Achraf Alala v. Unifund Assurance Company, 2026 CanLII 53777

Citation: Alala v. Unifund Assurance Company, 2026 ONLAT 24-015551/AABS

Licence Appeal Tribunal File Number: 24-015551/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:

Achraf Alala

Applicant

and

Unifund Assurance Company

Respondent

DECISION

ADJUDICATOR: Jeff Chatterton

APPEARANCES:

For the Applicant: Licia Lionessa, Paralegal

For the Respondent: Robbie Brar, Counsel

HEARD: In Writing

OVERVIEW

1Achraf Alala, the applicant, was involved in an automobile accident on August 5 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, Unifund Assurance 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:

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 $2,288.00 ($2,518.88 less $230.88 approved) for physiotherapy services, proposed by E Clinic United Healing in a treatment plan/OCF-18 (“plan”) submitted on February 22, 2023?
3. Is the applicant entitled to $2,460.00 for psychological services, proposed by Elite Specialist Group in a plan submitted on May 30, 2024?
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 met his onus to demonstrate he should be removed from the Minor Injury Guideline.

4The applicant is entitled to the treatment plans and remaining balances in dispute.

5An award is not payable.

6Interest is payable as per s. 51 of the Schedule.

ANALYSIS

Should the applicant be removed from the MIG due to chronic pain?

7The applicant has demonstrated he should be removed from the MIG due to chronic pain with a functional impairment.

8Section 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.”

9An 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.

10The applicant submits he should be removed from the MIG because he is suffering from chronic pain syndrome, and as a result, suffers from lower back pain, depression and headaches. To support his claim, the applicant relies on the Clinical Notes and Records (“CNRs”) of his family physician, Dr. Ali Zedan Degan Al-Hellawi, CNRs from E-Clinic United Healing, and the CNRs from Pain Specialist Dr. Sev Perelman from Premier Pain Institute.

11The respondent argues that the applicant has not met his onus, because the CNRs from Dr. Al-Hellawi are handwritten, difficult to read, and point to a pattern where the applicant has not consistently followed up regarding his subject accident complaints. The respondent did not submit s. 44 examinations to rebut the medical evidence.

12The applicant makes a detailed submission regarding his symptoms, and compares them to the AMA Guidelines for the Evaluation of Permanent Impairment (6th Edition). The AMA Guidelines are not incorporated into the Schedule, but the Tribunal has determined that they are a helpful analytical tool when it comes to evaluating chronic pain. The applicant argues that he meets all six criteria in the Guidelines.

13I place significant weight on the analysis provided by Dr. Sev Perelman, because as a pain specialist, I find he has the expertise to best assess the applicant’s concerns. Dr. Perelman has diagnosed the applicant with chronic pain syndrome, which was caused by the accident. I find this diagnosis is contemporaneous to the issues in dispute, and aligns with the observations reported by Dr. Al-Hellawi.

14I am alive to the respondent’s arguments that the family physician arguments are hard to read. I have however, managed to read the CNRs and find that they indicate an ongoing and consistent history where the applicant makes numerous complaints about ongoing chronic pain after the accident, and documents trouble sleeping and depressed mood. I also find the applicant was given multiple prescriptions for various narcotics, pain relievers and sleep aids.

15In summary, I am convinced by the accident-related chronic pain diagnosis provided by pain specialist in Dr. Perelman. I find this diagnosis consistent with the complaints being reported to the applicant’s family physician. Furthermore, the respondent has not provided expert medical opinion to counter the applicant’s chronic pain diagnosis.

16I also find Dr. Perelman’s records indicate a functional impairment of decreased mobility due to chronic pain, especially in his lower back.

17For these reasons, I find the applicant has, on the balance of probabilities, met his onus to demonstrate he should be removed from the MIG due to chronic pain with a functional impairment.

Is the applicant entitled to physiotherapy?

18The applicant has met his onus to establish the balance of the treatment plan for physiotherapy is reasonable and necessary.

19To 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.

20In dispute is the balance of a plan for 16 sessions of physiotherapy, intended to reduce pain, increase strength and increase range of motion with a stated goal of a return to the activities of normal living.

21The applicant argues that physiotherapy is reasonable and necessary, and that he has produced ample evidence to indicate that physiotherapy has provided pain relief benefit since the accident.

22The respondent’s arguments were focused on the MIG. The respondent believed the applicant had suffered only a minor injury and that he should be held to the MIG. The respondent stated, “The Applicant has not directed the tribunal to any objective evidence in support of these disputed treatment plans.”

23I am convinced by the applicant’s evidence that physiotherapy is reasonable and necessary. I note multiple references to the benefits the applicant has received from physiotherapy in the treatment records and other OCF-18’s. I assign the most weight to the report from Dr. Perelman, where he recommends physiotherapy to help relieve pain symptoms. I find this, contrary to the respondent’s assertion that there is no objective evidence, to be an objective piece of medical evidence which supports the treatment plan in dispute.

24In summary, the applicant has provided medical evidence that indicates physiotherapy is reasonable and necessary. For this reason, I find the applicant has, on the balance of probabilities, met his onus to demonstrate that the balance of the treatment plan for physiotherapy services is reasonable and necessary.

Is the applicant entitled to a psychological assessment?

25The applicant has met his onus to demonstrate a psychological assessment is reasonable and necessary.

26The 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.

27In dispute is a psychological assessment, provided by e-Clinic United Healing, intended to help identify and decrease psychological problems with a stated goal of returning to the activities of normal living.

28The applicant argues that chronic pain syndrome is not purely a physical ailment, and that a psychological assessment is reasonable and necessary. I agree with the submission that chronic pain syndrome is not exclusively a physical condition.

29To support his claim, he relies on the OCF-18 from Psychologist Dr. Jaqueline Brunshaw, as well as the CNRs from his family physician and the pain specialist’s report from Dr. Perelman.

30The respondent has not made any arguments specific to the psychological assessment, but relies on the same arguments outlined above, specifically that there is no objective medical evidence to indicate that the treatment plans are reasonable and necessary.

31I find that the treatment plan is reasonable and necessary. I am convinced by the Clinical Notes and Records of Dr. Al-Hellawi. There are multiple references to psychological concerns through the history of the applicant’s visit to his family physician. On October 24, 2022, Dr. Al-Hellawi noted the applicant’s concerns about post MVA nightmares, fatigue, anxiety, depressed mood and poor sleep.

32Dr. Al-Hellawi further noted concerns regarding sleep and continued to note the applicant was using Xanax (an anti-depressant medication) on December 22, 2022, December 21, 2023, and February 8, 2024. I find these CNR’s to be objective evidence that a psychological condition exists which warrants further investigation by way of an assessment, and that therefore the treatment plan is reasonable and necessary.

33For these reasons, I find the applicant has met his onus to demonstrate that the treatment plan for a psychological assessment is reasonable and necessary.

Interest

34Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Interest applies, as per s. 51 of the Schedule.

Award

35The 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.

36The applicant’s argument in favor of an award were minimal and suggest only that the respondent was stubborn and imprudent. The respondent argued that the applicant has not referenced any particular reason why its behaviour should be considered as stubborn, or pointed to adjusters’ log notes to indicate how the insurer was being unreasonable.

37I find that while the respondent was mistaken, but the applicant has not established that its conduct has risen to the level justifying an award. The applicant’s submissions are general in nature and do not meet the onus. No award is payable.

ORDER

38The application is granted.

i. The applicant has met his onus to demonstrate he should be removed from the Minor Injury Guideline.

ii. The applicant is entitled to the treatment plans and remaining balance in dispute.

iii. An award is not payable.

iv. Interest is payable as per s. 51 of the Schedule.