Citation: Surla v. Certas Home and Auto Insurance Company, 2026 ONLAT 24-014409/AABS

Licence Appeal Tribunal File Number: 24-014409/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:

Amy Surla

Applicant

and

Certas Home and Auto Insurance Company

Respondent

DECISION

ADJUDICATOR:

Roderick Walker

APPEARANCES:

For the Applicant:

Justin N Walter, Paralegal

For the Respondent:

Melanie Sousa, Counsel

HEARD:

By Way of Written Submissions

OVERVIEW

1Amy Surla, the applicant, was involved in an automobile accident on June 4, 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, Certas Home and Auto Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

ISSUES

1The 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 $1,130.95 for chiropractic services, proposed by WIN altra Health Performance Centre in a treatment plan/OCF-18 dated November 7, 2022?

iii. Is the applicant entitled to $2,598.44 for a psychological assessment proposed by Kaplan & Levitt Psychologists in a treatment plan/OCF-18 dated, April 16, 2025?

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

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

RESULT

2The applicant’s injuries are predominantly minor and are subject to treatment within the MIG.

3No treatment plans are payable.

4No award or interest is granted.

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 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 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.

7The applicant in this case submits that she should be removed from the MIG on the basis of a chronic pain impairment and a psychological condition.

The applicant does not suffer from a Chronic Pain Impairment

8I find that the applicant does not suffer from a chronic pain impairment which would remove her from the MIG.

9The applicant relies on the clinical notes and records (CNRs) of Niagara Health dated June 4, 2022, the CNRs of the family doctor, Dr. D. Dec, dated from June 2022 till January 7, 2025, the Disability Certificate (OCF-3) dated June 9, 2022, prepared by Dr. Slowinsky, Chiropractor, and the disputed plan completed by WIN altra Health Performance Centre for Chiropractic services.

10I find that the applicant has not established that she suffers from a chronic pain impairment that would remove her from the MIG.

11The respondent submits that the applicant does not have a chronic pain impairment and has failed to meet her burden of proof to establish entitlement to medical and rehabilitation benefits beyond the MIG limits. I agree.

12The applicant does not dispute that the physical injuries initially sustained in the accident meet the definition of minor injuries under the Schedule. These injuries consisted of soft tissue sprains and strains affecting the wrists, hands, lumbar spine, neck, shoulders, and ankle, as well as reported pain in the knees.

13The issue for determination is whether the applicant subsequently developed a chronic pain impairment arising from sprains and strains affecting the wrists, hands, lumbar spine, neck, shoulders, and ankle and knees to remove her from the MIG.

14The medical evidence does not support such a finding. The June 4, 2022 records indicate that imaging revealed no fractures, normal anatomical alignment, and no neurological concerns. There was no loss of consciousness or amnesia. The treatment recommended at that time was conservative in nature, including ice, muscle rubs, over‑the‑counter medication, and other supportive measures.

15Of significance is the absence of contemporaneous accident‑related clinical entries for a lengthy period between June 2022 and October 25, 2024. This gap of over two years weakens the applicant’s position that she developed a chronic pain condition arising from the accident.

16Although Dr. Dec noted on October 25, 2024 that the applicant’s pain had become “chronic in nature,” I do not accept that this constitutes a diagnosis of a chronic pain impairment. Dr. Dec did not diagnose a chronic pain disorder, nor did he identify any functional limitations or disability resulting from pain. His entry continues to reference ongoing soft tissue injuries rather than a distinct or qualifying chronic pain condition.

17Further, there is no evidence before me that the applicant sought additional medical treatment for her accident‑related injuries after October 2024. The record does not establish ongoing impairment or functional restriction attributable to chronic pain because of the June 4, 2022 CNR’s of Niagara Heath indicate that imaging revealed no fractures, normal anatomical alignment, and no neurological concerns. The treatment recommended at that time was conservative in nature, including ice, muscle rubs, over‑the‑counter medication, and other supportive measures.

18While I acknowledge the applicant’s desire to achieve a full recovery, the medical evidence does not demonstrate that she has developed a chronic pain impairment sufficient to remove her from the MIG.

The applicant does not suffer from a psychological condition

19The applicant does not suffer from a psychological condition that would warrant removal from the MIG.

20The applicant submits that she sustained accident‑related psychological impairments that remove her from the MIG. In support of this position, she relies primarily on an initial assessment dated July 17, 2024, completed by Ms. Helen Wiens, Registered Psychotherapist. In that assessment, Ms. Wiens noted symptoms described as severe post‑traumatic stress disorder, as well as moderate depression and anxiety, which the applicant attributed to the motorcycle accident of June 4, 2022. The applicant was assessed by her self reported symptoms to Ms. Wiens and there was no Psychometric testing done at this time.

21The respondent disputes that the applicant has any qualifying psychological impairment. The respondent submits that the applicant did not begin reporting psychological concerns related to the accident until approximately May 2024, nearly two years post‑accident, and that prior to that time her mental health was reported as well-controlled. The respondent further submits that any psychological symptoms arose secondary to ongoing pain complaints and do not constitute an impairment removing the applicant from the MIG.

22I find the report of Ms. Wiens to be of limited persuasive value. Ms. Wiens conducted a single initial assessment and did not administer any formal psychological testing or objective assessment measures to support the conclusions reached. Her opinion appears to be based primarily on the applicant’s self‑reported symptoms. Further, there is no evidence that Ms. Wiens was operating under the supervision of a psychologist or psychiatrist. As a registered psychotherapist in Ontario, Ms. Wiens is not authorized to diagnose psychological disorders. As such, I afford limited weight to her conclusions regarding the presence of severe PTSD, depression, or anxiety.

23I have also considered the clinical notes and records of the applicant’s family physician, Dr. Dec. On May 22, 2024, Dr. Dec noted that the applicant reported overthinking and anxiety related to concerns about potential legal action from passengers, as well as disrupted sleep due to shift work. Importantly, there were no reports of suicidal ideation or self‑harm. These records do not document a diagnosed psychological condition or functional impairment. No medication was prescribed by her family doctor.

24Further, the medical evidence reflects that by November 12, 2024, the applicant advised that she was no longer interested in counselling and requested that her counselling file be closed. This suggests that any psychological symptoms were limited in duration and did not result in ongoing impairment.

25I note that there is no contemporaneous medical evidence of accident‑related psychological complaints in the period immediately following the June 2022 accident. The absence of timely reporting or treatment of psychological symptoms significantly undermines the causal link between the accident and the psychological impairments alleged.

26While I acknowledge that the applicant may have experienced situational stress or emotional distress, the evidence does not establish that she sustained a psychological impairment that falls outside the definition of a minor injury under the Schedule, or that would independently remove her from the MIG.

27For these reasons above, I find on the balance of probabilities that the applicant does not suffer a psychological condition that warrants her removal from the MIG.

28As the applicant is not removed from the MIG, it is not necessary for me to address whether the treatment plans in dispute are reasonable and necessary.

29In terms of the sufficiency of the denial letters, the applicant argues that the denial notices issued by the respondent do not comply with the requirements of section 38(8) of the Schedule.

30Section 38(8) requires an insurer to inform an insured person, within ten 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 an impairment to which the MIG applies.

31The respondent asserts that the denials are compliant with the Schedule. The respondent argues that it is sufficient for the denials to say that the applicant’s injuries fall within the MIG, particularly because it had little medical documentation to refer to or base its reasons on. The respondent points out the applicant submitted the disputed OCF-18s without corroborating evidence to support her claim. As a result, of the limited amount of medical documentation provided by the applicant, the respondent submits that its medical reasons were sufficient. I agree.

32The respondent cites several cases where the Tribunal has considered the MIG to be a medical reason, because it indicates that the applicant’s injuries are minor as described in the Schedule, see: Holman v. Western Assurance Company, 2025 CanLII 81404 (ON LAT) at para. 37; Li v. Intact Insurance Company, 2025 CanLII 94802 (ON LAT) at para 45; He v. Economical Insurance Company, 2025 CanLII 84248 ( ON LAT) at para 31.

33Also, the standard for sufficient notice is contained in T.F. v. Peel Mutual Insurance Company, 2018 CanLII 39373 (ON LAT). In her decision, Executive Chair Lamoureux states, at paragraph 19:

[…] an insurer’s “medical and any other reasons” should, at the very least, include specific details about the insured’s condition forming the basis for the insurer’s decision or, alternatively, identify information about the insured’s condition that the insurer does not have but requires. Additionally, an insurer should also refer to the specific benefit or determination at issue, along with any section of the Schedule upon which it relies. An insurer’s “medical and any other reasons” should be clear and sufficient enough to allow an unsophisticated person to make an informed decision to either accept or dispute the decision at issue. Only then will the explanation serve the Schedule’s consumer protection goal.

34The applicant argues that the November 21, 2022 Explanation of Benefits (EOB) is not compliant with s. 38(8) for the plan for chiropractic services in the amount of $1,130.95 dated November 7, 2022. The EOB from the respondent gives the reason for denial that the applicant’s injuries are minor and are in the MIG. It also states the applicant can submit supporting documentation for the respondent’s review and consideration.

35I find that the EOB identifies the treatment plan and advises that the insurer does not agree to pay for it. It provides a medical reason in stating that, based on the information that the insurer has to assess this case, the applicant is treated within the MIG for the injuries sustained in the accident. I find that the EOB provides a principled rationale, based fairly on the claimant’s file, to which the applicant can respond to. I find that the reference to the MIG and a “minor injury” is a medical reason and is a clear explanation sufficient enough to allow the applicant to make an informed decision to either accept or dispute the denial. I find that the respondent is compliant with s.38(8) and s. 38(9).

36With respect to the May 12, 2025, EOB for the plan for mental health assessment services, the EOB from the respondent gives a reason that the applicant’s injuries are minor and are in the MIG. It also states that the applicant’s medical documents do not support the need for psychological assessment. Specifically, that as per the Disability Certificate dated June 9, 2022, that applicant was diagnosed with sprain/strain injuries that fall within the MIG. As per Dr. Slowinsky's records, there are no psychological complaints related to this accident. It also states that the applicant has been actively working, socializing, riding a motorcycle, and has gone for trips and tours. The EOB further states that in the absence of psychological complaints the plan is not reasonable and necessary.

37I find that this EOB advises that the insurer does not agree to pay for the psychological treatment plan. It provides a medical reason in stating that based on the information provided. The EOB provides the applicant with a principled rationale, based fairly on the claimant’s file, to which the applicant can respond to. I find that it gives specific reasons to the applicant about the medical documentation not supporting psychological injuries. I find that the respondent is compliant with s.38(8).

38In summary, I find that the EOBs in this case are compliant with s. 38(8) of the Schedule.

Interest

39Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since no benefits are payable, no interest is award.

Award

40The applicant sought an award under s. 10 of Reg. 664 because the respondent failed to provide the necessary medical reasons for denying the disputed OCF-18s. Under section 10, the Tribunal may grant an award of up to 50 per cent of the total benefits payable if it finds that the insurer unreasonably withheld or delayed the payment of benefits. Since no benefits are payable, the respondent is not liable to pay an award.

ORDER

41I find on the totality of the evidence that:

i. The applicant’s injuries fall within the MIG.

ii. The applicant is not entitled to any of the treatment plans.

iii. No interest is awarded, and the respondent is not liable to pay an award.

iv. The application is dismissed.