Licence Appeal Tribunal File Number: 24-011015/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:
Courtney Samuels
Applicant
and
Belair Insurance Company Inc.
Respondent
DECISION
ADJUDICATOR:
Dominique Setton
APPEARANCES:
For the Applicant:
Carla Barcelo, Paralegal
For the Respondent:
Theomarcus Giannou, Counsel
HEARD: In Writing
OVERVIEW
1Courtney Samuels, the applicant, was involved in an automobile accident on March 29, 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:
i. 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?
ii. Is the applicant entitled to $2,200.00 for a psychological assessment, proposed by Pro-Active Health Group Associates Inc. in a treatment plan/OCF-18 submitted on August 19, 2022, and denied on September 7, 2022?
iii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
iv. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3I find the applicant’s injuries are predominantly minor that the applicant is held in the MIG.
4I find the applicant is not entitled to the treatment plan in dispute, interest or an award.
ANALYSIS
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?
5I find that the applicant’s injuries are predominantly minor as defined in s. 3 of the Schedule and therefore subject to treatment within the $3,500.00 Minor Injury Guideline limit.
The applicant did not meet his onus to establish that removal from the MIG is warranted.
6Section 18(1) of the Schedule provides that the medical and rehabilitation benefits are limited to $3,500.00 if the injured sustains impairments that are predominantly minor injury. Section 3(1) defines a “minor injury” as one or more sprain, strain, whiplash associated disorder, contusion, abrasion, laceration, or subluxation and includes clinically associated sequelae to such an injury.
7An insured can 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 condition combined with compelling medical evidence stating that the condition precludes recovery if 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.
8The applicant submits that he should be removed from the MIG on the grounds of both physical and psychological injuries that he sustained in the accident of March 29, 2022, and in addition, a head injury.
9The applicant complained of physical symptoms such as neck, and lower back pain over a week after the accident on April 7 and 8th 2022 to his family doctor, Dr. Manjeet Prewal which was provided in the clinical notes and records of the family doctor. The doctor recommended physiotherapy, chiropractic and massage treatment and prescribed medication to help him sleep. He told his family doctor, that he had some anxiety, and had trouble sleeping. The doctor assessed these complaints, and noted that he had no dizziness, visual changes, concentration, nausea or vomiting at this time. No further referral were made by the family doctor.
10The applicant visited his family doctor next on January 17, 2023, almost a year later, and he did not mention the accident then, nor in any subsequent visits up to January 29, 2025. This was evidence was provided in the clinical notes of the family doctor in the respondent’s evidence.
11The applicant attended physical therapy which helped him. It is unclear exactly to whom the applicant complained, but he had a psychological assessment which was conducted by Dr. Essam Abdelmotaal a psychologist from Pro-Health Group. As a result of this visit the applicant was diagnosed with post concussion syndrome by Dr. Abdelmotaal, and in his report of February 26, 2023, this doctor states that the applicant cannot be treated under the MIG limits.
12The respondent submits that the applicant’s injuries fall within the MIG, and therefore the applicant is not entitled to the claimed medical benefits. The respondent submits that the applicant has not provided compelling medical evidence to show that the injuries sustained in the accident warrant his removal from the MIG.
13The applicant relies on two CNR entries from his family doctor, Dr. Prewal, the first on April 7, 2022, and the second on August 8, 2022.
14In the first meeting, the applicant referred to the accident and complained of low back pain and neck pain of the left side. He did not suffer from headaches or dizziness, difficulties in concentration or nausea. His doctor suggested he do physiotherapy, massage and chiropractic treatment.
15t the next visit on August 8, of the same year, about 5 months later, the applicant reported having pain and tension in his back and neck. He also complained having difficulty sleeping, and anxiety. His doctor recommended he continue the physical therapy and also prescribed medication for his sleep. There are no further clinical notes and records from the family doctor.
16The respondent provided additional medical records from the applicant’s family doctor, which included CNRs from visits of January 26, 2023, February 6, 2023, November 27, 2023, and December 5, 2024. In these visits, the applicant does not refer to the accident, at all.
Psychological Impairment
17I find therefore that the applicant does not suffer from a psychological impairment, that would remove him from the MIG.
18To establish a psychological impairment, the applicant relies on a psychological report from Dr. Essam Abdelmotaal dated February 26, 2023, which I note is almost a year after the accident and seven months after his last visit to his family doctor.
19The psychological report stated that the applicant was asked to describe why he was visiting the psychologist. The applicant described the accident and the resulting pain. No further medical documents were reviewed. The report provided that the applicant was healthy and had denied any previous medical or surgical conditions, and he had never been seen by a psychiatrist. I note that the applicant provided no evidence that there had been a head injury in the medical data.
20The applicant also reported attention and memory issues to Dr. Abdelmotaal, as well as some depression and lack of motivation. He reported no previous seizures, or head trauma or concussions. He had no mental health issues in either his immediate family or family history. In his conclusions, Dr. Abdelmotaal found that the applicant suffers from post-concussion syndrome due to a car accident of in March 2022.
21The respondent provided an insurer’s examination report of Dr. Lotfalizadeh, psychologist, which is dated June 5, 2023, following an examination of June 5, 2023. In this report the applicant expressed physical complaints in his left wrist, and neck pain when sleeping. He also expressed that the pain had improved since the accident.
22The report based its findings not only on the self assessment of the applicant, but also on psychometric tests administered, as well as a review of the treatment plan provided by Dr. Bhardwaj, Psychologist of August 19, 2022, and the psychological assessment of Dr. Essam Abdelmotaal, of February 26, 2023. I found that this report was comprehensive, in that he considered the CNRs of the family doctor, the report of the psychiatrist, and psychologist, as well clinical tests administered to the applicant.
23Dr. Bhardwaj determined that the applicant did not suffer from a diagnosable psychological disorder in accordance with the DSM-5. Did he provide an opinion on the post-concussion syndrome?
24When comparing the applicant’s and the respondent’s reports, I prefer the report of Dr. Lotfalizadeh, because he bases his conclusion on a review of the medical file, psychological testing and a clinical interview, rather than solely on the self-reported data of the report of Dr. Abdelmotaal.
25After considering the clinical notes of the family doctor, there is no evidence of a head injury or a concussion. This is corroborated by the report of the [Dr. Lotfalizadeh, psychologist. I found it persuasive that Dr. Lotfalizadeh administered formal psychological testing and reviewed his medical evidence such as his family doctors’ clinical notes, whereas there is no evident that Dr. Abdelmotal did that. It would have been clear that the family doctor reviewed the applicant’s symptoms and did not find post-concussion symptoms. I find therefore that the applicant does not suffer from a psychological impairment, that would remove him from the MIG.
Chronic Pain with Functional Impairment
26The applicant submitted that he continued to suffer from neck and back pain that affected his daily activities. The applicant relies on the Tribunal decision, in HS vs Aviva Canada [please include the full citation] 2019 where in that case “a concussion and post-concussion syndrome are not defined in the Schedule as minor injuries and therefore do not fall in the MIG”.
27In order to support this position, the applicant relies on the report of Dr. Abdelmotaal, who diagnosed the applicant with post concussion syndrome due to a car accident in March 2022.
28The respondent submits that that there has been no long-term change in the applicant’s functionality following the accident due to his accident related injuries. It argues that the applicant continues to operate his construction company, he doesn’t take any medications, his personal relationships are unaffected, he continues to drive, he is able to participate in household tasks, he is independent with personal care, all of which are often referred to in the AMA Guides to the Evaluation of Permanent Impairment (“Guides”) as a method to assess whether an applicant suffers from chronic pain. The Guides cite the following criteria associated with chronic pain syndrome:
Use of prescription drugs beyond the recommended duration and/or abuse of or dependence on prescription drugs or other substances.
Excessive dependence on healthcare providers, spouse, or family.
Secondary physical deconditioning due to disuse and/or fear avoidance of physical activity due to pain.
Withdrawal from social milieu, including work, recreation, or other social contacts.
Failure to restore pre-injury function after a period of disability, such that the physical capacity is insufficient to pursue work, family, or recreational needs.
Development of psychosocial sequelae after the initial incident, including anxiety, fear-avoidance, depression, or nonorganic illness behaviours.
29The respondent submits that there is no evidence that the applicant meets any of these diagnostic criteria. [Did the applicant provide any submissions on the chronic pain criteria or direct you to any evidence supporting these criteria? If not, that is worth mentioning as well]
30I find that the applicant has not provided any compelling evidence of pain as a result of the accident that has caused a functional impairment. [you will need to provide reasons supporting this finding – did the applicant direct you to a chronic pain diagnosis? What did the family doctor CNRs reveal about how often the applicant reported pain – I would be specific about that; was he prescribed prescription pain medication or referred to pain specialists? Did he direct you to evidence of functional impairment? If not, I would mention all that as well]
31I find that the applicant ‘s injuries were predominantly minor and therefore subject to treatment within the $3,500 limit and in the MIG.
32As I have found that the applicant’s accident-related impairments do not warrant removal from the MIG, it is not necessary for me to consider the reasonableness and necessity of the treatment plan in dispute.
Interest
33There is no interest applicable, as interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule.
Award
34I find there is no award that applies as no benefits are payable or were unreasonably withheld or delayed.
ORDER
35For the above reasons I find:
a. The applicant’s injuries are predominantly minor and therefore subject to the MIG.
b. The applicant is not entitled to the treatment plan in dispute, interest or an award.
c. The application is dismissed.
Released: June 4, 2026
Dominique Setton
Adjudicator