Licence Appeal Tribunal File Number: 25-001197/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:
John Masih
Applicant
and
Belair Insurance Company Inc.
Respondent
DECISION
ADJUDICATOR:
Sarah Guergis
APPEARANCES:
For the Applicant:
Sunish R Uppal, Counsel
For the Respondent:
Asal Karimi, Counsel
HEARD: In Writing
OVERVIEW
1John Masih, the applicant, was involved in an automobile accident on May 20, 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, 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:
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?
Is the applicant entitled to $200.00 ($1,330.86 less $1,130.86 approved) for chiropractic services, proposed by 9221018 Canada Inc. in a treatment plan/OCF-18 (“plan”) submitted August 15, 2023, and denied September 11, 2023?
Is the applicant entitled to $5,957.70 for physiotherapy services, proposed by 9221018 Canada Inc. in a plan submitted September 19, 2023, and denied September 28, 2023?
Is the applicant entitled to $4,399.40 for chiropractic services, proposed by 9221018 Canada Inc. in a plan submitted December 13, 2024, and denied December 31, 2024?
Is the applicant entitled to $2,200.00 for a psychological assessment, proposed by Injury Management & Medical Assessments in a treatment plan dated September 19, 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
3I find that the applicant’s injuries are within the MIG.
4I find that because the applicant’s injuries are within the MIG, no analysis is required regarding the reasonableness or necessity of the plans in dispute.
5As no plans are payable, no interest is owing.
6No award is owing.
ANALYSIS
Minor Injury guideline
7I find that the applicant is within the MIG.
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 that his injuries and impairments fall outside the MIG on the following grounds:
i. A pre-existing medical condition, namely the March 2023 left-wrist fracture and surgical fixation; and
ii. The development of chronic pain and psychological sequelae causing functional impairment beyond the scope of a minor injury.
Pre-existing Injury
11I find the applicant is not removed from the MIG based on a pre-existing injury.
12The applicant submits that he was involved in an accident approximately two months prior to the subject accident, where he sustained a left wrist fracture requiring surgery.
13Further, when his vehicle spun out during the subject accident, his splinted hand was twisted on the steering wheel, causing an aggravation of the surgical site.
14The applicant relies on CNRs from Dr. Counti, chiropractor, dated June 4, 2025, where he concludes that the applicant suffers from chronic-recurrent left wrist sprain/strain and chronic pain syndrome. He found the applicant limited in prolonged sitting, standing, and gripping, and assessed overall recovery at less than 25%, recommending continued physiotherapy and chiropractic treatment.
15In his sworn affidavit dated June 12, 2025, the applicant stated that his left wrist pain worsened immediately after the subject accident, in the same anatomical location as his surgical repair, that his pain persists to date, and that he cannot perform daily chores or heavy tasks.
16The respondent submits that the only reasonable conclusion supported by the evidence before the Tribunal is that the applicant sustained only minor injuries in the subject accident and he is subject to the MIG limits.
17Further, that although the applicant reported that the accident aggravated his wrist injury, medical records indicate that post-accident diagnostic imaging showed good alignment. By August 1, 2024, he had regained full range of motion, reported minimal pain or tenderness, and his X-rays confirmed complete healing.
18The respondent relies on an evaluation from the emergency room directly following the subject accident. The applicant was seen by Dr. Osama Benmoftah, MD, who wrote “his x-ray looked good in terms of alignment. He has restricted range of motion, less than 5 degrees flexation and extension of the wrist, he has barely any pronation.”
19The respondent further relies on a consultation report also from Dr. Benmoftah, from January 8, 2024, which states, “the patient was here for follow-up with regard to his left wrist open reduction and internal flexation. He has full range of motion and not much pain. No tenderness. X-rays showed complete healing of the radius. He does have ulnar styloid process fibrous union.”
20I do not find that the applicant pointed me to compelling medical evidence which would establish that he has a pre-existing injury which would preclude his recovery if kept within the confines of the MIG.
21Based on his medical records which indicate good alignment, full range of motion, minimal pain or tenderness, and X-rays which confirmed complete healing, I have not been pointed to evidence from the applicant that his pre-existing wrist injury will prevent him from achieving maximal recovery if subject to the MIG limits.
22Therefore, the applicant is not removed from the MIG based on a pre-existing condition.
Chronic pain
23I find the applicant is not removed from the MIG based on chronic pain with a functional impairment.
24Chronic pain with a functional impairment is not included in the minor injury definition and a finding that the applicant sustained chronic pain with a functional impairment as a result of the accident would permit him to seek treatment beyond the $3,500.00 funding limit provided by the MIG.
25Although not part of the Schedule, the Tribunal has found the six criteria for a chronic pain condition outlined by the American Medical Association Guides to the Evaluation of Permanent Impairment (“AMA Guides”). While the Guides are not a definitive test to determine if someone suffers from chronic pain, they provide a helpful tool in that they set forth that a person must meet at least three of six criteria to support a diagnosis of chronic pain. These criteria are:
I. Use of prescription drugs beyond the recommended duration and/or abuse of or dependence on prescription drugs or other substances.
II. Excessive dependence on health care providers, spouse, or family.
III. Secondary physical deconditioning due to disuse and or fear-avoidance of physical activity due to pain.
IV. Withdrawal from social milieu, including work, recreation, or other social contracts.
V. 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.
VI. Development of psychosocial sequelae after the initial incident, including anxiety, fear-avoidance, depression, or nonorganic illness behaviours.
26The applicant submits that as a result of the accident he developed chronic pain causing functional impairment beyond the scope of a minor injury.
27The applicant submits he meets 3 of the 6 criteria required for a diagnosis of chronic pain, namely;
a) Excessive dependence on healthcare providers, spouse or family,
b) Secondary physical deconditioning due to disuse and/or fear, avoidance of physical activity due to pain, and
c) Development of psychological sequelae after the initial accident including anxiety, fear, avoidance, depression or nonorganic illness behaviours.
28The applicant relies on the following evidence:
i. Records from Alpha Physiotherapy June 4, 2025, where Dr. Counti, chiropractor, prepared an opinion concluding that the applicant suffers from chronic-recurrent cervical and lumbar sprain/strain, chronic-recurrent left wrist sprain/strain, and chronic pain syndrome.
ii. Dr. Counti, also stated “sleep disturbance, low/depressed mood, and anxiety leading to difficulties with memory/concentration and interpersonal relationships are further indicated.”
iii. The applicant relies on his sworn affidavit dated June 12, 2025, where he states that the subject accident aggravated his left wrist and lower back injuries from a previous MVA. Further, that he lives with his brother and relies entirely on him to perform the housekeeping chose at home and he avoids physical activity out of fear of aggravating the pain. Lastly, that due to his pain and associated limitations, his mood is lower than before the subject accident, he is less interested in recreational activity, suffers from anxiety especially while driving and has insomnia.
29The respondent submits that the applicant’s evidence is limited and fails to prove that his injuries require treatment beyond the MIG limits.
30The respondent relies on a s. 44 physician assessment report from January 28, 2025, completed by Dr. Sabrina Ming Wait Tu, GP. She noted that the applicant had reported his wrist pain as being very intermittent and mild before the accident, causing no functional limitations at home. Further, that this pre-existing condition would not be expected to materially complicate recovery from the accident-related soft tissue injuries.
31Further, on April 3, 2025, Dr. Tu conducted a comprehensive paper review of the applicant's medical records. Despite this thorough reassessment, her opinion remained unchanged.
32I find that the applicant has not pointed me to sufficient evidence which would establish that he sustained chronic pain with a functional impairment as a result of the subject accident.
33I acknowledge the applicant’s diagnosis of chronic pain syndrome from Dr. Counti. However, I find that it is outside of the scope of his profession as a chiropractor to make a diagnosis of chronic pain syndrome.
34I also acknowledge the applicant’s submissions regarding the AMA guides. However, I find that I was not pointed to evidence which would establish the applicant’s excessive dependence on healthcare providers or family. I acknowledge the applicant’s sworn affidavit regarding his dependence on his brother. However, this alone is not compelling evidence.
35Further, I find that I was not pointed to evidence which would establish the applicant’s secondary physical deconditioning due to disuse and/or fear, avoidance of physical activity due to pain. Again, the applicant’s own affidavit is not sufficient evidence to establish secondary deconditioning.
36Therefore, the applicant is not removed from the MIG based on chronic pain with a functional impairment.
Psychological sequelae
37I find the applicant is not removed from the MIG based on psychological sequelae.
38The applicant submits that he has psychological sequelae beyond the scope of a minor injury.
39The applicant relies on Dr. Counti, who also noted anxiety and low mood related to pain.
40The respondent submits that the medical evidence does not substantiate a diagnosis of psychological injury. Further, that the applicant has not attended a s. 44 psychological assessment, despite having multiple opportunities to do so, as the assessment was rescheduled several times.
41I do not find that the applicant has pointed me to evidence of a psychological injury as a result of the subject accident. I acknowledge that the applicant states in his affidavit that he suffers from anxiety and fear while driving. However, this is not compelling evidence which warrants his removal from the MIG.
42I considered both parties submissions regarding the MIG and prefer the evidence of the respondent as Dr. Tu is a medical doctor with approximately a decade of experience. Her Musculoskeletal Paper Review provides a more in-depth analysis of the applicant’s pre- and post-accident injuries.
43I find that Dr. Tu is qualified to assess the applicant’s injuries and agree with her report which finds that that the applicant’s pre-existing condition would not be expected to materially complicate recovery from the accident-related soft tissue injuries. Further, I find that the opinion letter from Dr. Counti, holds less weight, as he is a chiropractor and a diagnosis of chronic pain or psychological injury fall outside of the scope of his practice.
44I do not find that the applicant provided compelling evidence to establish their injuries warrant removal from the MIG.
45Therefore, on a balance of probabilities, I find that the applicant is not removed from the MIG
46I find that because the applicant was not removed from the MIG, no analysis of the reasonableness or necessity of the plans in dispute is required.
Interest
47As no plans are payable, no interest is owing.
Award
48The applicant did not make any written submissions regarding an award. As there were no submissions, he has not met his onus, and no award is owing.
ORDER
49I find that the applicant’s injuries are within the definition of the MIG.
50I find that because the applicant’s injuries are within the MIG, no analysis regarding the reasonableness or necessity of the plans in dispute is required.
51As no plans are payable, no interest is owing.
52No award is owing.
Released: June 15, 2026
Sarah Guergis
Adjudicator