In this edition of our newsletter, we will be reviewing the recent Tribunal decision of Zapanta v. Security National Insurance Company, 2026 ONLAT 24- 010462/AABS [1].
On April 20, 2022, Ms. Mariedel Zapanta was involved in a motor vehicle accident. She sought benefits pursuant to the Statutory Accidents Benefits Schedule (SABS).
Ms. Zapanta, the applicant, was denied benefits by the respondent, Security National Insurance Company, and she applied to the Licence Appeal Tribunal to resolve the dispute.
The applicant was diagnosed with a concussion following the accident. The respondent maintained that her injuries were minor and that she was therefore subject to the minor injury guideline (MIG) and the $3,500 treatment limit.
According to section 3(1) of the SABS, a minor injury is defined 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” [2].
Ms. Zapanta had a medical history that includes diagnoses of borderline personality disorder, attention deficit and hyperactivity disorder, hyperacusis and central auditory processing disorder, autism, and two prior concussions in 2016 and 2017.
The applicant claimed that the MIG categorization and $3,500 in medical and rehabilitation benefits was insufficient for her to recover from her injuries because of her pre-existing health and functional status [2].
The respondent continued to believe that the applicant’s most recent accident was minor, and suggested that she was using her experience as an accident benefit claims adjuster, to further her claim. The respondent also argued that the applicant’s past medical history and pre-existing mental and behavioural impairments impacted her current presentation and course of injuries.
A few days after her accident, Ms. Zapanta sought medical attention at the hospital. She was diagnosed with a concussion by the emergency department physician, and was subsequently diagnosed with post-concussion syndrome by a chiropractor.
After review of the case and medical evidence, the Tribunal found that the applicant had provided clear and uncontroverted medical evidence that she sustained a concussion as a result of the accident. The hospital records documented a concussion diagnosis, and the chiropractor’s assessment documented post-concussion syndrome.
The Tribunal also considered the respondent’s concerns that the applicant continued to her destination after the accident, delayed seeking medical attention, returned to work, had pre-existing concussions, had a history of hitting her head against walls, and delayed applying for accident benefits. However, the Tribunal found that these factors were not sufficient to refute the medical diagnoses of a concussion.
Importantly, the Tribunal noted that a concussion is not a minor injury, as concluded from the recent case of Marcelo v. The Personal Insurance Company, 2026 ONSC 974 [3].
As a result, the Tribunal established that Ms. Zapanta sustained a concussion and was not subject to the MIG or the $3,500 funding limit.
Section 18(2) of the SABS further explains that the MIG does not apply to an insured person if, a “health practitioner determines and provides compelling evidence that the insured person has a pre-existing medical condition that was documented by a health practitioner before the accident and that will prevent the insured person from achieving maximal recovery from the minor injury if the insured person is subject to the limit or is limited to the goods and services authorized under the Minor Injury Guideline” [2].
Although the applicant used her pre-existing conditions in her argument that the MIG and its funding limit, were insufficient for her recovery, the Tribunal’s decision to remove her from the MIG was primarily based on the finding that she sustained a concussion, which is not a minor injury.
However, being classified outside of the MIG did not mean that all of the applicant’s requested treatment and benefits were payable. She was still required to demonstrate that the specific benefits and treatment plans were reasonable and necessary as a result of the accident.
The applicant was unable to demonstrate that services, including occupational therapy and psychology, were reasonable and necessary, and her claims for income replacement benefits and attendant care benefits were also denied.
In conclusion, the applicant was successful for her claim to be categorized outside of the MIG based on medical evidence of her concussion.
The Tribunal awarded her with two optometric treatment plans totalling $6,440, as well as 25% of the amounts withheld after the respondent continued to classify Ms. Zapanta’s concussion as minor.
Individuals who sustain a concussion and are diagnosed with post-concussion syndrome may experience an invisible disability and may have difficulty demonstrating their need for therapy due to impaired memory, attention, and judgement.
It is the role of the Occupational Therapist (OT) to assess the client, collect functional data, and identify rehabilitation needs. The OT communicates with the client and insurer about services that may benefit the client, in order to improve their functional independence and facilitate their return to daily activities, including self care, housekeeping, childcare, driving, work, and leisure, among many others.
It is highly recommended that an OT functional assessment be completed routinely, once the client is out of the MIG. At GLA Rehab, our Occupational Therapists provide comprehensive assessments and detailed reports to support clients’ rehabilitation needs and can provide important clinical evidence to support their need for rehab and use of their accident benefit claims.
References:
[1] Zapanta v. Security National Insurance Company, 2026 ONLAT 24- 010462/AABS, https://www.canlii.org/en/on/onlat/doc/2026/2026canlii39697/2026canlii39697.pdf
[2] O. Reg. 34/10: Statutory Accident Benefits Schedule – Effective September 1, 2010, https://www.ontario.ca/laws/regulation/100034 [3] Marcelo v. The Personal Insurance Company, 2026 ONSC 974 (CanLII), https://canlii.ca/t/kjfwr