Licence Appeal Tribunal File Number: 24-012601/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:
Ravi Gedela
Applicant
and
TD General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Aric Bhargava
APPEARANCES:
For the Applicant:
Kim Mohammed-Sieudhan, Paralegal
For the Respondent:
Katherine Dempsey, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Ravi Gedela, the applicant, was involved in an automobile accident on December 12, 2020, 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, TD 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:
i. Are the applicant’s injuries predominantly minor as defined in section 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 $2,460.00 for a chronic pain assessment, proposed by Elite Specialist Group Inc., in a treatment plan/OCF-18 (“plan”) submitted on July 13, 2023?
iii. Is the applicant entitled to interest on any overdue payment of benefits?
iv. Is the respondent liable to pay an award under section 10 of Regulation 664 because it unreasonably withheld or delayed payments to the applicant?
3The parties agree the MIG limit has not been exhausted. The amount paid to the date of the case conference is $3,420.84, leaving $79.16 of the $3,500.00 MIG limit remaining.
RESULT
4The applicant is subject to the MIG.
5As the applicant is subject to the MIG, it is not necessary to consider if the treatment plan in dispute is reasonable and necessary.
6As there are no overdue benefits, the applicant is not entitled to interest.
7The applicant is not entitled to an award under section 10 of Regulation 664 because no payments were unreasonably withheld or delayed.
ANALYSIS
Application of the Minor Injury Guideline
8I find the applicant’s injuries are predominantly minor injuries subject to treatment within the MIG limit.
9Section 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 of subluxation and includes any clinically associated sequelae to such an injury.”
10The applicant may be removed from the MIG if he can establish his accident-related injuries fall outside of the MIG or, under section 18(2), that he has a documented pre-existing condition combined with compelling medical evidence stating that the condition precludes maximal recovery if he is kept within 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.
11The applicant submits that his accident-related injuries include neck, back, leg, shoulder, and right foot pain. The applicant submits he should be removed from the MIG on the grounds of psychological impairments, and chronic pain. While the applicant’s submissions refer to maximal recovery within the MIG limit, he makes no submissions about pre-existing injuries.
12The respondent submits the applicant lacks medical evidence to support his claim and his injuries do not fall outside of the definition of a minor injury.
Does the applicant have chronic pain with functional impairment?
13I find the applicant has not established that he suffers from chronic pain with a functional impairment that warrants removal from the MIG.
14The applicant submits that he should be removed from the MIG because he suffers from chronic pain in his lower back and neck with muscle strain and headaches. The applicant relies on the section 25 orthopaedic chronic pain assessment report dated October 18, 2023, prepared by Dr. Osama Benmoftah, orthopaedic surgeon, the clinical notes and records (“CNRs”) of Physio Fix and Fitness for the period of December 7, 2020 to July 27, 2021, and the initial assessment of Prime Health Care dated July 14, 2021, prepared by Dr. Chad Hefford, chiropractor.
15Dr. Benmoftah notes the applicant meets criteria i), ii), iii), iv), and v) of the American Medical Association’s Guides to Evaluation of Permanent Impairment, 6th Edition (“AMA Guides”) for chronic pain. Dr. Benmoftah diagnosed the applicant with chronic pain disorder, sprain and strain of cervical, thoracic, lumbar spine, bilateral shoulder, hip, knee, puncture of the right first toe, sleep disorder, symptoms of depression and anxiety, and headaches.
16While I acknowledge the applicant’s range of motion testing by Dr. Benmoftah indicates he has some limited movement in his cervical, lumbar, shoulder, hip, and knee, I have not been directed to contemporaneous medical evidence that the applicant meets any of the AMA Guides criteria for chronic pain. I find Dr. Benmoftah’s report, almost three years after the accident, describes no functional limitations as a result of his ongoing pain.
17I have reviewed the CNRs of Physio Fix and Fitness for the period of December 7, 2020 to July 27, 2021, that mostly note lower back, shoulder, or neck pain. The CNRs note the applicant’s self-reported pain was mild or infrequent and improved over time in response to the ongoing treatment.
18I place less weight on Dr. Hefford’s initial examination report because it provides limited insight into the applicant’s injuries or any ongoing accident-related pain or impairment. Dr. Hefford’s initial examination report lists the applicant’s self-reported complaints, the applicant’s lumbosacral spine flexion, extension, left and right rotation. I do not find the initial examination report supportive of the applicant’s claims.
19The respondent submits the applicant has not met his onus to demonstrate he has experienced a functional limitation.
20The respondent relies on the CNRs of Dr. Ramesh Seegobin, family physician, for the period of December 2019 to April 2022. Dr. Seegobin concludes that on review of the available CNRs, the applicant did not report any accident-related injuries or problems as a result of the accident.
21The respondent further relies on the section 44 multidisciplinary report of Mr. Marco Chiodo, psychologist, and Dr. Michael Ko, physiatrist, dated March 18, 2024. The section 44 multidisciplinary report was updated with an addendum dated April 15, 2024. Both Mr. Chiodo and Dr. Ko conclude the applicant has no condition, psychological or physical, that would remove him from the MIG.
22Dr. Ko’s section 44 notes the applicant was assessed in-person and diagnosed the applicant with minor injuries and that there was no evidence of musculoskeletal pathology. Mr. Chiodo’s section 44 notes, from a psychological perspective, the applicant’s psychological symptoms are transient and there was no condition found that would remove him from the MIG. In my view, the applicant has established that he was experiencing ongoing pain as a result of the accident, however, the applicant has not met his onus to establish that he has chronic pain and a functional limitation.
23The applicant argues that Dr. Ko and Dr. Chido are not specialized in chronic pain and not qualified to provide an opinion on chronic pain. However, in my view, it is Dr. Benmoftah’s diagnosis in the section 25 report that is not consistent with the applicant’s self-reported mild or infrequent pain since the accident. Also, I assign more weight to the section 44 assessments because they are consistent with the applicant’s contemporaneous self-reporting.
24I find the applicant has not met his evidentiary onus to prove that he suffers from chronic pain with a functional impairment that warrants removal from the MIG.
Does the applicant have a psychological impairment?
25I find the applicant has not met his burden to prove that he suffers from a psychological impairment that warrants removal from the MIG.
26To establish accident-related psychological impairments, the applicant relies on the psychological pre-screen interview report conducted by Dr. Jacqueline Brunshaw, psychologist. The psychological pre-screen interview report is undated. The applicant submits Dr. Brunshaw notes ongoing pain in the jaw, upper, middle, and lower back including headache and the applicant complained of sleep disturbance, loss of appetite, a decline in his memory, nervousness as a pedestrian, and nervousness as a driver and passenger in a vehicle.
27I place less weight on Dr. Brunshaw’s pre-screening report because it is based on the applicant’s self-reporting, and there are no objective tests or diagnosis included in the report.
28Mr. Chiodo’s section 44 multidisciplinary report and addendum note the applicant was assessed in-person and his symptoms were transient, and as such, the applicant’s symptoms do not meet the threshold for a diagnosis.
29While I am alive to the applicant’s self-reported feelings as a result of the accident, I find the applicant has not established with persuasive evidence that he has a psychological impairment due to the accident.
30I find on a balance of probabilities that the applicant has not met his burden to establish that he has a psychological impairment as a result of the accident.
Are the treatment plans reasonable and necessary?
31Having found that the applicant is subject to the MIG, I do not need to consider whether the treatment plans in dispute are reasonable and necessary.
Interest
32Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no benefits are owed, no interest is payable.
Award
33The applicant sought an award under section 10 of Regulation 664. Under section 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 this threshold.
34The applicant submits the respondent unreasonably withheld payment of medical and rehabilitation benefits. However, the applicant has not directed me to evidence in support of this and no reply submissions were submitted.
35The respondent submits the applicant has not met his onus and no payments were unreasonably withheld or delayed.
36I find an award is not appropriate and no award is payable.
ORDER
37For the reasons outlined above, I find that;
i. The applicant is subject to the MIG.
ii. As the applicant is subject to the MIG, it is not necessary for me to consider if the treatment plans in dispute are reasonable and necessary.
iii. As there are no overdue benefits, no interest is owing.
iv. The respondent is not liable to pay an award.
38The application is dismissed.
Released: April 17, 2026
Aric Bhargava
Adjudicator