Citation: Saulter v. Intact Insurance Company, 2026 ONLAT 24-013919/AABS

Licence Appeal Tribunal File Number: 24-013919/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:

Chantel Saulter

Applicant

and

Intact Insurance Company

Respondent

DECISION

VICE-CHAIR: Amanda Marshall

APPEARANCES:

For the Applicant: Julia Logoutova, Paralegal

For the Respondent: Mark Esteireiro, Paralegal

HEARD: By way of written submissions

OVERVIEW

1Chantel Saulter, the applicant, was involved in an automobile accident on August 7, 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, Intact Insurance Company, because the respondent determined that her accident-related impairments fell under the Minor Injury Guideline (“MIG”). The applicant disagreed 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 MIG limit?
2. Is the applicant entitled to $3,997.40 for Physiotherapy treatment, proposed by Aqua Wellness in a treatment plan/OCF-18 (“plan”) dated January 25, 2024?
3. Is the applicant entitled to $3,862.40 for Physiotherapy treatment, proposed by Aqua Wellness in a plan dated January 24, 2024?
4. Is the applicant entitled to $3,817.40 for Physiotherapy treatment, proposed by 2430307 Ontario Ltd. in a plan dated January 23, 2024?
5. Is the applicant entitled to $3,547.40 for Physiotherapy treatment, proposed by Aqua Wellness. in a plan dated November 8, 2024?
6. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

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

4As the applicant remains in the MIG, it is not necessary to determine if the treatment plans are reasonable and necessary.

5The applicant is not entitled to the physiotherapy treatment plans in the amounts of $3,997.40, $3,862.40, and $3,817.40 as a result of a defective notice under s. 38(8).

6The applicant is entitled to any incurred amount of the $3,547.40 treatment plan for a period of 120 days as the denial notice was found to be defective under s. 38(8).

7No interest is payable on the treatment plans in the amounts of $3,997.40, $3,862.40 and $3,817.40.

8Interest is payable on any incurred amount of the $3,547.40 physiotherapy treatment plan for a period of 120 days.

ANALYSIS

Applicability of the Minor Injury Guideline

9I find that the applicant has not demonstrated on a balance of probabilities that she suffers from accident-related injuries that warrant removal from the MIG.

10Section 18(1) of the Schedule sets out that medical and rehabilitation benefits are capped at $3,500.00 if the insured person 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.”

11In order to be removed from the MIG, an insured person must 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 supported by compelling medical evidence stating that the condition precludes recovery if they are kept within the MIG limits. The Tribunal has also determined that concussion or concussion syndrome, chronic pain with functional impairment, or a psychological condition may be grounds for removal from the MIG. In all cases, the burden of proof lies with the applicant.

12The applicant submitted clinical notes and records (“CNRs”) from her family physician, Dr. Afshan Azam, and from her treating physiatrist, Dr. Mark Mason. Her submissions briefly reference pre‑accident back pain and note complaints of back and neck pain following the accident. However, the applicant has not explained the grounds on which she seeks removal from MIG. She has not provided a summary of her accident-related impairments nor made submissions that a pre‑existing condition prevents maximal recovery if kept within the MIG. In addition, the applicant does not claim to suffer from chronic pain or from a psychological condition resulting in functional impairment that would warrant removal from the MIG. Although she appears to assert that she continues to experience pain, she does not allege that the pain is chronic and has not identified evidence supporting a finding of chronic pain.

13As a result, I find that the applicant has not satisfied her burden of proving on a balance of probabilities that her accident-related impairments warrant removal from the MIG limit.

14As I have found that the applicant’s accident-related impairments do not warrant treatment beyond the MIG limits, it is not necessary for me to address the reasonableness and necessity of the treatment plans in dispute. In any event, the applicant’s submissions do not address whether the treatment plans in dispute are reasonable and necessary. Instead, she contends the denial notices issued by the respondent do not comply with the requirements of s. 38(8) and/or s. 44(5) of the Schedule.

15The respondent maintains that the applicant is not entitled to the treatment plans in dispute on the basis that they are not reasonable and necessary. Also, the respondent contends the denials were compliant with s. 38(8) and s. 44(5).

16Under s. 38(8), an insurer has the obligation to, within 10 business days after it receives a treatment plan, provide an insured person with a notice identifying the medical and all other reasons why the insurer finds the treatment plan not to be reasonable and necessary. There should be clear and sufficient information for an unsophisticated person to make an informed decision to either accept or dispute the denial.

17If the insurer fails to give a notice in accordance with s. 38(8) in connection with a treatment and assessment plan, the following, found in s. 38(11) apply: (a) the insurer is prohibited from taking the position that the insured person has an impairment to which the MIG applies; and (b) the insurer must pay for all goods, services, assessments and examinations described in the treatment plan that relate to the period starting on the 11th business day after the day the insurer received the application and ending on the day the insurer gives notice as described in subsection (8).

18Additionally, under sections 38(10) and 44(1), an insurer may notify an insured person that they are required to be examined by a regulated health professional. Section 44(5) requires an insurer to provide a Notice of Examination (“NOE”) which sets out “the medical and any other reasons for the examination.” The medical and any other reason should be clear and sufficient enough to allow an unsophisticated person to make an informed decision to either accept or dispute the insurer’s request to attend the assessment.

Physiotherapy Treatment in the amount of $3,997.40

19I find that the respondent’s denial letters comply with sections 38(8) and 44(5) of the Schedule. Accordingly, the treatment plan is not payable.

20The applicant submitted a treatment plan seeking $3,997.40 for physiotherapy services. The respondent denied the plan on December 22, 2023, and arranged for the applicant to attend at an Insurer’s Examination (“IE”). Following the applicant’s attendance, the respondent issued a further denial letter dated February 5, 2024.

21The applicant submits that the respondent failed to explain how the injuries listed in the treatment plan fell within MIG and did not address the proposed services in full in the December 22, 2023 denial letter.

22While the applicant has suggested that the respondent did not describe the applicant’s injuries, I note that the respondent is not required to list or describe the applicant’s injuries, as suggested. Rather, the respondent must provide sufficient medical and other reasons to allow an unsophisticated person to decide whether to dispute the determination.

23The December 22, 2023 denial letter states that, based on the documentation provided, the applicant’s accident‑related injuries appeared to be soft‑tissue in nature and that no compelling medical evidence had been submitted to support treatment outside the MIG. The letter further explains that, as a result, the respondent was unable to determine whether the proposed treatment was reasonable and necessary and that an IE was required to assess the need for further treatment.

24I find that this notice satisfies the requirements. The respondent advised the applicant of the requirement to attend an IE and provided the physician’s name, specialty, date, time, location, and the reason for the assessment.

25The February 5, 2024 denial letter referenced the treatment plan in dispute, identified the type of treatment sought, set out the reasons for the denial, and included a copy of the IE report. I find that this letter complies with section 38(8) of the Schedule.

26The applicant has not established entitlement to the treatment plan on the basis of an improper notice.

Physiotherapy Treatment in the amount of $3,862.40

27I find that the respondent’s denial letter complies with sections 38(8) and 44(5) of the Schedule. Accordingly, the treatment plan is not payable.

28The applicant submitted a treatment plan seeking $3,862.40 for physiotherapy services. The respondent denied the plan on February 5, 2024, and advised that an IE was necessary. After the paper review IE, the respondent provided a follow-up denial letter on March 14, 2024.

29The applicant submits that the respondent failed to advise her that it was refusing to pay for the proposed treatment, did not describe the services sought, and that the NOE provided no additional information.

30I do not accept this submission. The February 5, 2024 correspondence clearly informed the applicant that funding for the proposed plan was denied for medical and other reasons as it included the amount of the treatment plan and described the nature of the services being sought. With respect to the NOE, the letter indicates the applicant is not required to attend as a paper review will be conducted. It provides the doctor’s name, speciality, and date of the review along with reasons for the paper review.

31The March 14, 2024 letter discusses the outcome of the IE, outlines the amount of the treatment that was being sought and the breakdown of the type of treatment. It also provided medical and other reasons why the respondent was denying the treatment plan. It explained that Dr. Charanjit Sandhu, general practitioner, found that the applicant’s presentation was consistent with residual symptoms from myofascial sprains to her cervical spine, shoulders, and lumbar spine. The doctor found that additional facility-based treatment was not warranted and that the applicant’s focus for rehabilitation should be through an independent exercise program. A copy of the IE report was included with the letter.

32I find the denial letters are compliant as the applicant provided medical and other reasons for the denial. The applicant has not established entitlement to the treatment plan on the basis of an improper notice.

Physiotherapy Treatment in the amount of $3,817.40

33I find that the respondent’s denial letter complies with s. 38(8) and 44(5) of the Schedule. Therefore, the treatment plan is not payable.

34The applicant submitted a treatment plan seeking $3,817.40 for physiotherapy services. The respondent denied the plan on April 24, 2024, and advised that a paper review IE was necessary. Once the IE was completed, the respondent sent a further denial letter on May 31, 2024.

35The applicant submits that the respondent offered the essentially the same explanation for the treatment plan for $3,817.40 as it did for the treatment plan in the amount of $3,862.40.

36Upon review, I find the denial letter described the treatment sought and clearly advised that funding would not be provided because based on Dr. Sandhu’s January 25, 2024 report the doctor found that the applicant injuries fall within the MIG as they were consistent with myofascial sprains to her cervical spine, shoulders, and lumbar spine. The doctor recommended an independent exercise program. The letter also explained that a paper review would be conducted, and included the reviewing physician’s name, specialty, and the review date.

37In its May 31, 2024, correspondence, the respondent confirmed, after receiving the IE paper review report from Dr. Sandhu, that it would not fund the treatment plan. The letter set out the services at issue and provided reasons for the denial which mirror the reasons it provided initially, that being that the applicant’s symptoms are consistent with myofascial sprains and that rehabilitation efforts should include an independent exercise program.

38I find the denial letters are compliant. The applicant has not established entitlement to the treatment plan on the basis of an improper notice.

Physiotherapy treatment in the amount of $3,547.40

39I find that the respondent’s denial does not comply with s. 38(8) of the Schedule, as the respondent failed to properly notify the applicant of its position within 10 business days of receiving the treatment plan.

40The treatment plan for physiotherapy services in the amount of $3,547.40 was submitted to the respondent on November 8, 2024. The respondent asserts that it denied the plan on November 28, 2024 and, pursuant to s. 33, requested additional information from the applicant’s treating practitioners to assess entitlement.

41I find that the information contained within the denial letter was complaint with s. 38(8) as it outlined the amount of the treatment plan, the type of treatment being sought, that the applicant was found to be within the MIG, and that more evidence was needed for review to determine if the applicant should be removed from the MIG. The letter asked for clinical notes and records from the applicant’s family doctor and other treatment providers from August 7, 2023. However, the respondent did not meet the 10-day response deadline.

42The applicant submits that she did not receive the November 28, 2024 denial letter and therefore was not properly notified of the respondent’s denial. As a result, she submits that the treatment plan is payable.

43The respondent submits that the denial letter was mailed to the applicant on November 28, 2024, with a copy sent to the applicant’s legal representative. The respondent further submits that it served a complete copy of the accident benefits file, including the denial letter, on March 25, 2025.

44I note that the applicant’s address is consistent across the treatment plans and that the denial letter states a copy was provided to the applicant’s legal representative. However, the respondent did not provide proof of service, such as a fax confirmation, email, or other evidence demonstrating that the denial letter was delivered on November 28, 2024. I am therefore unable to find that the applicant was properly notified on that date. The respondent confirmed that the applicant received a complete copy of the accident benefits file on March 25, 2025, which included the denial letter, and provided email correspondence confirming service on the applicant’s legal representative on that date. Accordingly, I find that proper notice was provided on March 25, 2025.

45I find that the denial letter was defective pursuant to s. 38(8) because the respondent did not reply within 10 days of receiving the treatment plan. However, I find that the applicant was properly notified of the denial on March 25, 2025, and that the denial letter contained the required medical and other reasons. As I find that the respondent was late in its response, pursuant to s. 38(11) of the Schedule, the respondent is required to pay for treatment expenses incurred from November 25, 2024, the 11th business day following submission of the treatment plan, to March 24, 2025, inclusive, a period of 120 days.

Interest

46Pursuant to s. 51 of the Schedule, interest is payable on any overdue benefits. As I have found that the respondent must pay the incurred physiotherapy treatment relating to the treatment plan in the amount of $3,547.40 for a period of 120 days, the respondent is also required to pay interest on that amount in accordance with s. 51. The applicant is not entitled to interest on the remaining physiotherapy treatment plans as I have found the applicant remains within the MIG and the treatment plans are not payable.

ORDER

47For the above reasons, I find:

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

ii. As the applicant remains in the MIG, it is not necessary to determine if the treatment plans are reasonable and necessary.

iii. The applicant is not entitled to the physiotherapy treatment plans in the amounts of $3,997.40, $3,862.40, and $3,817.40 in dispute as a result of a defective notice under s. 38(8).

iv. The applicant is entitled to any incurred amount of the $3,547.40 treatment plan for a period of 120 days as the denial notice was found to be defective under s. 38(8).

v. No interest is payable on the treatment plans in the amounts of $3,997.40, $3,862.40 and $3,817.40.

vi. Interest is payable on any incurred amount of the $3,547.40 physiotherapy treatment plan for a period of 120 days.