Licence Appeal Tribunal File Number: 25-001636/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:
[SN] (A minor by way of her Litigation Guardian)
Applicant
and
Unifund Assurance Company
Respondent
DECISION
ADJUDICATOR: Bernard Trottier
APPEARANCES:
For the Applicant: Hermia Leung, Paralegal
For the Respondent: Asal Karimi, Counsel
HEARD: By way of written submissions
OVERVIEW
1[S.N.], the applicant, was involved in an automobile accident on February 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 Unifund Assurance Company, the respondent, and applied to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
2At the time of the accident, the applicant was ten years old. This matter is proceeding by way of her litigation guardian.
ISSUES
3The 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 $1,174.46 for physical therapy services, proposed by Maple Health Care and Rehab in a treatment plan/OCF-18 (“treatment plan”) dated February 13, 2023?
Is the applicant entitled to $2,400.00 for a psychological assessment, proposed by Baskakova Psychology Professional Corp. in a treatment plan dated September 13, 2023?
Is the applicant entitled to $1,000.00 for osteopathy therapy, submitted on a claim form/OCF-6 (“claim form”) dated July 7, 2023?
Is the applicant entitled to $299.99 for a vision therapy assessment, submitted on a claim form dated November 11, 2024?
Is the applicant entitled to $2,634.00 for vision therapy and eyeglasses, submitted on a claim form dated March 3, 2025?
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
4The applicant is removed from the MIG as she has demonstrated, on a balance of probabilities, that her injuries fall outside the definition of a “minor injury” as defined under s. 3(1) of the Schedule.
5The applicant is not entitled to the proposed treatment plans for physical therapy services and a psychological assessment.
6The applicant has not established entitlement to the expenses on the disputed claim forms.
7An award under s. 10 of Reg. 664 is not payable.
8Since no benefits are payable, no interest is payable.
ANALYSIS
The Minor Injury Guideline limit
9The two treatment plans in dispute sought treatment outside of the MIG limit. In its written submissions, the respondent indicated that it had approved medical benefits to the $3,500 MIG limit.
10Section 18(1) of the Schedule provides that medical and rehabilitation benefits are limited to $3,500 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.”
11An 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.
12The parties dispute whether the applicant suffered a concussion, vision impairments and psychological injuries, as a result of the accident, warranting removal from the MIG, and whether the treatment plans and expense claims in this matter are reasonable and necessary.
The applicant’s concussion diagnosis removes her from the MIG
13The Tribunal has held that concussions and post-concussion syndrome do not fit the definition of a “minor injury” under the Schedule, because the definition under s. 3(1) does not include brain injuries.
14On February 26, 2022, the applicant was the front-seat-belted passenger in a vehicle that was rear-ended. The applicant submits that, following the accident she was diagnosed with concussion, strabismus (eye misalignment) and bilateral esotropia (inwardly crossed eyes) with inducible double vision, and post-concussion esotropia. She submits that her condition has led to episodes of nausea, dizziness, headaches, balance issues and psychological symptoms.
15The applicant directed me to the clinical notes and records (“CNRs”) and reports of the following health practitioners as evidence of her concussion and post-concussive symptoms:
March 2, 2022, with Dr. Pooja Prabhu, pediatrician, where the doctor notes that the applicant reported headaches, nausea and some neck pain. Dr. Prabhu diagnosed the applicant with a concussion and post-crash muscle spasm, and suggested treatment with pain medication, heat and muscle relaxants. Dr. Prabhu provided the applicant’s family with the applicant’s school board concussion protocol, with instruction to follow up if the protocol suggested.
March 7, 2022, with Justin Louie, physiotherapist with Maple Healthcare and Rehab (“Maple”), where Mr. Louie noted concussive symptoms, whiplash-associated disorder Grade 2 (“WAD II”) neck pain, and a knee contusion.
On April 7, 2022, with Dr. Eric Vandergugten, chiropractor with Maple, where the applicant reported headaches with nausea three to four times per week. Dr. Vandergugten provided a differential diagnosis (i.e., a potential diagnosis) of concussion, and diagnoses of WAD II neck pain and cervicogenic (originating from the neck) headache.
April 12, 2022, with Dr. Prabhu, where the applicant reported nausea and emotional regulation difficulties.
July 25, 2022, with Dr. Prabhu, where the applicant reported headaches and nausea.
February 20, 2024, with Dr. Prabhu, where the applicant reported double vision, headaches and mood swings, and Dr. Prabhu concluded that the applicant had possible persistent concussion symptoms.
October 7, 2024, with Dr. Prabhu, where the applicant reported nausea, perceived motion and headaches, and Dr. Prabhu ordered an MRI and referred the applicant to a neurologist.
October 29, 2024, with Dr. Yvonne Au, optometrist, who noted the inward turn of the applicant’s eyes that had started after the accident.
September 30, 2025, with Dr. Dexter Furlonge, ophthalmologist, where he diagnosed the applicant with post-concussion esotropia.
[16]
16The applicant argues that there is sufficient and compelling medical evidence that she suffered a concussion as a result of the accident and that her strabismus and esotropia are accident related. The applicant argues that her impairments require treatment outside of the MIG to recover.
17The respondent submits that paramedics at the scene of the accident noted that the applicant was conscious, alert and oriented, and that she had walked to a nearby location before their arrival. The respondent submits, further, that the applicant was discharged from the hospital on the same day as the accident without any diagnosis or specific discharge instructions. The respondent directed me to the hospital records from that day, that indicated neck pain and headaches, but that the applicant exhibited no dizziness or nausea.
18The respondent submits that Dr. Prabhu’s diagnosis of a concussion, on March 2, 2022, was based solely on the applicant’s reported symptoms, and no tests were administered nor was imaging ordered to substantiate it. The respondent submits further that the concussion diagnosis is unsupported by the paramedic report and hospital records from the day of the accident or thereafter, nor is it confirmed by a specialist.
19The respondent argues that the applicant has not met the burden of proof to demonstrate that she suffered a concussion as a result of the accident. It argues that a general practitioner’s diagnoses of a concussion and post-concussive injuries require corroboration by a concussion expert, such as a neurologist, citing Wadood v. Economical Insurance, 2023 CanLII 9251 (ON LAT) (“Wadood”). The respondent argues that the medical documentation provided as evidence by the applicant does not corroborate a concussion diagnosis. In particular, the respondent argues that Dr. Furlonge’s note does not corroborate a concussion. The respondent argues that Dr. Furlonge’s note indicated that the applicant mentioned the 2022 concussion diagnosis to him in his 2025 assessment, but that he did not diagnose the applicant with a concussion.
20I find that corroboration from a specialist or neurologist is not required to confirm a concussion diagnosis. In Ontario, a physician, nurse practitioner or neuropsychologist can diagnose a concussion. (See, for example: Singh v. Aviva General Insurance, 2025 CanLII 3764 (ON LAT) (“Singh”). I find that Wadood is distinguishable from the present matter. In Wadood, the applicant relied on notes of concussive symptoms from the physiotherapist and a chiropractor, but the physician did not provide a concussion diagnosis. While I am not bound by the decision in Singh, I find that the balance of case law at the Tribunal indicates that a diagnosis from a physician is sufficient to demonstrate a concussion.
21I find that, although the paramedic report and hospital records from the day of the accident do not indicate any head trauma, dizziness or nausea, they do indicate headaches, consistent with Dr. Prabhu’s later concussion diagnosis and reports of post-concussive symptoms from March 2, 2025 to July 25, 2022. I find that other health practitioners also note post-concussive symptoms in their records.
22I find that the weight of the evidence before me demonstrates that the applicant suffered a concussion as a result of the accident. Because concussions are not considered a minor injury, the applicant’s removal from the MIG is warranted.
23Having found that the applicant sustained a concussion as a result of the accident, it is unnecessary for me to address whether the applicant’s claimed vision impairments and psychological injuries also warrant removal from the MIG.
The proposed physical therapy services are not reasonable and necessary
24To 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 the treatment, how the goals would be met to a reasonable degree, and that the overall costs of achieving them are reasonable.
25The treatment plan submitted by Maple on February 13, 2023, proposed physiotherapy, massage therapy and chiropractic services, across 18 sessions. The stated goals of the treatment plan are to reduce pain, increase strength, increase range of motion and return to activities of daily living.
26From March 9, 2022, to February 11, 2023, the applicant received 22 physiotherapy sessions at Maple. Following treatment, the applicant reported reduced stiffness and improvements to her pain, but she also reported ongoing nausea and trouble focusing.
27From April 9, 2022, to February 11, 2023, the applicant received 12 sessions of chiropractic treatment and massage therapy at Maple. Following treatment, the applicant reported pain relief, but she also reported occasional nausea and headaches.
28The applicant argues that the proposed physical therapy services are reasonable and necessary for her recovery, as it provides relief of her pain symptoms.
29The respondent relies on the opinion of Dr. Mohamed Lamine, general practitioner, in his insurer’s examination (“IE”) report dated March 15, 2024, to argue that further physical therapy was not reasonable or necessary at that point in her recovery. Dr. Lamine found that the applicant exhibited normal range of motion, and he noted no musculoskeletal abnormalities. He opined that, from a musculoskeletal standpoint, there was no need for further clinical treatments beyond those already provided.
30On December 30, 2024, Dr. Lamine provided an addendum report based on further medical documentation provided by the applicant, including diagnostic imaging. In his addendum report, Dr. Lamine opined that his findings did not demonstrate objective functional impairment or musculoskeletal abnormalities, and that the time elapsed since the accident was beyond the expected recovery for soft tissue injuries.
31I find that the applicant has not advanced evidence, beyond the treatment plan itself, that further physical therapy was needed to treat her pain symptoms. I find that the applicant has not demonstrated how the goal of pain reduction would be met to a reasonable degree and that the overall costs of achieving them are reasonable compared to lower cost alternatives. I find that the opinion of Dr. Lamine, who opined that the applicant’s soft tissue injuries would have resolved by the time the treatment plan was submitted, is reasonable given his observations on the applicant’s range of motion, pain complaints and functionality.
32For the reasons above, I find that the proposed treatment plan for physical therapy is not reasonable and necessary, and therefore not payable.
The applicant is not entitled to the proposed psychological assessment
33The applicant submits that she had no history of psychological impairments before the accident that limited her activities of daily living, including her schooling or extra-curricular activities. The applicant submits that, in post-accident visits with Dr. Prabhu on March 15, 2022 and October 3, 2022, she reported anxiety, emotional regulation difficulties and sleep difficulties. The applicant directed me, further, to Dr. Prabhu’s CNRs of March 18, 2024, where Dr. Prabhu assessed the applicant as having moderate depression, and she prescribed her minerals and melatonin supplements to improve her sleep and energy.
34The disputed treatment plan for a psychological assessment was submitted on September 13, 2023. On September 26, 2023, the respondent denied the proposed psychological assessment due to insufficient medical documentation to establish a psychological injury, and it requested CNRs under s. 33 of the Schedule. After receipt of the CNRs, the respondent scheduled a psychological IE under s. 44 of the Schedule to further evaluate the claim. The respondent submits that the applicant did not attend the scheduled IE on March 23, 2024, and did not attend the re-scheduled IE on May 25, 2024.
35On May 28, 2024, the respondent informed the applicant that the treatment plan remained denied due to non-compliance with the IE requests, and it provided further information that, if the applicant provided a reasonable explanation for the IE non-attendance, the IE would be re-scheduled. The respondent submits that the applicant never provided an explanation, and the IE never took place. The respondent argues that it would be prejudicial to entitle the applicant to the proposed psychological assessment without allowing the respondent to have the applicant assessed by a psychological specialist.
36The respondent directed me its correspondence of May 8, 2024, where it indicated that, under s. 55 of the Schedule, failure to comply with a request for an IE may mean that the applicant cannot dispute the benefit before the Tribunal.
37Under s. 55(1)2 of the Schedule, an insured person shall not apply to the Tribunal for resolution of the dispute if the insurer has provided notice that it requires an examination under s. 44, and the insured person has not complied with the notice or notices. Under s. 55(2), the Tribunal may permit an insured person to apply despite non-compliance with IE notices.
38The applicant provided no submissions as to why she did not comply with the psychological IE requests, and she did not provide any submissions as to why the Tribunal should permit the claim to move forward under s. 55(2).
39The onus lies with the applicant to demonstrate why she is entitled to the benefit claimed. I find that the applicant was non-responsive to three requests for psychological IEs (March 23, May 8 and May 28, 2024). I find, further, that the respondent indicated that the applicant would be precluded from applying to the Tribunal under s. 55 if she did not comply with the IE notices. Lastly, I find that the applicant has not provided me with any reasons why she should be permitted to claim the benefit under s. 55(2).
40For these reasons, I find that the applicant has not demonstrated that she is entitled to the proposed treatment plan for a psychological assessment.
The respondent is not liable for the OCF-6s submitted without OCF-18s
41Section 38(2) of the Schedule states that an insurer is not liable to pay an expense in respect to a medical and rehabilitation benefit or assessment before the insured submits a treatment and assessment plan.
42Under s. 38(3)(c), a treatment and assessment plan must include a statement by a health practitioner that the goods and services described in the plan and their proposed costs are reasonable and necessary for the injured person’s rehabilitation.
43Exceptions to ss. 38(2) and 38(3) are allowed, and an insurer is liable to pay an expense for medical and rehabilitation benefits, in the following situations:
The insurer gives the injured person a notice that it will pay the expense without a treatment and assessment plan;
The expense is for goods and services provided on an emergency basis not more than five business days after the accident;
The expense is for drugs prescribed by a regulated health professional; or
The expense is for goods with a cost of $250 or less per item.
44In addition, under s. 24 of the Schedule, an insurer is liable to pay for reasonable expenses to repair or replace prescription eyewear that was lost or damaged as a result of the accident.
45The submitted claim forms comprise the following items:
$1,000.00 for osteopathy therapy sessions;
$299.00 for a vision therapy assessment; and
$2,634.00, comprised of $1,699.00 for vision therapy sessions and $935.00 for prescription eyewear.
46The applicant submits that there is compelling medical evidence that her physical and visual impairments are related to the accident, and therefore the requested reimbursement for the claimed items should be approved.
47The respondent states that the OCF-6s were submitted without treatment plans to substantiate them. The respondent states, further, that it communicated to the applicant that the appropriate procedure was to submit OCF-18s, and that medical and rehabilitation benefits would not be approved if not submitted per the proper method under s. 38(2) the Schedule. The respondent indicates that, after this communication, the applicant has not submitted OCF-18s related to the claimed goods and services.
48The respondent argues that the applicant is required to submit proposed treatment and assessments via OCF-18s to facilitate the evaluation (including scheduling of IEs, if warranted) and potential approval of the requested goods and services.
49I find that, whether or not there is compelling evidence that the impairments are accident-related, the proper method to seek funding from the insurer is via OCF-18s, per s. 38(2) of the Schedule. I find, further, that none of the exceptions to ss. 38(2) and 38(3) apply to the submitted expense claims, and the claim for prescription eyewear does not apply under s. 24.
50For the reasons above, I find that the respondent is not liable for the goods and services submitted under the disputed claim forms.
The applicant is not entitled to an award under s. 10 of Reg. 664
51Under s. 10 of Reg. 664, 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. Since I have found that no benefits are payable, I do not find that the respondent unreasonably withheld or delayed payment. As a result, an award under s. 10 of Reg. 664 is not warranted.
The applicant is not entitled to interest
52As no benefits are owing, the applicant is not entitled to interest on overdue benefits in dispute.
ORDER
53The applicant’s injuries warrant removal from the MIG.
54The applicant is not entitled to the disputed treatment plans for physical therapy and a psychological assessment.
55The applicant is not entitled to the claimed expenses for medical benefits, and they are not payable.
56The applicant is not entitled to an award.
57The applicant is not entitled to interest.
Released: May 14, 2026
Bernard Trottier
Adjudicator```