Licence Appeal Tribunal File Number: 24-014791/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:
Hussain Aliasgar Sadriwala
Applicant
and
Primmum Insurance Company
Respondent
DECISION
ADJUDICATOR:
Jeff Chatterton
APPEARANCES:
For the Applicant:
Aminder Hayher, Counsel
For the Respondent:
Naguena Alingary, Counsel
HEARD: In Writing
OVERVIEW
1Hussain Aliasgar Sadriwala, the applicant, was involved in an automobile accident on October 14, 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, Primmum 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 limit (“MIG”)?
- Is the applicant entitled to $2,004.96 for chiropractic services, proposed by Progressive Rehab Clinic in a treatment plan/OCF-18 (“plan”) dated August 31, 2023?
- Is the applicant entitled to $3,491.40 for psychological treatment, proposed by AMS Assessments in a plan dated October 30, 2024?
- Is the applicant entitled to $2,460.00 for a psychological assessment, proposed by Dr. Leon Steiner in a plan dated October 20, 2024?
- Is the applicant entitled to $2,460.00 for a physiatry assessment, proposed by AMS Assessments in a plan dated August 21, 2024?
- Is the applicant entitled to $2,460.00 for an orthopedic assessment, proposed by AMS Assessments in a plan dated August 21, 2024?
- Is the applicant entitled to interest on any overdue payment of benefits?
3Both parties agree that a preliminary issue, raised by the respondent at the case conference regarding s.44 examination non-attendance, has been withdrawn.
RESULT
4The applicant has, on the balance of probabilities, met his onus to establish he should be removed from the MIG, due to both physical and psychological injuries.
5The applicant is entitled to the treatment plans in dispute (issues 2 and 3)
6The applicant is not entitled to a physiatry assessment or an orthopedic assessment (issues 5 and 6).
7Interest is payable, as per s. 51 of the Schedule.
PROCEDURAL ISSUES
8The respondent has raised an issue regarding the late exchange of documentary evidence, and submits that allowing evidence produced after the Case Conference Report and Order (“CCRO”) deadline would negatively prejudice the respondent. In dispute are the updated clinical notes and records (“CNRs”) of Dr. Ihsan Warraich, updated CNRs from Silver Pain Center, a report of Dr. Shahmalek, and a receipt for physical therapy.
9The applicant submits that they have made best efforts to receive the requested evidence, including multiple follow up requests. The applicant has attached copies of the requests for documents from treatment providers dated March 12, 2025, the day of receipt for the CCRO. I also note follow up requests dated March 31, April 22, August 11, and August 12, 2025.
10I note the final document exchange took place August 12, 2025, while the CCRO identified a deadline of April 10, 2025. While I do note the documents have been submitted late, I also note the multiple requests of the treatment providers.
11I find that the documents are admissible for the following reasons:
i. While I note the respondent’s submissions on prejudice, I am not convinced such prejudice exists. The respondent claims documents were exchanged August 12, 2025, while the respondent’s written submissions were not submitted to the Tribunal until October 3, 2025. This allowed the respondent close to two full months to examine and respond to the applicant’s evidence.
ii. I find that if prejudice to the respondent were to exist, it would be outweighed by the prejudice to the applicant. The CNR’s from a family physician are relevant because the family physician is objective and familiar with his medical history. Similarly, the report from Dr. Shahmalek is objective and provides important insights into the condition of the applicant. As such, I find the prejudice to the respondent, in light of the time they still had available, to be minimal, while the prejudice to the applicant in excluding highly relevant medical evidence would be significant.
iii. I find the applicant has made a good faith effort to secure the documentary evidence, and has provided evidence of such effort.
ANALYSIS
The applicant is removed from the MIG
12Section 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.”
13An 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.
14The applicant argues that he should be removed from the MIG because he suffers from accident-related chronic pain with functional limitations as well as a psychological impairment.
Chronic pain
15I find the applicant has, on the balance of probabilities, met his onus to establish he should be removed from the MIG on the basis of chronic pain with a functional limitation.
16The applicant submits that he is suffering from chronic pain, specifically in his shoulders and lower back, which is chronic, long-term and persistent. To support his claim, the applicant relies upon the Clinical Notes and Records (“CNRs”) from his family physician, Dr. Ihsan Waraich, as well as Psychiatrist Dr. Shahzad Shahmalek and Pain Specialist Dr. Fernando Gonzalez.
17Dr. Shahmalek is an OHIP funded Psychiatrist who was referred by the applicant’s family physician, and he diagnosed the applicant with “persistent pain and panic disorder” on May 19, 2024.
18Dr. Waraich, the applicant’s family physician, noted ongoing complaints of pain and functional limitations with the applicant’s shoulders. The first complaint was October 29, 2022, with ongoing and repeated complaints dated December 7 2022, January 10 2023, February 6 2023, December 29 2023, and culminating in a chronic pain diagnosis on May 28, 2024.
19Dr. Gonzalez, a chronic pain specialist, diagnosed the applicant with myofascial shoulder pain on July 10, 2024. I also note that from the evidence presented to me, it appears that all three doctors are OHIP funded and have not submitted treatment plans in dispute. I find this relevant because it speaks to their objectivity.
20The respondent submits the applicant’s injuries are minor and are simply sequalae from the initial accident. To support its claim, the respondent relies on a s.44 Insurers Examination by Physiatrist Dr. Michael Ko, dated November 9, 2023. In this report, Dr. Ko diagnosed the applicant with sprain and strain type injuries.
21I give more weight to the applicant’s evidence. The applicant has produced medical evidence from three separate objective medical professionals, all of whom have diagnosed the applicant with some form of persistent and long-term chronic pain as a result of the accident. I further note that Dr. Ko stated he was unable to move the applicant’s shoulders “due to severe pain.” I find this statement gives support to the applicant’s argument that he continues to suffer long-term shoulder pain, especially given that the respondent’s IE was conducted over a year after the initial accident when simple “sprain and strain” type injuries would have resolved.
22In summary, the applicant has produced ample objective evidence, in the form of multiple reports from objective medical treatment providers, to indicate that he is suffering from chronic pain, while even the respondent’s evidence appears to support the applicant’s narrative that he is in persistent pain, with the functional limitation of being unable to lift his shoulders.
23I find the applicant has, on the balance of probabilities, met his onus to establish he should be removed from the MIG on the basis of chronic pain with a functional limitation.
Psychological injury
24Although I have found that the applicant should be removed from the MIG on the basis of chronic pain, I also find that the applicant has met his onus to establish he should be removed from the MIG on the basis of psychological injury.
25The applicant submits he has multiple psychological disorders caused by the accident, and depends on the CNRs from Dr. Waraich, Dr. Shamalek and Psychologist Dr. Leon Steiner.
26On May 19, 2024, the Applicant was seen by Psychiatrist Dr. Shahzad Shahmalek through a referral from his treating physician, who diagnosed the Applicant with Major Depressive Disorder, Post-Traumatic Stress Disorder (“PTSD”), Somatic Symptom Disorder, persistent pain and panic disorder as a result of the accident.
27On May 28, 2024, the applicant’s family physician diagnosed the applicant with Chronic Pain Disorder, Depression, and PTSD also as a result of the accident. Dr. Waraich also diagnosed the applicant with severe anxiety in July 2024. Prior to this, I note repeated complaints of accident-related psychological concerns to Dr. Waraich on December 29, 2023, January 10 2024, February 26 2024 and March 8 2024. It is worth noting that the majority of complaints note a direct relation to the MVA in question.
28In September 2024, Dr. Steiner also diagnosed the applicant with severe depression and somatic symptom disorder.
29The respondent disagrees, and relies upon a s.44 Insurers Examination conducted by Psychologist Dr. Terra Seon, dated April 5, 2024. In her report, Dr. Seon identified that the applicant still had difficulties with personal care and grooming, and depended on his girlfriend for simple activities such as feeding him breakfast. Dr. Seon reported that the applicant may be malingering, suggesting that his test scores indicated an exaggeration of his symptoms.
30While I am alive to the concerns raised by the respondent regarding malingering and exaggeration, I still find that the applicant’s evidence meets the onus to establish an accident-caused psychological disorder.
31The applicant’s family physician reported accident-related psychological issues on multiple occasions, outlined in paragraph 25 above. I find this evidence to be objective and persuasive. I further note accident-related psychological conditions were confirmed by Psychologist Steiner and Psychiatrist Shamalek.
32For these reasons, I find the applicant has, on the balance of probabilities, also met his onus to establish he should be removed from the MIG on the basis of psychological injury
33As the applicant has been removed from the MIG, I now turn to the Chiropractic services in dispute (issue #2).
34To receive payment for a treatment and assessment plan under s. 15 and 16 of the Schedule, the applicant bears the burden of demonstrating on a balance of probabilities that the benefit is reasonable and necessary as a result of the accident. To do so, the applicant should identify the goals of treatment, how the goals would be met to a reasonable degree and that the overall costs of achieving them are reasonable.
Chiropractic services
35The OCF-18 for Chiropractic services calls for 16 sessions of therapy, with a stated goal of pain reduction and increased range of motion to return to the activities of normal living. The applicant submits he has received considerable pain relief from chiropractic treatments in the past.
36I note that there are several references to the applicant receiving pain relief from therapy in the CNRs of Dr. Waraich, such as on February 6 2023 and March 4 2023. I also note that the applicant reported to the insurer’s medical experts, Dr. Seon and Dr. Ko, that he receives relief from his pain while receiving rehabilitative treatments. The respondent did not provide submissions as to whether or not the services were reasonable or necessary. In the denial letter they state that the services were denied due to the MIG.
37As I have found that the applicant is in chronic pain due to the accident, and that he benefits from rehabilitative treatments, I find on the balance of probabilities that chiropractic services are reasonable and necessary.
Physiatry Assessment and Orthopedic Assessment
38Also in dispute are an orthopedic assessment and a physiatry assessment.
39The purpose of an assessment is to determine whether a condition exists. For an insured, they bear the onus to demonstrate that there are grounds on which to believe that a condition exists that would warrant further investigation by way of an assessment.
40I have ruled that there is reason to believe a condition exists, as the applicant has been diagnosed with chronic pain disorder. I find that the question as to determination whether or not a condition exists has been answered.
41I have not been led to submissions from the applicant as to why both a physiatry assessment and an orthopedic assessment are necessary, nor have I been led to submissions as to why they would not be a duplication of service. The applicant has submitted that he suffers from chronic pain, but I was not led to a submission indicating why he has requested an orthopedic or physiatry assessment versus a chronic pain assessment. Upon review of the OCF-18’s in question, I see only “Test, Musculoskeletal system NEC” and “Assessment (examination) total body.”
42Furthermore, I note that the applicant has already been diagnosed with chronic pain disorder, and has already been receiving chronic pain treatments.
43For these reasons, I find the applicant has not met his onus, on a balance of probabilities to establish that a physiatry assessment and an orthopedic assessment are reasonable and necessary.
Psychological Services and Assessment
44Also in dispute are OCF-18s for a Psychological Assessment, as well as 16 sessions of psychological services in the form of counseling and associated support activity.
45I have found that the applicant should be removed from the MIG on the basis of psychological injury. While this particular assessment is being recommended by Dr. Steiner, I find it is corroborated by both Dr. Shahmalek, who recommended further counseling, and Dr. Waraich who recommended a Psychiatric Assessment in his CNRs of 29 December 2023.
46I find the proposed services and a psychological assessment are supported by the evidence before me. Multiple psychological professionals and the applicant’s family doctor have recommended both an assessment and psychological services. I find that that 16 sessions is a reasonable of counseling sessions, and commensurate with the scope of psychological concerns.
47The respondent has not provided a clear submission as to why the Psychological Services and Assessment would not be reasonable and necessary.
48In summary, I find that the applicant has suffered a psychological injury as a result of the accident, and that he has provided objective medical evidence to indicate that an assessment and treatment are both reasonable and necessary.
49I find on the balance of probabilities that both the assessment and psychological services are reasonable and necessary.
Interest
50Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule.
ORDER
51I find that:
i. The applicant is removed from the MIG on the basis of psychological injury and chronic pain with a functional limitation.
ii. The applicant is entitled to the treatment plans in dispute for chiropractic services, a psychological assessment and psychological counseling (issues 2, 3 and 4.)
iii. The applicant is not entitled to the treatment plans for an orthopedic assessment or physiatry assessment (issues 5 and 6).
iv. Interest applies, as per s. 51 of the Schedule.
Released: May 1, 2026
__________________________
Jeff Chatterton
Adjudicator