Licence Appeal Tribunal File Number: 24-008783/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:
[VO]
(A minor by their litigation guardian [UO])
Applicant
and
The Dominion of Canada General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Timothy Porter
APPEARANCES:
For the Applicant:
Adriano Pranzitelli, Counsel Hojung (Cindy) Yeom, Counsel
For the Respondent:
Mary Morin, Counsel Alfred Cheng, Counsel
HEARD:
In Writing
OVERVIEW
1[VO], a minor applicant, was involved in an automobile accident on April 26, 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, the Dominion of Canada 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:
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? Note: The parties agree the MIG limits have not been exhausted, and their submission identify the amounts remaining as $198.16.
ii. Is the applicant entitled to services proposed by [Medical Centre] in a treatment plan/OCF-18 (“plan”) as follows:
a. $1,525.84 for a chiropractic services, in a treatment plan submitted August 30, 2022; and
b. $2,023.23 for a chiropractic services, in a treatment plan submitted October 11, 2022?
iii. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant has not met her onus to demonstrate, on a balance of probabilities, her injuries are not minor.
4As the applicant remains in the MIG and the MIG limit is largely exhausted, the treatment plans in dispute are not reasonable or necessary.
5No interest is due.
ANALYSIS
The applicant remains within the minor injury guideline
6The applicant has not met her onus to demonstrate that her injuries are not minor.
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 submits that her persistent injuries and chronic back pain are non-minor injuries and relies on the clinical notes and records (“CNRs”) of her family health provider [Medical Doctor] and the [Hospital].
10The applicant did not initially show any signs of injury from the subject accident. The applicant visited [Hospital] on the day of the subject accident, April 26, 2022. A note from the emergency room physician the following day details that the applicant “looked completely well,” fell asleep comfortably in the waiting room and showed no adverse physical signs from the subject accident.
11The applicant’s mother reported what I find can be characterized by the Schedule as minor injuries to her daughter’s family physician. The applicant’s mother reported that the applicant was experiencing back pain on April 28, 2022, and again on June 1, 2022, but then does not appear to mention back pain again while attending [Medical Centre]. The physician does not note any objective signs of physical discomfort or injury in relation to these reports. Of note, at the June 1 visit the applicant was assessed against age-related developmental milestones and was found to be progressing normally. All of which suggest to me that the applicant appears normal to the family physician.
12On September 11, 2022, the applicant attended [the Hospital] for abdominal pain. The applicant was assessed through ultrasound to have a normal appendix and a benign abdomen. There is a note about fecal loading in the bowel and rectum, and it is implied that this may be an accident-related injury. I note that the applicant first speaks to her family health provider at the [Medical Center] regarding constipation on February 12, 2021, which suggests to me that this is not an issue brought on by the subject accident.
13The applicant has not met her onus to demonstrate functionally disabling pain. I am not persuaded by the submissions of the applicant that she suffers from chronic pain. I afford the applicant’s submissions regarding chronic pain a diminished weight because the applicant has not provided insight to her lived experience with regard to pain and has not pointed to any persuasive evidence of a functional limitation due to pain. The Tribunal has consistently held that ongoing pain is not in and of itself sufficient to remove an applicant from the MIG. The applicant submits she has chronic pain; however, she has not shown persuasive evidence of a functional limitation due to pain, nor that the pain is in relation to the subject accident. I have also not been pointed to any evidence of a diagnosis of chronic pain. In my mind, the applicant has not adduced evidence sufficient to demonstrate that her injuries are not minor.
14The applicant has not met her onus to demonstrate that her injuries are not minor.
15To 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.
16Because the applicant remains within the MIG, the Tribunal need not assess the reasonableness and necessity of the disputed treatment plans beyond the MIG limits. The MIG is largely exhausted and of an amount that would not allow for any of the proposed treatment plans to be approved. Therefore the treatment plans in dispute are not reasonable and necessary.
Interest
17Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As no benefits are owing no interest is due.
ORDER
18The applicant has not met her onus to demonstrate her injuries are not minor.
19As the applicant remains in the MIG and the MIG limit is largely exhausted, the treatment plans in dispute are not reasonable or necessary.
20No interest is due.
Released: June 5, 2026
Timothy Porter
Adjudicator