Licence Appeal Tribunal File Number: 24-014108/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:
Anthony Addo
Applicant
and
Co-operators General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Roderick Walker
APPEARANCES:
For the Applicant:
Renata Szady, Paralegal
For the Respondent:
Lisa Armstrong, Counsel
HEARD: In Writing
By Way of Written Submissions
OVERVIEW
1Anthony Addo, the applicant, was involved in an automobile accident on October 10, 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, Co-operators General Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
2The applicant was previously involved in a separate accident on December 9, 2021, approximately 10 months before. The applicant submits the injuries sustained as a result of the December 9, 2021 accident were aggravated by the October 10, 2022, accident. The respondent disputes this and submits that the applicant’s injuries from the 2021 accident have healed and are not an issue for the case at hand.
ISSUES
3The 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 limit (“MIG”)?
ii. Is the applicant entitled to $3,832.28 for Physiotherapy Services, proposed by Rouge Valley Sports and Injury Wellness in a treatment plan/OCF-18 (“plan”) dated November 2, 2022?
iii. Is the applicant entitled to $3,092.28 for Physiotherapy Services, proposed by Rouge Valley Sports and Injury Wellness in a plan dated February 2, 2023?
iv. Is the applicant entitled to $2,200.00 for a Psychological Assessment, proposed by Counselling and Psychological Services of Metropolitan Toronto in a plan dated October 10, 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
4The applicant’s injuries are predominately minor, and the applicant remains in the MIG. The applicant is not entitled to the treatment plans in dispute, interest or an award.
ANALYSIS
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. In this case, the applicant is relying on a chronic pain impairment and a pre-existing injury to be removed from the MIG.
The applicant does not suffer from a chronic pain impairment or a pre-existing injury
7I find that the applicant does not suffer from a chronic pain impairment or a pre- existing injury warranting removal from the MIG.
8The applicant relies on an OCF-3 Disability Certificate prepared by Dr. Karen Peronilla, Chiropractor, dated December 2, 2022, and the clinical notes and records (CNRs) from Rouge Valley Physio. The OCF-3 stated the injuries to the applicant as: Sprain and Strain of the thoracic spine, Sprain and Strain of the lumbar spine, Strain and Sprain of the shoulder joint, contusion of the knee and lumbar region, headaches, and disorders of initiating sleep. Dr. Peronilla also opined that the applicant is disabled from performing the essential tasks of his pre-accident employment, but that he can return to work on a modified basis. The doctor also stated in the OCF-3 that he suffers from a complete inability to carry on a normal life. Dr. Peronilla recommended medication and physiotherapy. Also, the applicant relies on the CNRs from his family doctor, Dr. T. Ying, dated from March 31, 2022, to November 21, 2024, and the disputed treatment plans for physiotherapy services.
9The respondent submits the applicant has not met his onus to prove that his injuries fall outside the MIG. It argues that the applicant’s submissions regarding the MIG are vague and fail to cite specific, objective, contemporaneous evidence demonstrating a need for removal from the MIG and his injuries are mainly minor and should remain classified under the MIG.
10The applicant submits that Dr. Ying diagnosed him with chronic lumbar strain, along with continued neck and back pain, radiating leg pain, and sleep difficulties. He argues that Dr. Ying also confirmed ongoing psychological distress, including sleep disturbance, low mood, depression and anxiety, aggravated post-accident. Dr Ying recommended physiotherapy to relieve the applicant’s pain.
11Further, the applicant argues that the pre-existing injuries sustained in the previous accident in December 2021, occurring only ten months earlier, have persisted and been aggravated by the subject accident. The applicant suggests that this is supported by clinical notes and records from Dr. Ying.
12I find that the applicant has not established removal from the MIG on the basis of pre‑existing conditions or chronic pain.
13To be removed from the MIG due to a pre‑existing condition, an applicant must do more than simply assert that such a condition existed. The applicant must provide compelling medical evidence demonstrating both the existence of a pre‑existing condition and that the condition will prevent maximal recovery from the minor injury within the MIG framework.
14The MIG clearly states that removal is permitted only in extremely limited circumstances, where compelling evidence from a health practitioner demonstrates that a pre‑existing condition documented prior to the accident will prevent the individual from achieving maximal recovery from the minor injury. This evidentiary threshold has not been met in this case.
15Although the applicant alleges pre‑existing injuries arising from a motor vehicle accident in December 2021, the evidence does not support this claim. At the time of the subject accident, the applicant was not receiving treatment for any pre‑existing complaints. Further, the OCF‑3 Disability Certificate explicitly indicates that there were no pre‑existing conditions. There is no medical documentation demonstrating that any alleged pre‑existing injuries were aggravated by the accident, nor is there evidence that such conditions would prevent recovery within the MIG limits, as required by s. 18(2).
16The applicant also submits that he suffered from chronic pain. I find that the CNR’s of Dr. Ying confirm that the applicant only attended Dr. Ying’s office once to report low back pain on August 19, 2024, almost two years after the accident, radiating down his right leg with difficulty walking and standing. Also, an Xray on August 23, 2024, indicated that the applicant had low back pain, however Dr. Ying concluded that it was the early degenerative spurring along with some vertebral bony margins with possible spina bifida occulta. I find that the evidence does not support a functional impairment as a result of accident-related pain.
17Based on the totality of the evidence, I find that the applicant has failed to establish the existence of any relevant pre‑existing condition. Moreover, there is no medical or expert opinion evidence demonstrating that any such condition whether physical was exacerbated by the accident or would prevent recovery within the MIG limits. The burden of proof rests with the applicant, and in this case, that burden has not been met.
18Accordingly, for these reasons above, I find the applicant has not met his onus and on a balance of probabilities the applicant does not suffer from a chronic pain impairment or a pre-exiting injury to warrant removal from the MIG.
The applicant does not suffer from a psychological condition.
19I find that the applicant does not suffer from a psychological condition warranting removal from the MIG.
20The applicant submits that he sustained a psychological impairment as a result of the accident such that his injuries should fall outside the MIG. After considering the totality of the evidence, I do not accept this submission. I find that the evidence does not establish the existence of a psychological impairment caused by the accident that would warrant removal from the MIG.
21The applicant relies primarily on the CNRs of his family physician, Dr. T. Ying, as well as a psychological pre‑screening report prepared by Dr. G. Fiati. Upon review, I find that this evidence does not support a finding that the applicant sustained a psychological condition arising from the accident.
22The records from Dr. Ying document complaints of low mood, irritability, sadness, anxiety, poor sleep, appetite changes, and cannabis use during visits on April 25, 2023, May 10, 2023, May 24, 2023, and March 12, 2024. However, these records consistently attribute the applicant’s symptoms to non‑accident‑related stressors, including work and financial pressures and significant life events, most notably the death of the applicant’s father and later his sister. A contemporaneous Disability Certificate further indicates that the applicant’s symptoms first arose on April 24, 2023, were not related to any motor vehicle accident, and were not the result of an accident. While Dr. Ying prescribed Citalopram 10 mg, the medical records do not link this prescription to an accident‑related psychological impairment.
23During a follow‑up visit on May 10, 2023, the applicant reported constant worry about work and finances. Again, the accident was not referenced as a contributing factor. The next documented psychological complaint was a year later, on March 12, 2024, following the recent death of the applicant’s sister. No further psychological symptoms were reported thereafter. I find that these records undermine the applicant’s position that his psychological symptoms were caused or exacerbated by the accident.
24The applicant also relies on a pre‑screening psychological assessment conducted by Dr. G. Fiati, Psychologist, on September 27, 2024, nearly two years post‑accident. Dr. Fiati provisionally identified symptoms consistent with anxiety, post‑traumatic stress, and difficulty coping with chronic pain, and recommended further psychological assessment and psychotherapy. However, this report is based entirely on the applicant’s subjective self‑reporting and did not include any psychometric testing.
25The Tribunal has consistently held that psychological pre‑screening reports, without objective testing or corroborating medical evidence, do not constitute compelling evidence of a diagnosable psychological impairment. A pre‑screening evaluation is not a diagnosis, and in this case, it stands in isolation from the contemporaneous medical records of the applicant’s treating physician. As such, I assign limited weight to Dr. Fiati’s pre‑screening report.
26While the applicant cites decisions such as Ferguson v. The Co‑operators, 2022 CanLII 106455 and Lechowski v. Waterloo Insurance Company, 2023 CanLII 58504 in support of his position, those cases involved objective medical evidence establishing psychological impairments. That is not the circumstance here. Each case must be determined on its own facts, and in this case, the evidentiary foundation required to establish a psychological impairment arising from the accident is absent.
27I am persuaded by the respondent’s submissions that the applicant’s psychological complaints were attributable to work‑related stress and personal grief rather than the motor vehicle accident. No psychological diagnosis was made by Dr. Ying in relation to the accident, no psychological assessment or testing was conducted proximate to the accident, and no psychotropic medication was prescribed on an accident‑related basis.
28The burden rests with the applicant to establish that his injuries fall outside the MIG. Based on the evidence before me, I find that the applicant has not met this burden. The evidence does not establish the existence of an accident‑related psychological impairment, nor does it demonstrate that his condition falls outside the statutory definition of “minor injury.”
29For these reasons, and on a balance of probabilities, I find that the applicant’s injuries fall within the Minor Injury Guideline.
30Since I have found that the applicant’s injuries are predominantly minor and can be treated within the MIG, it is not necessary for me to consider whether the disputed treatment plans are reasonable and necessary.
Interest
31Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. The applicant is not entitled to any interest because no benefits are payable.
Award
32Since no benefits were unreasonably withheld or delayed, the respondent is not liable to pay an award.
ORDER
33On the totality of the evidence, I order that:
i. The applicant’s injuries are predominately minor, and the applicant remains in the MIG.
ii. The applicant is not entitled to the treatment plans in dispute, interest, or an award.
iii. The application is dismissed.
Released: April 28, 2026
Roderick Walker
Adjudicator