An Ontario tribunal has handed Certas Direct Insurance Company a clean win, ruling that an applicant's car-accident injuries stayed inside the province's Minor Injury Guideline cap of $3,500.
The decision, released May 6, dismissed Abhishek Sharma's bid to access more than $14,700 in treatment and assessment plans tied to a November 2021 crash.
Sharma argued his injuries belonged outside the MIG on two fronts: chronic pain with functional impairment, and psychological impairments. The adjudicator, Harouna Saley Sidibé, rejected both.
Section 18(1) of the Statutory Accident Benefits Schedule caps medical and rehab benefits at $3,500 where injuries are "predominantly a minor injury." Section 3(1) defines that 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." Chronic pain with functional impairment or a psychological condition can break the cap - but the applicant has to prove it.
On chronic pain, the adjudicator went straight to the family physician's notes. Sharma first saw Dr. Abeer El Morsy on April 14, 2022, about five months after the accident. He reported right shoulder, right wrist, and low back pain. The pain was described as mild and improving with physiotherapy. No neurological symptoms. Imaging in July 2022 came back largely clean: mild straightening of the cervical lordosis, no fractures, a normal right shoulder X-ray, and no acute rotator cuff issues on ultrasound.
Sharma leaned on an orthopaedic assessment by Dr. Manoj Bhargava, who diagnosed chronic pain in the cervical spine, lumbar spine, and right shoulder with a guarded prognosis. The adjudicator accepted Bhargava could diagnose chronic pain. The problem was reconciling that opinion with the objective evidence of functional impairment - which the record did not really show.
What hurt Sharma most: he returned to full-time work in December 2021 and kept working. The decision said this "weighs against a finding of significant or ongoing functional impairment." Medical evidence also thinned out after August 2022.
The psychological argument followed a similar arc. Sharma relied on a report by psychologist Dr. Kenneth Keeling, based on an assessment conducted by registered psychotherapist Mila Popova on June 30, 2022. Keeling diagnosed Major Depressive Disorder, single episode, moderate, and Pain Disorder with Related Psychological Factors, and reported extreme impairment on the WHODAS 2.0 scale.
Certas relied on a section 44 assessment - an insurer-arranged medical exam - by psychologist Dr. Tatiana Dumitrascu. She found Sharma was working full-time as a forklift operator, managing personal care, and handling household tasks. She flagged symptom magnification and validity concerns in the psychometric testing, and concluded he did not meet DSM-5 criteria for a psychological disorder.
The adjudicator preferred Dumitrascu's evidence, calling it "more consistent with the contemporaneous primary care records" and aligned with "the applicant's demonstrated level of functioning, including sustained full-time employment."
The takeaway for Certas: Sharma's injuries were ruled "predominantly strain- and sprain-type soft-tissue injuries and associated sequelae." With Sharma kept inside the MIG, the adjudicator never had to assess whether the disputed treatment plans were reasonable and necessary. No benefits were overdue, so no interest was owed. The application was dismissed.
