Licence Appeal Tribunal File Number: 24-008636/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:
Mary Grace Abrazaldo
Applicant
and
Belair Insurance Company Inc.
Respondent
DECISION
ADJUDICATOR:
Nadia Mauro
APPEARANCES:
For the Applicant:
Frances Panganiban, Paralegal
For the Respondent:
Leanne Zawadzki, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Mary Grace Abrazaldo, the applicant, was involved in an automobile accident on June 26, 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, Belair Insurance Company Inc., 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 $3,397.16 for physiotherapy services, proposed by 101 Physio in a treatment plan (“OCF-18”) dated June 30, 2022?
Is the applicant entitled to $539.00 for translation services, proposed by 101 Assessments in an OCF-18 dated August 23, 2022?
Is the applicant entitled to $5,272.00 for psychological treatment, proposed by 101 Assessments in an OCF-18 dated October 25, 2022?
Is the applicant entitled to $2,460.00 for a psychological assessment, proposed by 101 Assessments in an OCF-18 dated July 29, 2022?
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?
3The applicant sent email correspondence to the Tribunal on April 23, 2025, advising that she withdrew issue 2 as listed on the case conference report and order (“CCRO”), dated October 16, 2023. The respondent sent email correspondence to the Tribunal on April 24, 2025, advising it withdrew issue 9 as listed on the CCRO. The applicant and respondent confirmed in their submissions that the remaining substantive issues left in dispute are as listed above.
RESULT
4The applicant injuries are predominantly minor and, therefore, are within the MIG.
5The applicant is not entitled to the treatment plans for physiotherapy treatment, translation services, and psychological treatment.
6The expenses incurred under the treatment plan for psychological assessment are payable pursuant to s. 38(11) of the Schedule, plus interest.
7The respondent is not liable to pay an award.
ANALYSIS
The applicant’s injuries are predominantly minor
8I find that the applicant has not proven, on a balance of probabilities, that her accident-related injuries warrant removal from the MIG.
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 or subluxation and includes any clinically associated sequelae to such an injury.”
10An 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.
11The applicant submits that she should be removed from the MIG because of psychological impairments and physical injuries as a result of the accident.
a) Psychological injuries
12I find that the applicant has not proven, on a balance of probabilities, that she has sustained psychological impairments as a result of the accident that warrants her removal from the MIG.
13The applicant submits that she has suffered psychological impairments that would warrant her removal from the MIG. The applicant relies on the s. 25 report of Dr. Konstantinos Papazoglou, dated September 12, 2022, wherein the applicant was diagnosed with Adjustment Disorder (with mixed anxiety and depressed mood) and Specific (Isolated) Phobia (Passenger). The applicant submits that Dr. Papazoglou opined that her psychological injuries fall outside of the definition of “minor injury”.
14The respondent submits that Dr. Papazoglou’s report is cursory, with actual testing results in the moderate and average range. The respondent further submits that a review of the medical records as a whole does not support any psychological sequela as a result of the accident.
15I give little weight to the report of Dr. Papazoglou as I am not pointed to any corroborating evidence that would substantiate this assessor’s findings. I agree with the respondent in that the applicant’s medical records do not support a psychological impairment as a result of the accident. Despite presenting to her family practitioner, Dr. Randhawa, with accident-related physical complaints of neck and back pain on July 6, 2022, September 2, 2022, and October 16, 2024, the applicant did not report any psychological complaints. I am also not pointed to evidence of psychological impairment in the CNRs of 101 Physio Medical and Rehabilitation Centre. As such, I find that these CNRs do not corroborate the severity of the accident-related psychological impairments, as reported and diagnosed by Dr. Papazoglou. I am not directed to any further medical evidence from any other practitioner that opines on accident-related psychological complaints.
16What is more, Dr. Papazoglou’s report neither comments on, nor indicates a review of the applicant’s medical file. In this respect, Dr. Papazoglou’s report is conducted largely on the basis of the applicant’s self-reports. In my view, a lack of review of the applicant’s medical file as it would relate to the applicant’s psychological condition makes this report less persuasive. As such, I find that Dr. Papazoglou’s diagnoses do not correlate with the applicant’s reports to other health care practitioners, namely her family practitioner and treating physio clinic.
17I am persuaded by the report of s. 44 psychological assessor, Dr. Amena Syed, dated October 21, 2022, because I find that Dr. Syed’s report better aligns with the bulk of the applicant’s contemporaneous medical records. While the applicant reported complaints of being afraid of going into a car, is always unhappy, and experience nightmares to Dr. Syed, as I have stated above, the applicant did not make similar complaints during her visits to either her family practitioner, Dr. Randhawa nor 101 Physio. The report of Dr. Syed indicates, “the present psychological investigation found no objective psychometric evidence to substantiate Ms. Abrazaldo’s subjective self-report of psychological impairment related to the subject motor vehicle accident or that would remove her from the Minor Injury Guideline.”
18As I have given little weight to Dr. Papazoglou’s report for the reasons set out above and the applicant has not provided corroborating evidence of psychological complaints arising from the accident, I find that the applicant has not proven, on a balance of probabilities, that she has sustained a psychological impairment that would warrant removal from the MIG.
b) Physical Impairments
19I find that the applicant has not proven, on a balance of probabilities, that her physical injuries warrant removal from the MIG.
20The applicant submits that as a result of the accident, she has suffered physical injuries such as neck and back pain. The applicant relies on the CNRs of her family practitioner, Dr. Randhawa, who diagnosed whiplash.
21The applicant’s physical injuries all fall within the definition of a minor injury as defined by the Schedule. I am not directed to any further evidence that substantiates a non-minor physical injury.
22Given the above, I find that applicant has not proven, on a balance of probabilities, that she has suffered from accident-related physical impairments that warrant removal from the MIG.
23As I have found the applicant is not removed from the MIG, I find that it is not required to review the treatment plans in dispute to determine if they are reasonable and necessary.
24However, the applicant submits that for all the OCF-18s in dispute, the respondent failed to discharge its statutory obligations pursuant to the Schedule by not providing the medical and any other reasons as to why they were denied.
The denial letters dated July 11, 2022, August 31, 2022, and October 31, 2022 are complaint with s. 38(8) of the Schedule
25I find that the respondent’s denial letters dated August 31, 2022, and October 31, 2022, are complaint with s. 38(8) of the Schedule.
26Sections 38(8) and 38(11) of the Schedule set out strict notice requirements for insurers responding to treatment plans and specific consequences if they fail to comply. Section 38(8) requires an insurer to inform an insured person within ten business days after it receives an OCF-18 which goods, services, assessments, and/or examinations it agrees to pay for, and which it does not, as well the medical and other reasons why it considered any of the goods and services to not be reasonable and necessary.
27If an insurer fails to comply with its obligations under s. 38(8), the following consequences set out in s. 38(11) of the Schedule are triggered:
The insurer is prohibited from taking the position that the insured person has an impairment to which the Minor Injury Guideline applies.
The insurer shall pay for all goods, services, assessments, and examinations described in the treatment and assessment 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 a notice described in subsection (8).
28The denial letter dated July 11, 2022, for the OCF-18 for physiotherapy services, in the amount of $3,397.16, submitted on June 30, 2022, stated:
“We do not have the benefit of medical documentation to support that your injuries fall outside of the Minor Injury Guideline, or that you have pre-existing documented medical conditions that were made worse as a result of the accident. We are requesting clinical notes and records to assist in our consideration of the proposed treatment.
Clinical notes and records from Family doctor from the last 2 years prior to the DOL to current.
Clinical notes and records from the Hospital from the last 2 years prior to the DOL to current.”
29The denial letter dated August 31, 2022, for the OCF-18 for interpretation services, in the amount of $539.00, submitted on August 23, 2022, stated:
“The Treatment and Assessment Plan OCF-18 is requesting for translation services for psychological assessment that has not been approved. As such, translation services is [sic] not reasonable and necessary.”
30The denial letter dated October 31, 2022, for the OCF-18 for psychological services, in the amount of $5272.00, submitted on October 25, 2022, stated:
“There is insufficient compelling medical evidence produced by your health practitioner showing that your prior medical condition will not allow for a full recovery under $3,500.00 limit.
The medical and other reasons for this denial include: Dr. Amena Syed completed an insurers examination report on October 21, 2022 and concluded based on her psychological investigation she found no objective psychometric evidence to substantial [sic] claimants subjective self-report of psychological impairment related to the motor vehicle accident or that would remove you from the Minor Injury Guideline.”
31The applicant submits that the insurer’s notice must be clear and unequivocal and include a medical and any other reason for the denial, citing T.F. v Peel Mutual Insurance, 2018 CanLII 39373 (ON LAT) (T.F.). The applicant further submits that respondent failed to provide details of any kind concerning the applicant’s condition that would lead them to believe that her injuries were minor in nature. The applicant relies on my decision in Woodley v Aviva General Insurance, 2025 CanLII 1848 (ON LAT) (“Woodley”), where I found that the denial letters from the insurer were non-complaint with s. 38(8) of the Schedule because the insurer failed to make reference to specific records nor the specific injuries that led it to consider the applicant’s injuries to be minor.
32I agree with the applicant and her reliance on T.F., that an insurer must provide the medical reasons and any other reasons for its denial, however, I distinguish my decision in Woodley from the present case because I find that, in the above denials, the respondent listed the medical and any other reasons for its denial.
33I find that the respondent’s July 11, 2022, denial complies with s. 38(8) of the Schedule. While the wording of s. 38(8) states “medical reasons and any other reason”, Varriano v. Allstate Insurance Company of Canada, 2023 ONCA 78 clarifies that if an insurer is relying on a non-medical ground to deny the applicant of their benefits, then the provision requires only that the insurer provide notice of the non-medical reason for its denial. In the present case, the respondent’s denial letter is clear that they required medical documentation in order to assess the applicant’s ‘medical reasons’ as to whether the applicant’s injuries fall outside of the MIG, and specifically requested two types of clinical notes and records. As such, I find that the respondent’s denial was clear and sufficient such that an unsophisticated person could make an informed decision to either accept or dispute the denial.
34Similarly, I find that the respondent’s August 31, 2022, denial complies with s. 38(8) of the Schedule. As I have found above, in this letter, the respondent provided the other reasons that formed its denial, that being translation services were deemed not necessary as the corresponding OCF-18 was not approved. In my opinion, there would be no medical reasons to provide with respect to the translation services.
35Lastly, I find that the respondent’s denial letter, dated October 31, 2022, complies with s. 38(8) of the Schedule. I find that the denial letter provided medical reasons for the denial and was clear and sufficient enough to allow an unsophisticated person to make an informed decision to either accept or dispute the decision. The denial letter not only references the insurer’s examination report of Dr. Syed, but also clearly states that psychological investigation found no psychological basis to remove the applicant from the MIG. The applicant may disagree with the stated reasons or with the fact that the respondent relied on s. 44 assessment. However, that does not render a denial invalid.
36Therefore, I find that the respondent’s denial letters, dated July 11, 2022, August 31, 2022, and October 31, 2022, are compliant with s. 38(8) of the Schedule and the treatment plans are not payable.
The denial letter dated August 12, 2022, is non-complaint with s. 38(8) of the Schedule
37The denial letter dated August 12, 2022, for the OCF-18 for psychological services, in the amount of $2,460.00, submitted on July 29, 2022, stated:
“There is insufficient compelling medical evidence produced by your health practitioner showing that your prior medical condition will not allow for a full recovery under $3,500.00 limit.
The medical and other reasons for this denial include: we have made request [sic] to obtain further medical documentations without success. As such, a review of the documentation on file suggests that the injuries suffered as a result of the motor vehicle accident appear to be minor in nature. Due to the lack of evidence supporting a more serious impairment, and psychological impairment we feel it is appropriate to have a medical professional determine whether the proposed treatment plan is reasonable and necessary and if treatment outside the Minor Injury Guideline is required.”
38The applicant submits that the respondent failed to comply with s. 44(5) of the Schedule because the respondent’s Notice of Examination fails to mention what documentation they reviewed that has led them to their decision. Moreover, the applicant submits that the respondent failed to abide by its duty to properly adjust the file in response to new medical information, that being the s. 25 psychological assessment report of Dr. Papazoglou, contrary to s. 38 of the Schedule.
39While there is no specific statutory consequence for failing to comply with s. 44(5) of the Schedule, I find that the respondent’s denial letter, dated August 12, 2022, is non-complaint with s. 38(8) of the Schedule. While I appreciate that the respondent indicated in its denial letter that the applicant’s injuries are considered to be within the MIG, some or partial compliance with the Schedule is not enough. I find that the respondent’s denial letter does not reference any specific CNRs, assessments, or the specific injuries that are “minor” that it considered when rendering its decision. Moreover, unlike my decision with respect to the denial letters above, the respondent did not include a list of medical documentation that it would require in order to make a determination.
40What is more, the respondent, in its submissions, argues that the report of Dr. Syed found no objective psychometric evidence to substantiate the applicant’s self-report of psychological impairment. As such, as the applicant was found to be in the MIG. If the respondent relied on this information when rendering its decision, then the respondent should have indicated same in the denial letter.
41In my view, simply referring to the “documentation on file” without providing a single reference, is not sufficient to allow an unsophisticated person to make an informed decision to either accept or dispute the decision at issue. This also does not serve the Schedule’s consumer protection goal.
42The respondent further submits that a subsequent denial was made on October 31, 2022. The denial letter states:
“We have now received the Insurer’s Examination report completed by Dr. Amena Syed on October 21, 2022. We are providing the report to you as well as your health practitioner.
This decision is based on the following medical and all other reasons: The assessor concluded that the present psychological investigation found no objective psychometric evidence to substantiate a psychological impairment related to the motor vehicle accident. As such, the disputed treatment plan dated July 25, 2022 is not considered to be reasonable nor necessary.”
43Unlike the initial denial letter, I find that the respondent’s subsequent denial complies with s. 38(8) of the Schedule. In this letter, the respondent provided a medical reason, that being the opinion of Dr. Syed, and provided a copy of this assessor’s report for the applicant’s review. As such, I find that the respondent’s denial was clear and sufficient such that an unsophisticated person could make an informed decision to either accept or dispute the denial.
44Given the foregoing, I find that the respondent’s denial letter, dated August 12, 2022, is not compliant with s. 38(8) of the Schedule, but the subsequent denial, dated October 31, 2022, is complaint. Consequently, pursuant to the provisions set out in s. 38(11), I find that the respondent is liable to pay all expenses that were incurred by the applicant under the treatment plan between the 11th business day after the plan was submitted until the day the respondent cured its deficient notice by way of denial letter dated October 31, 2022.
Interest
45The applicant is entitled to interest on the payment of any overdue benefits pursuant to s. 51 of the Schedule.
Award
46I find that the applicant is not entitled to an award pursuant to s. 10 of Reg. 664.
47Pursuant to s. 10 of Reg. 664. Under s. 10, the Tribunal may grant an award 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 these criteria.
48The applicant submits that the respondent unreasonably withheld payment of the above-mentioned benefits, which has been detrimental to her recovery. The respondent submits that its decisions were reasonable and based on the information provided.
49Although I found that the respondent did not comply with s. 38(8) of the Schedule in issue 5, I do not find that its conduct rose to the level that would substantiate the applicant’s request for an award despite finding that denial letters did not meet the standard of notice required by the Schedule. This is because I find that the respondent’s non-compliance with s. 38(8) to be a wrong adjusting decision, rather than conduct that was “excessive, imprudent, stubborn, inflexible, unyielding, or immoderate” that I would deem to warrant an award.
50The respondent is therefore not liable to pay an award.
ORDER
51I find that:
i. The applicant’s injuries are predominantly minor;
ii. The applicant is not entitled the treatment plan for physiotherapy services, dated June 30, 2022;
iii. The applicant is not entitled the treatment plan for translation services, dated August 23, 2022;
iv. The applicant is not entitled the treatment plan for psychological treatment, dated October 25, 2022;
v. The expenses incurred under the treatment plan for a psychological assessment dated July 29, 2022, are payable pursuant to s. 38(11) of the Schedule;
vi. The applicant is entitled to interest pursuant to s. 51 of the Schedule; and
vii. The respondent is not liable to pay an award.
Released: January 22, 2026
Nadia Mauro
Adjudicator