Judge v. Definity Insurance Company
Licence Appeal Tribunal File Number: 24-004931/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:
Jasvir Judge
Applicant
and
Definity Insurance Company
Respondent
DECISION
ADJUDICATOR: Harouna Saley Sidibé
APPEARANCES:
For the Applicant: Jasmine Patel, Counsel
For the Respondent: Matthew Murphy, Counsel
HEARD: By way of written submissions
OVERVIEW
1Jasvir Judge, the applicant, was involved in an automobile accident on December 9, 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, Definity 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?
ii. Is the applicant entitled to $2,430.00 for physiotherapy services, proposed by Basra Chiropractic Clinic Inc. in a treatment plan/OCF-18 (“plan”) submitted June 3, 2022, and denied January 11, 2024?
iii. Is the applicant entitled to interest on any overdue payment of benefits?
3The parties agree that the MIG monetary limit has not been exhausted. The amount paid to date is $1,732.80, leaving $1,767.20 of the $3,500 MIG limit remaining.
RESULT
4For the reasons below, I find that:
The applicant’s injuries are predominantly minor, so the MIG monetary limit applies.
Because the applicant is bound by the MIG, it is not necessary to consider whether a treatment plan in dispute is reasonable and necessary. The applicant is entitled to treatment up to the MIG limits.
The applicant is not entitled to interest.
ANALYSIS
Are the applicant’s injuries predominantly minor?
5I find that the applicant has not established that his injuries fall outside the MIG.
6Section 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.”
7An 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.
8The applicant submits that he suffers from chronic pain and significant physical and psychological impairments, such that the MIG should not apply.
Chronic Pain
9I find that the applicant has not established that he suffers from chronic pain with a functional impairment that warrants removal from the MIG.
10The applicant relies on a February 2023 note from Dr. Mohammad Sadiq Hurmat Ali, a family doctor, which notes chronic pain and functional difficulties. He also relies on Gill v Allstate Insurance, 2023 CanLII 122925 (ON LAT), to support the principle that chronic pain with functional impairment may justify the removal of MIG.
11The applicant further argues that because the respondent approved a non-earner benefit (“NEB”), his injuries must necessarily fall outside the MIG.
12The respondent submits that the applicant’s medical evidence is insufficient to remove him from the MIG. The respondent highlights that the applicant did not seek medical attention on the date of the accident and did not begin treatment until January 4, 2022. It also relies on the gaps in treatment, limited documentation, and the absence of persuasive evidence establishing chronic pain syndrome with resulting functional impairment.
13Finally, the respondent notes that NEB entitlement does not automatically remove a claimant from the MIG because the tests for each benefit are distinct.
14The evidentiary record includes an OCF-3 dated January 4, 2022, in which a physiotherapist diagnosed sprain/strain injuries and documented symptoms such as headaches, insomnia, and stress.
15Both parties refer to clinical notes and records (“CNRs”) dated February 7, 2023, from Dr. Ali, in which the applicant reports pain and functional limitations. Dr. Ali notes chronic pain, but also indicates there are no neurological symptoms.
16On September 22, 2023, CNRs from Dr. Ameesh Grewal, a family doctor, noted right SI joint/hip pain radiating to the leg and shoulder. The symptoms reportedly improved with physiotherapy but recurred when treatment stopped. Dr. Grewal observed no weakness or numbness and documented that the applicant was sitting comfortably and able to get into bed without assistance. An X-ray was ordered.
17The September 23, 2023, X-ray shows no acute fracture, no malalignment, and preserved joint spaces. A calcification near the greater trochanter may be related to a prior avulsion.
18The applicant relies on a note from Dr. Harpreet Singh Bhatia, a consultant orthopaedic surgeon, diagnosing a prolapsed intervertebral disc (PIVD) with radiculopathy and recommending ongoing physiotherapy and possible surgery. Dr. Bhatia did not relate this diagnosis to the subject accident, and there is no corroboration of PIVD or accident causation in any contemporaneous records from him or from other treating practitioners. While a diagnosis by an orthopaedic surgeon can, in principle, stand on its own, in this case, the diagnosis and any causal link to the accident are uncorroborated by imaging, clinical notes, or independent assessments from other providers.
19I accept that chronic pain can, in appropriate circumstances, justify removal from the MIG. However, in this case, the evidence does not demonstrate a consistent or objectively supported pattern of pain reporting that would support a finding of chronic pain with associated functional impairment. The applicant has not identified any concrete examples of functional limitations arising from the reported pain, nor is there documentation from treating providers describing such impairment.
20The applicant relies heavily on Dr. Ali’s February 2023 note. This note was written more than a year after the accident and is not supported by medical records created closer in time to the accident or during ongoing care. Without contemporaneous treatment-period documentation, I give this note limited weight for the purpose of MIG removal.
21I also do not accept the argument that NEB entitlement automatically removes a claimant from the MIG. The tests are distinct, and the applicant provided no authority to the contrary.
22Accordingly, on a balance of probabilities, I find that the applicant has not demonstrated that he sustained chronic pain with a functional impairment warranting removal from the MIG.
Psychological Impairments
23I find that the applicant has not established that he sustained a psychological impairment.
24Although the applicant asserts psychological injury in his submissions, he provides no clinical records, assessments, or other evidence to describe the nature of the alleged psychological condition or to substantiate the claim.
25The respondent submits that there is no objective medical evidence of psychological impairment, nor any submissions from the applicant explaining or substantiating the nature of the alleged psychological injury.
26Regarding the applicant’s complaints of stress, insomnia, and headaches, I accept the respondent’s position that the record lacks consistent reporting, a formal diagnosis, or treatment by an appropriate medical professional to support the applicant’s claim.
27The applicant did not direct me to any clinical evidence of a psychological condition.
28Accordingly, I find that the applicant has not established a psychological impairment warranting removal from MIG.
29For these reasons, I find that the applicant has not discharged his onus of establishing that his injuries fall outside the MIG. On the evidence before me, his impairments are predominantly minor. Therefore, the applicant remains within the MIG.
Is the applicant entitled to the disputed physiotherapy treatment plan?
30Because the applicant remains within the MIG, I do not need to assess whether the disputed treatment plan is reasonable and necessary. The applicant is entitled to treatment up to the MIG limits.
Interest
31Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule. Since no benefit is owed, interest is not owed.
ORDER
32For the above reasons, it is ordered that:
i. The applicant’s injuries are predominantly minor, so the MIG monetary limit applies.
ii. Because the applicant is bound by the MIG, it is not necessary to consider whether a treatment plan in dispute is reasonable and necessary. The applicant is entitled to treatment up to the MIG limits.
iii. The applicant is not entitled to interest.
Released: February 3, 2026
Harouna Saley Sidibé Adjudicator