Citation: Prada v. Wawanesa Mutual Insurance Company, 2026 ONLAT 25-000648/AABS

Licence Appeal Tribunal File Number: 25-000648/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:

Maria Prada

Applicant

and

Wawanesa Mutual Insurance Company

Respondent

DECISION

ADJUDICATOR:

Bernard Trottier

APPEARANCES:

For the Applicant:

Kasthuri Thevarajah, Counsel

For the Respondent:

Elizabeth Scott, Counsel

HEARD:

By way of written submissions

OVERVIEW

1Maria Prada, the applicant, was involved in an automobile accident on September 3, 2023, 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 Wawanesa Mutual Insurance Company, the respondent, and applied to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

ISSUES

2The issues in dispute are:

1. 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?

2. Is the applicant entitled to $5,567.86 for physiotherapy services, proposed by True Life Rehab Centre in a treatment plan/OCF-18 (“OCF-18”) submitted April 15, 2024?

3. Is the applicant entitled to $2,200.00 for a psychological assessment, proposed by True Life Rehab Centre in an OCF-18 submitted November 17, 2023?

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

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

RESULT

3The applicant has not demonstrated that her injuries warrant removal from the MIG.

4Since the applicant’s injuries are considered minor, the proposed OCF-18s seeking services outside of the MIG are not payable.

5An award under s. 10 of Reg. 664 is not payable.

6Since no benefits are payable, no interest is payable.

ANALYSIS

The Minor Injury Guideline

7Section 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.”

8An 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.

9The OCF-18s in dispute sought services outside of the MIG. Neither party made submissions on whether the $3,500 MIG limit was exhausted or whether there were amounts remaining for treatment and assessment within the MIG.

10The applicant made no submissions that her injuries were outside of those defined as “minor” under s. 3(1) of the Schedule.

11The parties dispute whether the applicant suffered a chronic pain condition and psychological impairments, as a result of the accident, warranting removal from the MIG, and whether the proposed OCF-18s are reasonable and necessary.

The applicant’s pain complaints do not remove her from the MIG

12The applicant submits that, as a result of the accident, she sustained injuries to her shoulder, neck, hip, knees and back, accompanied by persistent headaches. The applicant submits that her persistent pain complaints are documented in the clinical notes and records (“CNRs”) of her family physician, Dr. Gail Firestone, and those of her physical therapists at True Life Rehab Centre. The applicant argues that her pain has become chronic, warranting removal from the MIG to provide treatment. She submits, further, that she was prescribed a muscle relaxant, cyclobenzaprine, to help her manage her symptoms, that she continues to take to the date of her hearing submissions.

13The applicant directed me to the following CNRs as evidence of her chronic pain:

1. December 12, 2023: Dr. Firestone, diagnosis of mechanical back pain;

2. April 15, 2024: Dr. Newsha Nargaski, chiropractor, noted tightness and tenderness in the spine, shoulders and back muscles, as well as intermittent headaches, sleep disturbance and stress; and

3. August 20, 2024: Dr. Kristen Munro, general practitioner with Southlake Regional Health Centre, who prescribed further physical therapy.

14The applicant argues that her pain is recurring and has lasted more than three to six months, which fits the definition of chronic pain used by the Tribunal to determine whether accident-related injuries warrant removal from the MIG.

15The respondent submits that the medical evidence presented by the applicant indicates that she suffered soft-tissue injuries that fit the definition of a “minor” injuries under s. 3(1) of the Schedule. The respondent submits that the hospital records and medical imaging performed after the accident all indicate that the applicant suffered strain/sprain injuries consistent with a minor injury.

16The respondent submits, further, that by March 24, 2025, (about 18.5 months post-accident) the CNRs of Dr. Firestone indicated that the applicant’s pain and range of motion difficulties from the accident had resolved.

17The respondent argues that the applicant did not suffer functional impairment due to her pain complaints, as she resumed her employment as a personal support worked (“PSW”) shortly after the accident, working up to her full duties.

18The respondent argues that a formal diagnosis of chronic pain syndrome, or an indication that chronic pain is the predominant injury, is required to remove an injured person from the MIG for reasons of chronic pain. The respondent argues that the applicant has not provided evidence that she suffers from medically defined chronic pain with functional impairment warranting removal from the MIG.

19While a formal diagnosis of chronic pain syndrome is not required for me to remove an injured person from the MIG for reasons of chronic pain, (see, for example, the Tribunal’s analyses in 17-007825 v. Aviva Insurance Canada, 2018 CanLII 98282 ON LAT, or in A. A. vs. Technology Insurance Company Inc., 2020 CanLII 12719 ON LAT), I find that the applicant has not directed me to evidence that she meets the criteria for chronic pain with functional impairment warranting removal from the MIG. The applicant has not led evidence that she suffers from severe and constant pain, more than ongoing, intermittent pain.

20I find that the evidence before me indicates that applicant’s pain complaints are a clinically associated sequela to her minor injuries, and that the pain has subsided over time.

21Lastly, I find that the applicant has not directed me to evidence that her pain has significantly disrupted her activities of daily living, including her work as a PSW.

22The onus remains with the applicant to demonstrate that her pain condition warrants removal from the MIG. For the reasons above, I find that the applicant has not directed me to evidence that she suffered from chronic pain with functional impairment warranting removal from the MIG.

The applicant’s psychological impairments do not remove her from the MIG

23The applicant submits that she suffered significant psychological trauma as a result of the accident. She submits that, as a result of the accident, she began receiving psychotherapies including cognitive-behavioral therapy, somatic body-oriented therapy, trauma-based modalities, relational therapy, and transpersonal therapy.

24The applicant submits that Ingrid Cryns, psychotherapist with Body Mind and Soul Psychotherapy, in her progress report dated April 22, 2025, recommended that the applicant increase her psychotherapy treatment to increase her emotional stabilization and reduce her distress. The applicant submits that Ms. Cryns diagnosed her, in the progress report, with anxiety and depressed mood, including a specific phobia related to driving and being a passenger.

25The applicant argues that her diagnosis of mixed anxiety and depression has been established, entitling her to further psychological assessment and treatment outside of the MIG.

26The respondent submits that the applicant began her attendances with Ms. Cryns on February 15, 2023, more than six months before the accident. The respondent submits that the CNRs of the psychotherapist, both before and after the accident, refer to relationship and grief difficulties that are unrelated to the accident.

27In addition, the respondent submits that Ms. Cryns’ progress report does not contain any psychological diagnosis. In Ontario, psychotherapists are not qualified to make psychological diagnoses, and Ms. Cryns limited her comments to the psychotherapy services she provided.

28In reviewing the CNRs of Ms. Cryns, covering 10 visits from February 15, 2023 to March 18, 2025, I find that any reference to the accident are secondary to relationship and grief issues that are unrelated to the accident. I find that her main psychological complaints started well before the accident, and they persisted after the accident. I find that Ms. Cryns’ CNRs do not mention the accident at all in the five visits after February 20, 2024. I find, also, that Ms. Cryns does not provide the psychological diagnoses claimed by the applicant in the progress report dated April 22, 2025. For these reasons, I find that the applicant’s claimed psychological issues are predominantly unrelated to the accident.

29The onus to demonstrate entitlement to benefits rests with the applicant, and I find that the applicant has not met that onus. For the reasons above, I find that the applicant has not demonstrated that she suffers from psychological injuries, as a result of the accident, warranting removal from the MIG.

The applicant is not entitled to funding for the proposed OCF-18s

30I find that the applicant’s injuries, because of the accident, are “minor” as defined by the Schedule.

31Since I have determined that the applicant’s injuries are “minor” as defined by the Schedule, the OCF-18s seeking treatment outside of the MIG are not reasonable and necessary, and therefore not payable. I have no information before me regarding whether the MIG limit has been exhausted. In light of my decision, the applicant may apply for treatment within the MIG, subject to the treatment being reasonable and necessary within the MIG.

Award

32The applicant sought an award under s. 10 of Reg. 664. Under s. 10, 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.

33Since I have found that no benefits are payable for the OCF-18s, 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.

Interest

34As no benefits are owing, the applicant is not entitled to interest.

ORDER

35The applicant has not demonstrated that her injuries warrant removal from the MIG.

36Since the applicant’s injuries are considered minor, the proposed OCF-18s seeking services outside of the MIG are not payable.

37The applicant is not entitled to an award.

38The applicant is not entitled to interest.