Licence Appeal Tribunal File Number: 25-001333/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:
Rathikanthan Pathmanathan
Applicant
and
Intact Insurance Company
Respondent
DECISION
ADJUDICATOR:
Raymond Selbie
APPEARANCES:
For the Applicant:
Julia Logoutova, Paralegal
For the Respondent:
Theomarcus Giannou, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Rathikanthan Pathmanathan, the applicant, was involved in an automobile accident on February 4, 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, Insurer, 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 the submissions shall identify the amounts remaining.
ii. Is the applicant entitled to $1,100.32 for physiotherapy services, proposed by Aqua Wellness Centre in a treatment plan/OCF/18 (“plan”) dated April 14, 2023?
iii. Is the applicant entitled to $532.91 ($1,097.00 less $564.09 approved) for physiotherapy services, proposed by Aqua Wellness Centre in a plan dated May 26, 2023?
iv. Is the applicant entitled to $3,815.18 for physiotherapy services, proposed by Aqua Wellness Centre in a plan dated June 6, 2023?
v. Is the applicant entitled to $3,544.43 for physiotherapy services, proposed by Aqua Wellness Centre in a plan dated August 11, 2023?
vi. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3I find that the applicant sustained predominantly minor injuries from the accident in accordance with the definition in the Schedule and that the MIG applies to the applicant. As I have found that the applicant remains subject to the MIG, it is not necessary for me to consider whether the treatment plans are reasonable and necessary.
ANALYSIS
The Minor Injury Guideline (MIG)
4I find that the applicant sustained predominantly minor injuries from the accident in accordance with the definition in the Schedule and that the MIG applies to the applicant. As I have found that the applicant remains subject to the MIG, it is not necessary for me to consider whether the treatment plans are reasonable and necessary.
5The MIG establishes a framework available to injured persons who sustained a minor injury as result of an accident. A ‘minor injury’ is defined in s. 3(1) of the Schedule as ‘one or more of a strain, sprain, whiplash associated disorder, a contusion abrasion, laceration, subluxation, and includes any clinically associated sequelae to such injury’.
6Section 18 (1) of the Schedule limits recovery for medical and rehabilitation benefits for predominantly minor injuries to $3,500.00. An applicant may receive payment for treatment beyond the $3,500.00 cap if they can just demonstrate with compelling evidence that a pre-existing condition, documented by a medical practitioner, prevents maximum recovery of any accident-related minor injury under the MIG or if they can provide evidence of a non-minor injury, such as a psychological impairment or chronic pain with a fundamental impairment. The burden to establish entitlement to coverage beyond the $3,500.00 cap rests on the applicant on the balance of probabilities.
7The applicant does not claim that he suffered a pre-existing condition documented by a medical practitioner that prevents recovery from any accident-related minor injury under the MIG.
8The applicant submits that he has sustained an injury that results in chronic pain, radiculopathy and fibromyalgia which do not constitute ‘minor injuries’ per s. 3(1) of the Schedule and therefore he should be removed from the MIG.
9The submissions of the applicant refer to TABS in evidence however, the TABS are not so marked, and I have reviewed the materials as best as can be expected when arguments point to TABS that are not so delineated. The applicant relies on his health prior to the accident when he did not suffer the physical symptoms now being experienced. The history of medical attendances upon the applicant are as follows;
i. The applicant first attended upon his family physician within a week of the accident and complained of moderate bilateral knee pain. X-rays showed mild osteoarthritic changes. An ultrasound was conducted and revealed a joint effusion, and the left knee was normal.
ii. On May 30, 2023, Dr. Kohli of the Scarborough Pain Clinic provided a report. Dr. Kohli assessed the applicant who complained of pain in his left shoulder. An x-ray performed at Bowmanville X-ray and Ultrasound revealed maintained alignment, no fractures, no dislocation and no subluxation.
iii. On October 26, 2023, the applicant complained of lower back pain. His range of motion was found to be full, and he was assessed with mechanical back pain.
iv. The report from Dr. R. Moolla, GP dated March 21, 2024, provides an impression that the applicant suffers from fibromyalgia, intrascapular and biceps tenderness, radiculopathy, myofascial pain, lower back pain chronic daily headaches and chronic pain syndrome.
v. On July 4, 2024, Dr. R. Moolla examined the applicant, and he complained of lower back pain without numbness or radiation, intermittent bilateral knee pain without swelling, knee giving way, numbness or radiation.Dr. R. Moolla diagnosed the applicant with bilateral knee strain, left shoulder strain (resolved) and lumbosacral myofascial strain.
vi. The applicant made application for Ontario Disability Support Program assistance. The applicant relies on the findings from a form completed by a doctor at the Warden Finch Medical Clinic (signature indecipherable). as of July 28, 2023. The argument appears to be that the application for ODSP is sufficient to establish injuries that cannot be treated under the MIG as the applicant suffers from sleep dysfunction, requires support with grocery shopping, and has become withdrawn.
vii. The applicant refers to the different conclusions in the reports of Dr. R. Moolla and Dr. Kohli and given the short period of time, argues that the report of Dr. R. Moolla be given more weight.
10The respondent argues:
i. The review of the applicant’s visits to the Warden Finch Medical Clinic from March 2022 to May 2025 disclose that the applicant did not suffer a pre-existing condition documented by a medical practitioner that prevents recovery from any accident-related minor injury under the MIG.
ii. Dr. R. Moolla concluded that the applicant’s injuries were uncomplicated strains without musculoskeletal or neurological complications and that the injuries fall within the MIG. Also, the applicant reported that he remained independent with his self care, childhood activities with his daughter, assisting in cooking, shopping and normal social activities.
iii. The respondent notes that the application for ODSP reflect the applicant’s restricted ability to conduct several daily activities without support as of July 28, 2023. However, on July 4, 2024, the applicant was examined by Dr. R. Moolla and those restricted activities were apparently resolved. The applicant reported no concerns over those previously set forth in the ODSP application.
iv. The ODSP application does not mention the accident and there is no evidence that the issues listed in the application are attributable to the accident.
v. The respondent further notes that the applicant has not provided any medical evidence that he suffers from accident-related psychological symptoms, if any.
vi. The applicant refers to the report of Dr. R. Moolla dated March 21, 2024, and argues that the mention of chronic pain is sufficient to remove an applicant from the MIG. The respondent argues that three or more criteria are required to ascertain chronic pain as set out in the AMA Guides to Evaluation of Permanent Impairment (the ‘Guide”). The respondent argues that none of the criteria have been established by the applicant.
vii. Dr. R. Moolla opines in his report of May 30, 2024, that the applicant’s progress is good for a full recovery.
11I have weighed the evidence of the applicant and the respondent as above. In particular, the following evidence has been weighed by me, and I find that the applicant’s physical difficulties do not reasonably and necessarily require treatment outside the MIG:
i. The applicant did not serve and file a reply submission to the respondent’s submissions;
ii. The reports of the applicant’s family physician Dr. Kohli within a week of the accident to May 30, 2023, found moderate bilateral knee pain and shoulder pain. The x-ray and ultrasound showed maintained alignment, tenderness and lower back pain no fractures, no dislocation and no subluxation. Further he concluded that the applicant suffered mechanical back pain. Dr. Kohli concluded that the applicant suffered from chronic pain syndrome.
iii. The applicant relies on the application for ODSP dated July 28, 2023, and I note that the application concludes that the applicant is restricted in his daily activities and cannot function same without support. However, the respondent argues that the ODSP application does not provide and evidence that the medical findings are attributable to the accident. The disability that would support an ODSP application are countered by the report from Dr. R. Moolla of May 30, 2024, where he opines that the applicant’s progress is good for a full recovery.
iv. I note the contradiction findings of Dr.Kohli and Dr. R. Moolla coupled with the lack of reply submissions by the applicant and based on the onus of the applicant to establish his disabilities cannot be treated outside the MIG, and I find that the applicant has not established that his difficulties require treatment outside of the MIG.
The applicant is not entitled to any of the disputed treatment plans
12Having found that the applicant remains subject to the MIG, it is not necessary for me to consider whether the treatment plans are reasonable and necessary.
Interest
13Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. I find that interest does not apply as no benefits are overdue.
ORDER
[14] I find and order that:
i. The applicant’s injuries are predominantly minor as defined in s. 3 of the Schedule and therefore are subject to treatment within the $3,500.00 Minor Injury Guideline limit.
ii. The applicant is not entitled to any of the issues in dispute.
iii. The applicant is not entitled to interest.
Released: June 18, 2026
Raymond Selbie
Adjudicator