Licence Appeal Tribunal File Number: 24-001964/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:
Yanique Crooks
Applicant
and
TD General Insurance Company
Respondent
DECISION
ADJUDICATOR: Melanie Malach
APPEARANCES:
For the Applicant: Bianca Crocetti, Counsel
For the Respondent: Ashley Dunkley, Counsel Jennifer Kiss, Counsel
HEARD: By way of written submissions
OVERVIEW
1Yanique Crooks, the applicant, was involved in an automobile accident on December 5, 2021, 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, TD General Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
2This decision is a rehearing as a result of the reconsideration decision dated May 11, 2026, that cancelled the initial decision pursuant to Rule 18.4 of the Licence Appeal Tribunal Rules, 2023. The matter was ordered to be reheard based on the parties’ submissions and evidence from the initial written hearing.
ISSUES
3The 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 limit?
ii. Is the applicant entitled to the assessments proposed by Brampton Physiocare and Wellness Centre, as follows:
a) $1,962.00 for chiropractic services, in a treatment plan submitted on April 26, 2022;
b) $1,660.02 for physiotherapy services, in a treatment plan submitted on November 15, 2022;
c) $4,205.26 for physiotherapy services, in a treatment plan submitted on February 14, 2023; and
d) $2,000.00 for a psychological assessment, in a treatment plan submitted on March 29, 2022?
iii. Is the applicant entitled to $2,000.00 for a chronic pain assessment, proposed by Ortho Neuro Physiocare in a treatment plan submitted on October 27, 2022?
iv. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
v. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
4I find that the applicant’s injuries are predominantly minor as defined in s. 3 of the Schedule and therefore she is subject to treatment within the $3,500.00 MIG limit.
5I find that the applicant is not entitled to the treatment plans in dispute, interest or an award.
PROCEDURAL ISSUES
6The respondent submits that the applicant’s submissions are in non-compliance with the Case Conference Report and Order (“CCRO”) due to her failure to consecutively number the paragraphs in her submissions. The respondent further submits that the applicant has failed to pinpoint the exact evidence in which she is referencing in her 1185-page brief. The respondent argues that it is not the role of the respondent nor the Tribunal to read the entire 1185 pages and presume to know which page in the brief the applicant is referencing.
7The respondent relies upon the Tribunal decision in Barlow v. Wawanesa Mutual Insurance Company, 2024 CanLII 67359 (ON LAT), which held that when a CCRO expressly specifies that the parties’ submissions must make specific reference to the evidence and law by tab and page number, and a party fails to do this, it is not the Tribunal’s role to advocate for that party. The Tribunal cannot presume to know which evidence or portion thereof, if any, that a party intends to rely on in advancing its case.
8While I agree with the respondent that the applicant’s submissions do not have paragraph numbers which has made it more difficult to read, I do not agree to disregard the applicant’s submissions on this basis. I find that the respondent has not indicated what prejudice it has suffered by the lack of paragraph numbers. I find that any prejudice to the respondent, if any, by allowing the applicant’s submissions, is greatly outweighed by the prejudice to the applicant if I were to not allow them. I therefore accept the applicant’s submissions as submitted despite their non-compliance with the CCRO.
9With respect to the respondent’s submission that the applicant has failed to pinpoint the exact evidence in which she is referencing, I agree with the respondent that the lack of references and page numbers has made it increasingly difficult to locate the medical evidence referred to in her submissions. Again, I do not agree to dismiss the applicant’s submissions on this basis, as the prejudice to the applicant outweighs any prejudice to the respondent. However, I remind the parties that the Tribunal can only assess evidence which is pointed to and directed to by the party. It is not the role of the Tribunal to make either party’s case for them.
ANALYSIS
The applicant sustained predominantly minor injuries as defined under the Schedule
10I find that the applicant sustained a minor injury as a result of the accident and, therefore, is subject to the $3,500.00 funding limit on treatment.
11Section 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) of the Schedule defines a “minor injury” as “one or more of a strain, sprain, whiplash associated disorder, contusion, abrasion, laceration or subluxation and includes any clinically associated sequelae to such an injury.”
12An 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) of the Schedule, that they have a documented pre-existing condition combined with compelling medical evidence stating that the condition precludes maximal medical 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.
13In this matter, the applicant submits that her injuries are not predominantly minor, and she relies on all of the medical evidence submitted in support of that position. She relies upon the Disability Certificate, prepared by Nirat Mann, physiotherapist, at Physiocare and Wellness Clinic, dated December 21, 2021, which confirms her injuries and disability including pain, strain and sprain of thoracic spine; sprain and strain of lumbar spine; and sprain and strain of other and unspecified parts of lumbar spine and pelvis.
14The applicant further relies upon the Clinical Notes and Records (“CNRs”) of her family physician, Dr. Ali Kassam, to support the injuries she sustained in the subject accident. Specifically, she submits that the CNR dated December 6, 2021, states that she is complaining of lower back pain. The CNR on December 16, 2021, notes her complaints of lower back pain, a prescription for pain killers and muscle relaxants and a referral for physiotherapy. The applicant further relies upon an Attending Physician’s Statement – Short Term Disability Claim for Canada Life, dated December 21, 2021, which states she suffers from lower back pain, shoulder pain and strain, neck pain and a concussion due to the accident. The CNR dated February 26, 2022, notes complaints of anxiousness, low mood, difficulty relaxing, constant worry, irritability, muscle tension and sleep disturbance. The CNR dated March 26, 2022, notes complaints of anxiety and post-traumatic stress disorder (“PTSD”). The CNR dated February 2, 2023, notes complaints of right knee pain. She further relies on the CNRs of Physiocare and Wellness where she attended for treatment and a prescription summary from Shoppers Drug Mart setting out the medications she was prescribed.
15The applicant also submits that she attended Credit Valley Hospital on June 6, 2022, with severe headaches, light and sound sensitivity and pain to the right side of her neck. She returned to the emergency department on June 20, 2022, with complaints of a headache and migraine and was referred to a neurologist. On June 29, 2022, she returned again due to her headaches. On September 15, 2022, she returned a final time with complaints of headaches and blurred vision.
16The respondent submits that the applicant has sustained only a minor injury as a result of the subject accident. The respondent argues that the applicant has failed to meet her burden of proof that her injuries fall outside of the MIG. The respondent submits that the applicant has attempted to make claims that she suffers from chronic pain and psychological impairments however, there is no compelling evidence to suggest that she should be removed from the MIG.
17The respondent submits that with respect to chronic pain, there is no medical evidence adduced by the applicant that suggests a diagnosis of chronic pain or chronic pain syndrome. In addition, the respondent submits that the applicant does not satisfy any of the chronic pain diagnostic criteria as set out in the American Medical Association Guides to the Evaluation of Permanent Impairment (the “AMA Guides”).
18The respondent submits that with respect to the applicant’s psychological impairments, she has only given broad summaries of her alleged complaints without evidence. The respondent submits that the applicant stopped mentioning any psychological impairments to her family physician after March of 2022. The respondent further relies upon the Psychological Insurer Examination (“IE”) report of Dr. Zubina Ladak, dated August 16, 2022, which concluded that the applicant did not have any psychological diagnosis as a result of the accident.
19I find that the applicant has not identified on what basis she should be removed from the MIG. She has not made specific submissions that she should be removed from the MIG due to a pre-existing condition, a concussion, chronic pain or a psychological impairment.
20I find that with respect to removal from the MIG based on a pre-existing condition, the applicant has not pointed the Tribunal to any documented pre-existing condition combined with compelling medical evidence stating that the condition precludes maximal medical recovery if she is kept within the confines of the MIG. I therefore do not find that the applicant has established removal from the MIG on the basis of a pre-existing condition.
21I find that the applicant has not provided persuasive evidence to support that she suffered a concussion as a result of the subject accident that would remove her from the MIG. While the applicant refers to an Attending Physician’s Statement – Short Term Disability Claim, dated December 21, 2021, that states under secondary and/or complications that she suffers from a concussion, the applicant has not pointed the Tribunal to any further medical documentation that makes a diagnosis of concussion. In addition, upon review of the CNRs from Credit Valley Hospital, while the applicant attended and claimed to suffer headaches in June 2022, there is no diagnosis of a concussion made and it is noted on June 29, 2022, that her headaches are “consistent with tension headaches likely related to her manual work at Amazon.” I further find that the applicant has not pointed the Tribunal to any evidence that neurological testing was performed to assess whether the applicant suffered a concussion or that any treatment was performed in respect to a concussion. While she notes that she was referred to a neurologist, she has not directed the Tribunal to any report prepared by a neurologist assessing her condition. I therefore do not find that the applicant is removed from the MIG on the basis of a concussion.
22I find that the applicant has not made any specific submissions that she suffered a chronic pain condition as a result of the accident which would warrant removal from the MIG. I find that her claim that her injuries are outside of the MIG is based on the CNRs of Dr. Kassam where she made complaints about pain.
23I find that ongoing pain alone is insufficient to remove the applicant from the MIG, as the pain must be of a severity that it causes suffering and distress accompanied by functional impairment or disability. I find that the applicant has not proven on a balance of probabilities that her ongoing pain was of a significant level or was accompanied by some functional impairment or disability. I find that the applicant’s pain was merely sequelae or a symptom of her minor injuries. I find that the applicant has not provided any submissions or pointed the Tribunal to evidence that her pain prevented her from pursuing work, family or recreational needs, or that she developed psychosocial sequelae.
24I find that the applicant’s accident-related impairments fall squarely within the definition of minor injuries under the Schedule. I find limited medical evidence to support the applicant’s submissions that her accident-related impairments are significant, or really what specific impairments she believes fall outside of the scope of the MIG. Further, while I accept the applicant’s claims that she had ongoing pain and attended for treatment, she has not provided a medical opinion or other medical evidence that states she would be prevented from reaching maximal medical recovery if she is kept within the MIG as required by s. 18(2) of the Schedule.
25I further find that there is no diagnosis of chronic pain or chronic pain syndrome in the CNRs referred to by the applicant in her submissions. I further agree with the respondent that the applicant’s submissions do not engage with any of the six criteria under the AMA Guides. Indeed, while the applicant may have ongoing pain, I do not find that her pain causes the type of functional impairment that would warrant removal from the MIG, as she has not directed the Tribunal to any evidence that she has been referred to any specialists, and she did not point the Tribunal to any functional issues with her daily activities. I therefore do not find that the applicant is removed from the MIG on the basis of chronic pain.
26With respect to any psychological impairment sustained by the applicant to justify removal from the MIG, I find that the applicant has referred to a CNR of Dr. Kassam dated February 26, 2022, which notes complaints of anxiousness, low mood, constant worry, irritability, muscle tension and sleep disturbance. She also refers to the CNR of Dr. Kassam dated March 26, 2022, which notes complaints of anxiety and PTSD.
Despite referring to these psychological complaints in Dr. Kassam’s records, the applicant has not provided any submissions or evidence to support whether the applicant was referred to any specialist for these complaints or received any treatment. In addition, I find that the Tribunal was not directed to an actual diagnosis of an accident-related psychological impairment that would warrant removal from the MIG.
27I give weight to the IE Psychological report of Dr. Ladak, which is the only psychological assessment before me. I accept Dr. Ladak’s opinion that from a psychological perspective, the applicant’s symptoms are considered to meet the criteria of a minor injury. I further accept Dr. Ladak’s findings that the applicant is experiencing some emotional difficulties in response to her pain and physical limitations but that she does not meet the full criteria for a formal DSM 5 diagnosis as it relates to the accident.
28I therefore do not find that the applicant is removed from the MIG on the basis of a psychological impairment.
29For the reasons outlined above, I find that the applicant has not proven on a balance of probabilities that her accident-related impairments warrant removal from the MIG.
Entitlement to the Treatment Plans in Dispute
30I find that other than listing the treatment plans in dispute, the applicant has not provided specific submissions about the reasonableness and necessity of the services and assessments recommended. As I have found that the applicant remains within the MIG, and the treatment plans in dispute seek treatment outside of the MIG, it is unnecessary for me to determine whether the treatment plans in dispute are reasonable and necessary.
31In the alternative, the applicant submits that the respondent did not comply with s. 38(8) of the Schedule in its notice denying the treatment plans in dispute. The applicant argues that the respondent’s denial letters state that the reason for denial of the treatment plans is due to the applicant’s injuries being considered minor in nature. The applicant submits that the denials are merely boiler plate responses to the submission of the treatment plans and provide an opinion of the injuries from the adjuster’s perspective rather than from a medical one.
32Section 38(8) of the Schedule sets out that within 10 business days of receipt of the treatment plan, insurers are required to provide an insured with a notice, identifying the goods and services described in the treatment plan that it agrees to pay for and the medical and all other reasons why it considers the goods and services not to be reasonable and necessary. In addition, if any insurer believes that the MIG applies it shall indicate so in its denial pursuant to s. 38(9). The consequences of an insurer’s failure to comply with s. 38(8) and (9) is that the benefits are payable as set out in s. 38(11). If an insurer fails to advise that it believes the MIG applies, then an insurer must pay the benefits.
33I find that other than submitting that the reasons in the respondent’s denial letters are boilerplate and provide an opinion of the injuries from the adjuster’s perspective rather than from a medical one, the applicant has not provided specific submissions on the content of each of the respondent’s denial letters.
34The applicant in her submissions has provided the Tribunal with a copy of five denial letters. I find upon review of these letters, that they are all valid denial letters. The letters advise of the date of the treatment plan and the services being recommended. Each letter indicates that the treatment plan is denied based on the applicant’s injuries falling within the MIG. The denial letters also provide further specifics as to why the treatment plans are denied. The letter dated April 21, 2022, dealing with the treatment plan for a psychological assessment, states that a s. 44 assessment would be arranged to determine the applicability of the minor injury. The letter dated May 11, 2022, states that it is currently waiting for the s. 44 Independent Examination Report to determine the applicability of the minor injury and once the completed s. 44 report is received, it may reconsider the plan. The letters dated December 1, 2022, March 1, 2023, and March 22, 2023, indicate that the treatment plans are denied based on the s. 44 report dated August 29, 2022, which concluded that the applicant’s injuries and symptoms meet the criteria of a minor injury.
35I find that the respondent provided clear medical and other reasons in its denial notice, sufficient to allow the applicant to make an informed decision as to whether to accept or dispute the decision. I find that each letter is a clear and unequivocal denial. Although the applicant may disagree with the respondent’s stated reasons, it does not render the notice invalid.
36For the reasons outlined above, I find on a balance of probabilities, that the applicant has not met her burden of proving that these treatment plans are payable under s. 38(11) of the Schedule.
Interest
37Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. As I have found that there are no overdue benefits, no interest is payable.
Award
38The applicant sought an award under s. 10 of Reg. 664. Under s. 10, the Tribunal may grant an award of up to 50 percent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits.
39The applicant submits that the respondent should be liable to pay an award because it unreasonably withheld or delayed payments to the applicant.
40As I have found that the respondent did not unreasonably withhold or delay payment of any benefit, no award is warranted.
ORDER
41For the reasons outlined above, I find:
i. The applicant’s injuries are predominantly minor as defined in s. 3 of the Schedule and therefore she is subject to treatment within the $3,500.00 MIG limit;
ii. The applicant is not entitled to the treatment plans in dispute, interest or an award; and
iii. The Application is dismissed.
Released: June 17, 2026
Melanie Malach
Adjudicator