A claimant's own medical evidence undid her bid to escape Ontario's $3,500 Minor Injury Guideline cap, a tribunal has ruled.
The Ontario Licence Appeal Tribunal has dismissed a claimant's bid to escape the Minor Injury Guideline (MIG), the $3,500 limit the Statutory Accident Benefits Schedule places on medical and rehabilitation benefits where impairments are predominantly minor.
The applicant was a passenger in a vehicle rear-ended on February 20, 2021. Security National Insurance Company had approved treatment within the MIG but denied two further plans - $2,200 for psychological services proposed on February 28, 2024, and $3,175.90 for physiotherapy proposed on August 22, 2023 - on the basis both exceeded the guideline. The applicant argued for removal from the MIG on three grounds: a pre-existing condition, chronic pain, and a psychological impairment. Adjudicator Kimberly Gruetzman rejected all three and dismissed the application in full, along with claims for interest, a special award, and costs.
On the pre-existing condition, the applicant's family doctor's records confirmed neck and shoulder strain with pain complaints and a prescription dating back to 2019. The adjudicator found no compelling medical evidence that this condition would block recovery within the MIG, noting the doctor's records showed no accident-related complaints after March 22, 2021, roughly one month after the crash.
The applicant also pointed to an insurer's examination she said supported her case, from a physiatrist. That report was never filed in evidence; her account of its contents came only from a second insurer's examination, by a psychologist, who had summarized it. The physiatrist's own later report, dated October 7, 2024, was before the tribunal, and it found the applicant had sustained soft tissue injuries meeting the MIG's definition of minor injury, with no clinical evidence of cervical radiculopathy, and concluded further treatment would not be therapeutically beneficial.
The chronic pain argument fared no better. The adjudicator pointed to a significant gap between the applicant's last reported pain to her family doctor in March 2021 and insurer examinations conducted around sixteen months after the accident that recorded ongoing complaints, and noted the applicant had not disclosed a 2017 motor vehicle accident to either assessor - an omission that undercut the reliability of findings that had otherwise supported optional caregiver and housekeeping benefits.
On the psychological claim, the applicant relied on a diagnosis of adjustment disorder with mixed anxiety and depressed mood, plus somatic symptom disorder, from the psychologist's October 7, 2024 report. But that report tied the diagnosis to a second, unrelated accident in October 2023, not the 2021 collision. The report also recorded that the applicant had said she "was coping well as her physical condition had improved" until that later accident. The adjudicator found no accident-related psychological impairment stemming from the 2021 crash.
With the applicant confirmed inside the MIG, the adjudicator did not need to weigh whether the disputed treatment plans were reasonable and necessary. No benefits were found overdue, so no interest was payable. The insurer had not unreasonably delayed payment, so no special award followed under section 10 of Regulation 664, and no costs were ordered. The decision was released August 4, 2026.
