Licence Appeal Tribunal File Number: 25-000833/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:
Reginaldo Dela Cruz
Applicant
and
Co-operators General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Jeff Chatterton
APPEARANCES:
For the Applicant:
Bianca Crocetti, Paralegal
For the Respondent:
Emily Schatzker, Counsel
Kara Ramnaraine, Counsel
HEARD: In Writing
OVERVIEW
1Reginaldo Dela Cruz, the applicant, was involved in an automobile accident on March 15, 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 the respondent, Co-operators General Insurance 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:
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 (“the MIG”) limit?
Is the applicant entitled to $3,640.81 for chiropractic services, proposed by Complete Rehab Centre in a treatment plan/OCF-18 (“plan”) submitted March 31, 2023?
Is the applicant entitled to $49.08 ($1,351.10 less $1,302.02 approved) for chiropractic services, proposed by Complete Rehab Centre in a plan submitted June 30, 2023?
Is the applicant entitled to $1,831.60 for chiropractic services, proposed by Complete Rehab Centre in a plan submitted September 25, 2023?
Is the applicant entitled to the assessments proposed by Life Point Medical Inc., as follows:
i. $2,000.00 for a Psychological Assessment, in a treatment plan submitted October 3, 2023; and
ii. $2,200.00 for a Chronic Pain Assessment, in a treatment plan submitted November 17, 2023?
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
3The applicant has not met his onus to demonstrate that he should be removed from the MIG and is therefore to remain subject to the $3,500 MIG limit.
4As the applicant is being held to the MIG, it is not necessary for me to consider whether the treatment plans in dispute are reasonable and necessary.
5Neither interest nor an award are payable.
ANALYSIS
Should the applicant be removed from the MIG due to chronic pain?
6The applicant has not demonstrated he should be removed from the MIG due to chronic pain with a functional impairment.
7Section 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.”
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 applicant argues he has made complaints of pain to his lower back and diaphragm to his family physicians, General Practitioner (“GP”) Dr. Fatima Kapacee and GP Dr. Leena Dookhoo, on December 20, 2023, January 6, 2024, September 14, 2024 and March 20 2025. To support his claim, he relies on Dr. Kapacee’s and Dr. Dookhoo’s Clinical Notes and Records (“CNRs.”)
10The respondent argues that the applicant does not have accident-related chronic pain with a functional impairment. To support its position, it argues that of the applicant’s 19 visits to Dr. Kapacee since the accident, pain has only been mentioned 5 times. It further argues that the applicant has never been diagnosed with chronic pain, does not meet the criteria established by the American Medical Association’s Guidelines for the Evaluation of Permanent Impairment (“AMA Guides”), and has not submitted any evidence documenting a lack of functionality.
11I find that the evidence does not establish on a balance of probabilities that he should be removed from the MIG due to accident-related pain that results in a functional limitation.
12Having reviewed the CNRs, I find there are multiple visits for non-accident-related concerns, including for pain related to a previous injury to his diaphragm in a 2011 accident. The applicant reported to Dr. Kapacee on January 6, 2024 that he was still having pain related to a serious accident in 2011. He also reported that he was in the subject accident in March 2023, but that he did not sustain any major injuries. This evidence does not support the claim that the applicant is in chronic pain due to the March 2023 accident.
13Furthermore, there is no diagnosis of chronic pain in the medical evidence. While a diagnosis of chronic pain is not required to be removed from the MIG, I find it to be of significance that the evidence does not indicate either consistent reporting of accident-related pain, or a diagnosis of chronic pain. In addition, the applicant has not provided submissions on the criteria for chronic pain in the AMA Guidelines. The AMA Guidelines are not incorporated into the Schedule, but the Tribunal has found that they are a useful analytical tool for assessing chronic pain.
14Furthermore, to be removed from the MIG, accident-related chronic pain must be accompanied by a functional impairment. The applicant has not provided evidence of a functional impairment caused by pain due to the accident.
15For these reasons, I find, on the balance of probabilities, the applicant has not met his onus to establish he should be removed from the MIG due to chronic pain with a functional impairment.
Should the applicant be removed from the MIG due to a psychological condition?
16The applicant is not removed from the MIG due to an accident-related psychological condition.
17The applicant states he underwent a psychological pre-screen with Psychological Associate Mandeep Kaur Singh on September 8 2023, where he was provisionally diagnosed with Post-traumatic Stress Disorder and Adjustment Disorder with Anxiety and Depressed Mood. The applicant also relies upon Chan v Unifund Assurance Company, 2023 CanLII 40140 (ON LAT), where the Tribunal ruled that the applicant had suffered a non-minor injury due to a psychological condition.
18The respondent argues the pre-screen by Ms. Singh should be disregarded because it contains only self-reporting test results which were not tested for validity, and even then, the applicant’s test scores showed extremely mild results. The respondent relies on Riad v Economical Insurance Company, 2024 CanLII 61862 (ON LAT), where the Tribunal placed little weight on the pre-screen report given that it relied entirely on applicant self-reports, was unsupported by contemporaneous medical evidence, and the assessor did not review any medical evidence.
19I am not convinced by the applicant’s evidence and find he has not demonstrated a psychological condition that removes him from the MIG. I reach this conclusion for several reasons:
i. Having carefully reviewed his family physician CNRs, the applicant has not led me to any reports where he relayed psychological concerns to his primary treatment providers. This lack of contemporaneous evidence of psychological symptom reporting does not support the claim that the applicant was suffering from an accident-related psychological condition.
ii. I put little weight on the pre-screen report because it does not indicate which tests were performed, and what validity measures are in place. There is also no evidence that the applicant’s prior medical history was reviewed as part of the pre-screen. The assessment was conducted by Ms. Mandeep Kaur Singh, who is a psychological associate, not a psychologist.
iii. Although prior LAT decisions are not binding on me, I agree with the reasoning in Riad, in that it placed little weight on the pre-screen report based primarily on the applicant’s self-reporting. I have reviewed Chan and find it distinguishable because Chan relied upon a s.25 psychological assessment which had validity testing, and the results were consistent with the s.44 assessment conducted by the insurer.
iv. Finally, I have not been led to evidence which indicates that the applicant’s concerns are more significant than sequalae from the accident. Psychological sequelae are not, in and of themselves, sufficient to remove an applicant from the MIG.
20As such, I do not find that, on the balance of probabilities, the applicant has met the onus to demonstrate he should be removed from the MIG due to a psychological condition.
21As I have ruled that the applicant is being held to the MIG, it is not necessary for me to analyze the treatment plans or remaining balances to determine if they are reasonable and necessary.
Interest
22Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no benefits are overdue, no interest is payable.
Award
23The 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. As I have ruled that the insurer has not unreasonably withheld or delayed the payment of benefits, I find that no award is payable.
ORDER
24The application is dismissed.
i. The applicant has not met his onus to demonstrate that he should be removed from the MIG and is therefore subject to the $3,500 MIG limit.
ii. As the applicant is being held to the MIG, it is not necessary for me to consider whether the treatment plans in dispute are reasonable and necessary.
iii. Neither interest nor an award are payable.
Released: June 1, 2026
__________________________
Jeff Chatterton
Adjudicator