Licence Appeal Tribunal
Licence Appeal Tribunal File Number: 24-013287/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:
Yi Sing Lam
Applicant
and
Co-operators General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Jeff Chatterton
APPEARANCES:
For the Applicant:
Rakesh Sharma, Counsel
For the Respondent:
Simran Walia, Counsel
HEARD: In Writing
OVERVIEW
1Yi Sing Lam, the applicant, was involved in an automobile accident on November 18, 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, Co-operators 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:
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?
Is the applicant entitled to $102.47 ($1,300.00 less $1,197.53 approved) for physiotherapy services, proposed by Total Recovery Rehab Centre in a treatment plan/OCF-18 (“plan”) submitted January 23, 2024 and partially denied January 24, 2024?
Is the applicant entitled to $4,383.90 for chiropractic services, proposed by Total Recovery Rehab Centre in a plan submitted March 25, 2024 and denied April 3, 2024?
Is the applicant entitled to $2,144.93 for a psychological assessment, proposed by Somatic Assessments and Treatment Clinic in a plan submitted May 1, 2024 and denied May 2, 2024?
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 is being held to the MIG, and the $3,500 treatment limit.
4The applicant is not entitled to the individual treatment plans due to a procedural violation by the insurer.
5As the applicant is held to the MIG, it is not necessary to determine if the treatment plans are reasonable and necessary.
6Neither interest nor an award are payable.
ANALYSIS
Is the applicant removed from the Minor Injury Guideline and the $3,500 treatment limit?
7The applicant is held to the MIG.
8Section 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.”
9An 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.
10The applicant has chosen not to make submissions “on the applicability of MIG, but will dispute applicability of the MIG with respect to the denied substantive issues.”
11The onus is on the applicant to prove he should be removed from the MIG. Without any specific submissions on which ground he seeks removal and as I have not been directed to medical evidence supporting the applicant having a non-minor injury, I find he has not, on the balance of probabilities, established that he should be removed from the MIG.
12As I have found the applicant to be held within the MIG, it is not necessary for me to consider whether the treatment plans in dispute are reasonable and necessary.
Is the applicant entitled to the issues in dispute on procedural grounds?
13The applicant states, in paragraph 3 of his submissions, that “a trial by written hearing is limited to the applicant’s onus to prove on the balance of probabilities that the reasons provided by the respondent in section 54 statutory denial notices were flawed.”
14Although his submissions are unclear, the applicant states that the denials offered by the insurer in denying the issues in dispute are insufficient. The applicant appears to argue that the medical professionals submitting the OCF-18s in dispute have ticked the box indicating that the injuries suffered were non-minor injuries, and therefore not subject to the MIG.
15The applicant further argues that the denial reasons are “frivolous, flawed, arbitrary, statutory deficient or no reasons at all.”
16The respondent argues that the applicant has misstated the law in his written submissions, and that the onus is on the applicant to prove entitlement to benefits. The respondent notes that the applicant’s submission that the onus is on the Insurer to disprove entitlement is clearly wrong.
17I have examined the denial letters for the issues in dispute. I find the letters to be compliant with s. 38(8) of the Schedule.
18Section 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.
19The respondent sent three letters, dated January 24, 2024, April 3, 2024, and May 2, 2024, clearly outlining the treatment plan in dispute, the treatment provider, the amount that the insurer was willing to fund, and the medical reasons and other reasons for the denial.
20In the January 24 letter, the respondent agreed to pay for the treatment plan with the exception of $102.94, stating “It is our understanding that you have been attending this clinic since the subject motor vehicle accident receiving medical and rehabilitation treatment. We fail to understand why a reassessment is required.” I find this letter complies with the Schedule because they have clearly identified the treatment plan in question, the provider, what they agree to pay for, and the medical reason as to why they would not pay for treatment. I find questioning the need for a reassessment is a valid medical reason.
21In the letter of April 3, 2024 the insurer identifies the treatment plan and provider, and refers to the MIG as the primary reason for the denial. The April 3 letter also requested a variety of medical records, such as Clinical Notes and Records from the primary care physician, and a decoded OHIP summary from November 2018 to present. The respondent submits the applicant has not submitted the requested information. It is longstanding practice, which I agree with, that stating the applicant remains in the MIG is a valid medical reason. The MIG defines the injuries that fall within it, and therefore, this is a legitimate medical reason.
22The May 2, 2024 letter again denied paying for benefits, and reminded the applicant they were still awaiting requested medical information. Again, the respondent provided what I find to be valid medical reasons for denying the benefits, in that they refer to the MIG and the lack of supportive medical evidence.
23In sum, having reviewed the Explanation of Benefit Letters I find that they are compliant with s.38(8) of the Schedule.
24The applicant dedicates considerable space in his submissions to pointing out why the respondent’s decisions were incorrect, and that the treatment plans are reasonable and necessary. However, there is no need for me to review the treatment plans to determine whether they are reasonable and necessary because the applicant is being held to the MIG.
25The applicant appears to submit that the respondent is mistaken about the nature of the injuries sustained. However, even if the respondent had made a mistake of fact when they denied benefits, such a mistake by the insurer would not render a notice non-compliant.
26Finally, even if the notices were not compliant with 38(8), this does not remove an applicant from the MIG, but rather that the treatment plan in dispute is payable under s. 38(11) (see: Zheng, Cai v. Aviva Insurance Company of Canada, 2018 ONSC 5707).
27For these reasons, I find that the treatment plans in dispute are not payable for being non-compliant with s. 38 of the Schedule.
Interest
28Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no benefits are overdue, no interest is payable.
Award
29The 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. As no treatments are unreasonably withheld or delayed, no award is payable.
ORDER
30The application is dismissed.
i. The applicant is being held to the MIG, and the $3,500 treatment limit.
ii. The applicant is not entitled to the individual treatment plans due to a procedural violation by the insurer.
iii. As the applicant is held to the MIG, it is not necessary to analyze the treatment plans to determine if they are reasonable and necessary.
iv. Neither interest nor an award are payable.
Released: April 17, 2026
Jeff Chatterton
Adjudicator