Licence Appeal Tribunal File Number: 24-011170/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:
Dylan Mitrovski
Applicant
and
Co-operators General Insurance Company
Respondent
DECISION
VICE-CHAIR: Brian Norris
APPEARANCES:
For the Applicant: Kameliya Stancheva, Counsel
For the Respondent: Emily A. Schatzker, Counsel Bianca F. Hosseini, Counsel
HEARD: By way of written submissions
OVERVIEW
1Dylan Mitrovski (“the Applicant”) was involved in an automobile accident on September 11, 2023, and sought benefits from Co-operators General Insurance Company (“the Respondent”) 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 and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issues to be decided in the hearing are:
Are the Applicant’s injuries predominantly a minor injury as defined in section 3 of the Schedule and therefore subject to treatment within the Minor Injury Guideline (“the MIG”) and the $3,500.00 funding limit for a minor injury?
Is the Applicant entitled to non-earner benefits (“NEBs”) in the amount of $185.00 per week for the period from October 11, 2023 to September 11, 2025?
Is the Applicant entitled to a medical benefit in the amount of $1,581.98 for chiropractic services, proposed by Toronto Medical Centre in a treatment plan/OCF-18 (“plan”) dated December 22, 2023?
Is the Applicant entitled to a medical benefit in the amount of $3,160.90 for chiropractic services, proposed by Toronto Medical Centre in a plan dated September 12, 2023?
Is the Applicant entitled to a medical benefit in the amount of $1,356.35, less $1,156.35 approved by the Respondent, for chiropractic services, proposed by Toronto Medical Centre in a plan dated November 20, 2023?
Is the Applicant entitled to a medical benefit in the amount of $1,400.00 for transportation fees, submitted by Toronto Medical Centre in a plan dated September 15, 2023?
Is the Applicant entitled to a medical benefit in the amount of $1,400.00 for transportation fees, submitted by Toronto Medical Centre in a plan dated December 5, 2023?
Is the Applicant entitled to a medical benefit in the amount of $1,995.32 for a psychological assessment, proposed by Toronto Medical Centre in a treatment plan dated October 10, 2023?
Is the Respondent liable to pay an award under section 10 of Regulation 664 because it unreasonably withheld or delayed payments to the Applicant?
Is the Applicant entitled to interest on any overdue payment of benefits?
RESULT
3The Applicant sustained a minor injury as a result of the accident. He is subject to the MIG and the $3,500.00 funding limit for a minor injury.
4The Applicant is not entitled to the plans in dispute because they propose goods and services that fall outside the MIG and the $3,500.00 funding limit.
5The Applicant is not entitled to NEBs.
6No interest or award is payable.
BACKGROUND
7The Applicant was a passenger of a vehicle involved in an accident. There is no record indicating that he sought medical attention at the time of the accident, nor in the days immediately following the accident.
8The Applicant attended at Toronto Medical Center the day after the accident and met with Dr. S. Jahandideh, chiropractor, who completed a disability certificate, dated September 12, 2023. That document lists numerous soft-tissue injuries as well as headaches, and numerous psychological injuries or impairments sustained in the accident. The disability certificate finds that the Applicant is having difficulty with most activities of daily living. It also says that his health history is significant for four concussions over the last 5-10 years, an accident in 2023, and a broken left arm five years ago.
9About two weeks later, on September 26, 2023, the Applicant met with Dr. P. Masoudi, physician. During that visit he complained of a headache and sore back, neck and ribs. He reported that the pain radiates to his arms occasionally and with tingling and numbness in his fingers. He also complained of anxiety and irritability, and that he has dreams that a car is hitting him. He advised Dr. Masoudi that he started physiotherapy and that it is helpful. Dr. Masoudi provided a referral to Toronto Medical Centre, which the Applicant was already attending, due to his headache and neck and back pain. Dr. Masoudi also provided a written referral to Toronto Medical Centre due to the Applicant’s complaints of anxiety, irritability, dizziness, nervousness, and sadness. The Applicant was also sent for neck and back x-rays, but the results of the x-rays are not before me.
10The Applicant has made no accident-related complaints to Dr. Masoudi since that September 26, 2023, visit.
11The Applicant claims that he sustained severe, multifaceted impairments as a result of the accident. He submits that the impairments, which include acute psychological trauma, symptoms of PTSD and concussion, as well as depression, are not a minor injury.
ANALYSIS
Minor Injury Guideline (“MIG”)
12The MIG establishes a treatment framework available to injured persons who sustain a minor injury as a result of an accident. A “minor injury” is defined in the Schedule and includes sprains, strains, whiplash associated disorder, contusion, abrasion, laceration or subluxation and any clinically associated sequelae. The MIG provides that a strain is an injury to one or more muscles and includes a partial tear. Under section 18 of the Schedule, injuries that are defined as minor are subject to a $3,500.00 funding limit on treatment.
13The onus is on the Applicant to demonstrate that he sustained an injury that is not included in the minor injury definition outlined in section 3 of the Schedule.
14For the following reasons, I find that the Applicant has not demonstrated that he sustained an injury in the accident that is not included in the minor injury definition.
Psychological injuries
15I find that the Applicant has not met his onus to demonstrate on a balance of probabilities that he suffers from a psychological injury as a result of the accident.
16To support his claim that he sustained a psychological injury as a result of the accident, the Applicant relies on the clinical visit with Dr. Masoudi two weeks following the accident and the subsequent referral to Toronto Medical Centre, as well as the psychological pre-screen assessment conducted by qualifying registered psychotherapist C. Dowling, dated October 2, 2023.
17The Respondent submits that the Applicant has not sustained a psychological injury as a result of the accident. To the Respondent, the Applicant has not met his onus to demonstrate that he suffers from a psychological impairment that is not sequalae of his minor injuries. The Respondent further submits that “clinically associated sequalae”, as outlined in the MIG, includes some psychological issues. The Respondent also notes that there are no other accident-related psychological complaints in Dr. Masoudi’s CNRs, and the psychological injuries listed in the disability certificate are not supported by the medical file and are beyond the scope of a chiropractor, who completed the disability certificate.
18I agree with the Respondent and find that the Applicant has not demonstrated that he sustained a psychological injury as a result of the accident that cannot be treated within the supplementary goods and services provided by the MIG. The basis for this is that the MIG provides discretionary interventions during the treatment phase, which includes supportive interventions such as advice or education, to deal with accident-related psycho-social issues. These psycho-social issues include, but are not limited to, distress, difficulties coping with the event of an injury, and driving problems and stress.
19The Applicant has not demonstrated that his psychological complaints are not clinically associated sequalae of his minor injury. The evidence indicates that the Applicant made a single complaint of a psychological issue to his family physician and never made any accident-related psychological complaints thereafter. This suggests that the Applicant’s psychological injuries, if any, either resolved without any treatment or did not rise to a level that warranted psychological intervention.
20I find the psychological pre-screen report to be unpersuasive and give it no weight. The report is very broad and does not identify any specific examples indicating the Applicant suffers from an accident-related injury or impairment. Moreover, the complaints listed in the pre-screen report are not repeated anywhere else in the Applicant’s medical record. For example, the Applicant reports in the pre-screen report that physical and emotional problems interfere with his present daily functioning, which is unspecific and is not repeated in the records of Dr. Masoudi. Even if I were to give weight to the pre-screen report, it would not cause me to conclude that the Applicant suffers from a psychological injury, due to the lack of similar complaints in the rest of the Applicant’s medical record. As set out above, the MIG anticipates that people who suffer from a minor injury may also experience psycho-emotional sequalae that may not rise to the level of a psychological impairment and provides discretionary funding for it.
21Accordingly, I find that the Applicant has not suffered from an accident-related psychological injury which would preclude his maximal recovery if subject to the MIG and the $3,500.00 funding limit for a minor injury.
Other injuries
22I find that the Applicant has not met his onus to demonstrate on a balance of probabilities that his injuries fall outside the definition of a minor injury.
23As noted, the Applicant claims that he suffers from severe, multifaceted impairments as a result of the accident, and that the impairments, which include symptoms of a concussion, are not a minor injury. The Respondent is critical of the fact that the Applicant made only one accident-related complaint to his family physician and reported no functional limitations during that single visit. It did not address the Applicant’s submission that he suffers from concussion symptoms.
24I find no evidence demonstrating that the Applicant sustained a concussion in the accident and conclude that his injuries are consistent with a minor injury. The Applicant has provided no evidence that a healthcare provider diagnosed him with a concussion or concussion symptoms. Similarly, he has not provided his treatment records to indicate any ongoing concussion symptomology or impairment.
25I find that the Applicant has not demonstrated that his accident-related injuries are multifaceted and not included in the definition of a minor injury. As outlined above, a minor injury includes one or more of a sprain or other soft tissue injury and any clinically associated sequalae. Here, the Applicant has not led any evidence to suggest that he suffered from multiple accident-related injuries and that he is unable to reach maximal recovery if subject to the MIG and the $3,500.00 funding limit.
26Accordingly, I find that the Applicant has not demonstrated on a balance of probabilities that he suffered an injury that is not captured in the minor injury definition outlined in section 3 of the Schedule.
The Applicant is not entitled to the treatment and assessment plans in dispute
27The plans in dispute propose goods and services that fall outside the MIG. Having found that the Applicant is subject to the MIG, it follows that he is not entitled to the plans in dispute.
The Applicant is not entitled to transportation fees
28The Applicant has not demonstrated that he is entitled to transportation fees because he has not demonstrated that his trip to the treatment facility is more than 50 km, as required in section 3(1)(b) of the Schedule. Likewise, he has not demonstrated that he sustained a catastrophic impairment as a result of the accident which would entitle him to transportation expenses.
Non-Earner Benefits (“NEBs”)
29I find that the Applicant has not met his onus to demonstrate on a balance of probabilities that he is entitled to NEBs.
30To be entitled to NEBs, the Applicant must demonstrate that he suffers from a complete inability to carry on a normal life as a result of and within 104 weeks of the accident, pursuant to section 12 of the Schedule. The test for NEBs involves a consideration of the Applicant’s activities and life circumstances pre-accident and compares them to his activities and life circumstances post-accident. Sustaining serious injuries or minor life changes does not automatically entitle the Applicant to NEBs. Rather, according to the test in Heath v. Economical Mutual Insurance Company, 2009 ONCA 391, (“Heath”), he must demonstrate that his life circumstances have changed and that the change must be significant enough to continuously prevent him from substantially engaging in all the activities that he engaged in before the accident.
31The Applicant led no evidence to support his claim for NEBs. He submits that he was functionally independent prior to the accident, but following the collision, he suffers a complete inability to engage in substantially all his pre-accident activities. These activities include personal care, household maintenance, and social functioning. He further submits that he is unable to resume a normal life or pursue vocational activity. However, submissions are not evidence and the lack of any medical records confirming an accident-related impairment indicates that the Applicant does not suffer a complete inability to carry on a normal life. Further, the Respondent requested that the Applicant complete an “activities of normal life profile” to affirm his accident-related impairments, but the Applicant never completed the form.
32Having found that the Applicant led no evidence to support this claim for NEBs, it follows that he has not met his onus to demonstrate that his life circumstances have changed as a result of the accident and that the changes are significant enough to continuously prevent him from substantially engaging in all the activities that he engaged in prior to the accident.
33I find on a balance of probabilities, that the applicant is not entitled to NEBs.
Interest
34Interest applies on the payment of any overdue benefits pursuant to section 51 of the Schedule. Having found no benefits payable, it follows that no interest is payable.
Award
35The Applicant sought an award under section 10 of Regulation 664. Under section 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.
36Having determined that that Applicant sustained a minor injury and that no benefits are payable, it follows that no benefits have been unreasonable withheld or delayed by the Respondent. Thus, I find no award payable.
CONCLUSION AND ORDER
37The Applicant sustained a minor injury as a result of the accident.
38The Applicant is not entitled to the treatment plans in dispute, nor the transportation expenses.
39No interest or award is payable.
40The Application is dismissed.
Released: May 21, 2026
Brian Norris
Vice-Chair