and completion of psychometric tests, all of which rely solely on the applicant’s self reporting. The report is weakened due to being completely reliant on the applicant’s self reporting. Importantly, the report acknowledges that impressions, opinions, and conclusions may change if the report is found to be inaccurate or if new information is provided and found to be relevant to the facts of the case. For the following reasons, I find that the report is either inaccurate or not supported by contemporaneous medical evidence.

18The report states that the applicant had two previous accidents, one in 2015 and another in 2018. The latter resulted in a diagnosis of adjustment disorder with mixed anxiety and depressed mood, and specific isolated phobia or automobile anxiety. The assessors indicate that the applicant had not fully recovered from the accident in 2018. However, the respondent submits, and I find that as of November 3, 2022, four weeks pre-accident, records from the Centre for Addiction and Mental Health (“CAMH”) state there is no diagnosis at that time. The legal test does not explicitly require that the applicant continues to have the pre-existing condition immediately before the accident. While the CAMH records state that he did not meet criteria for a diagnosis, had no prescribed medication, or any functional impairment just prior to the accident, the applicant had pre-existing mental health conditions documented years prior to the accident, meeting the first prong of the test.

19As previously noted, the section 25 report drafted on the eve of the submission due date is not a reliable source of information and is unsupported by contemporaneous records of the family doctor. The applicant relies on the report for the opinion that his psychological condition is a barrier to recovery psychologically, physically, and functionally, especially considering his history of psychiatric difficulties. As reviewed above, the report is not based on any document review and totally dependent on self-reporting. Since the report is weak and I assign it no weight, I have reviewed the applicant’s other evidence to assess whether there is compelling medical evidence that his pre-existing condition precludes recovery under the MIG.

20I find that the applicant’s other evidence does not support his position that his pre-existing psychological condition precludes recovery if he is kept within the MIG. The pre-accident CAMH records of November 3, 2022 indicate the applicant was encouraged to reach out to his family doctor for mood concerns and for referrals if necessary, or present himself at the emergency department if there are safety concerns. I am not referred to any records of any such visits. After the subject accident on November 30, 2022, I am not referred to any records from the family doctor relating to accident-related psychological symptoms despite production of records covering a substantial period, almost three years post-accident. The Case Conference Report and Order states that the parties identified on January 16, 2025 that $2,329.64 remained available for treatment under the MIG limit. According to the applicant’s reply submissions dated September 12, 2025, this amount had not changed. Despite having $3,500.00 available, the applicant only incurred less than $1,200.00 under the MIG over almost a three-year period post-accident and did not make any accident-related complaints to his family doctor that would warrant removal from the MIG. Considering the preponderance of the contemporaneous evidence, the applicant has not offered compelling medical evidence warranting removal from the MIG.

21Accordingly, on a balance of probabilities, I find that the applicant has not established that he has a documented pre-existing injury or condition combined with compelling medical evidence stating that the condition precludes recovery if he is kept within the confines of the MIG.

Psychological condition warranting removal from the MIG

22The applicant submits he should be removed from the MIG on the basis of a psychological condition.

23He relies on the section 25 assessors who diagnosed the applicant with post traumatic stress disorder, pain disorder with related psychological factors, adjustment disorder with mixed anxiety and depressed mood.

24For reasons previously stated, I find that the report is unreliable. Despite numerous visits, the family doctor’s records do not support the applicant’s position regarding having an accident-related psychological condition warranting removal from the MIG. As of June 2023, the applicant’s family doctor who sees the applicant on a regular basis opined that he did not seem to have anxiety or depression. I give more weight to the applicant’s family doctor’s records who has known and treated the applicant over many years and referred him to appropriate professionals in the past when necessary.

25I find on a balance of probabilities that the applicant has not established a psychological condition that warrants removal from the MIG.

Minor Physical Injury

26The applicant’s submissions refer to physical complaints such as mild-degenerative disc disease and chronic pain in the context of removal from the MIG.

27As the respondent argues, the only visit to the family doctor relating to accident-related symptoms was in February 2024 where the applicant complained of a sore back on mornings. The applicant was assessed with muscular pain, recommended physiotherapy, exercise, and a topical muscle ointment. On March 19, 2024 the applicant reported to his family doctor that his lawyers advised him there was not enough information about his back pain. This note states that the applicant underwent a physical exam showing he had full range of motion in his lower back and full lower extremity strength. This is counter to the applicant’s submissions that the applicant has limited range of motion in the lumbar spine or any physical injury beyond the scope of the MIG.

28Accordingly, on a balance of probabilities, I find that the applicant has not established his injuries warrant removal from the MIG.

Non-Earner Benefit

29I find that the applicant is not entitled to a non-earner benefit of $185.00 per week from December 28, 2022, to December 28, 2024.

30Section 12(1) provides that an insurer shall pay an NEB to an insured person who sustains an impairment as a result of the accident, if the insured person suffers a complete inability to carry on a normal life as a result of and within 104 weeks after the accident. Section 3(7)(a) defines a “complete inability to carry on a normal life” as “an impairment that continuously prevents the person from engaging in substantially all of the activities in which the person ordinarily engaged before the accident.” The Court of Appeal set out the guiding principles for NEB entitlement in Heath v. Economical Mut. Ins. Co., 2009 ONCA 391 (“Heath”), which, generally, focuses on a comparison of the applicant’s pre- and post-accident activities.

31The applicant argues that he is entitled to a NEB because, despite incorporating a business a month after the accident, in December 2022, the applicant stopped working completely. The applicant submits that he earned $9,670.00 in 2021 and $7,150.00 in 2022, but that he should be eligible for a NEB and not an income replacement benefit.

32I am not persuaded that stopping work as described by the applicant satisfies the test in Heath, even if the work stoppage is established. Further, I agree with the respondent that the applicant has minor injuries as a result of the accident, and he has offered no evidence or comparison of his life before and after the accident to establish NEB entitlement. Further, that the applicant did not indicate any activities that he performed before the accident that he can no longer do after the accident. He offers no reliable, compelling or contemporaneous evidence regarding his abilities, or which activities held more value than others as per the test set out in Heath.

33For the reasons above, on a balance of probabilities, I find that the applicant is not entitled to a non-earner benefit of $185.00 per week from December 28, 2022, to December 28, 2024.

34Since the applicant is subject to the MIG, an analysis of whether the plans in dispute are reasonable and necessary is not warranted.

$3,622.73 for chiropractic services

35The applicant also makes arguments under s. 38(8) of the Schedule. I find that the applicant is entitled to the portion of the plan proposing $3,622.73 for chiropractic services, which was incurred during the period between January 6, 2023 and January 10, 2023, if incurred, under s. 38(11) of the Schedule.

36Section 38(8) requires an insurer to inform an insured person, within 10 business days after it receives the treatment plan, of the medical and other reasons why it considered the goods and services not to be reasonable and necessary if it denies a plan. Pursuant to s. 38(11), if an insurer fails to comply with its obligations under section 38(8), it must pay for the goods and services that relate to the period starting on the 11th business day after the insurer received the application and ending on the day the insurer gives a notice described in s. 38(8) and it is prohibited from taking the position that the insured person has a impairment to which the MIG applies.

37The applicant argues that a treatment plan for chiropractic services was submitted on December 19, 2022 and denied on January 10, 2023. The applicant submits this is 22 days later, rather than within 10 days as required by the Schedule. However, the Schedule counts business days whereas the applicant is counting calendar days. Still, I find the denial was provided late, being 14 business days after the accident.

38The applicant argues he is entitled to the incurred amount during the period prior to receiving the denial. The applicant has not referred to evidence to establish incurred amounts. According to the Schedule, the respondent is liable to pay for the incurred goods and services starting on the 11th business day and ending on the 13th business day. The plan submitted sought $3,622.73, to which the applicant is entitled, to the extent of the amount incurred starting on the 11th business day after submissions of the plan, and the 13th business day on which the denial notice was produced.

39Accordingly, on a balance of probabilities, I find that the applicant is entitled to the portion of the plan proposing $3,622.73 for chiropractic services, which was incurred during the period between January 6, 2023 and January 10, 2023, if incurred, under s. 38(11) of the Schedule.

Interest

40The applicant is entitled to interest if there are any overdue benefits. Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule.

Award

41The 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.

42I have determined that the applicant is entitled to the portion of the plan proposing $3,622.73 for chiropractic services, which was incurred during the period between January 6, 2023 and January 10, 2023, if incurred, under s. 38(11) of the Schedule. However, as noted earlier in this decision, the applicant did not lead evidence before me as to whether or not any portion of this plan was incurred. Accordingly, he has not established that the respondent withheld or delayed the payment of this benefit, or that such withholding or delay was unreasonable.

ORDER

43For the reasons above, I make the following orders:

i. The applicant’s injuries are predominantly minor as defined in s. 3 of the Schedule and therefore subject to treatment within the $3,500.00 MIG limit.

ii. The applicant is not entitled to a non-earner benefit of $185.00 per week from December 28, 2022, to December 28, 2024.

iii. Since the applicant is subject to the MIG, an analysis of whether the plans in dispute are reasonable and necessary is not warranted.

iv. The applicant is entitled to the portion of the plan proposing $3,622.73 for chiropractic services, which was incurred during the period between January 6, 2023 and January 10, 2023, if incurred, under s. 38(11) of the Schedule.

v. The respondent is not liable to pay an award under s. 10 of Reg. 664.

vi. The applicant is entitled to interest, if there are any overdue payments.