Category: Minor Injury Guideline

Applicant v. Coachman Insurance Company (16-003306)

The claimant sought entitlement to removal from the MIG, IRBs, ACBs, medical benefits, and special award. He argued that he sustained a fractured sternum, a concussion, and major depressive disorder as a result of the accident. Despite an IE assessor concluding that the fractured sternum was related to the accident, the insurer concluded otherwise based on the related CT scan being performed a month after the accident in a foreign country. Adjudicator Gosio concluded that the claimant did suffer a fractured sternum, a concussion, and psychological impairments from the accident. He removed the claimant from the MIG and awarded some of the claimed medical benefits. He awarded IRBs based on the claimant being unable to perform his employment as a realtor primarily due to psychological issues. Surveillance of the claimant being physically functional did not persuade Adjudicator Gosio that the claimant was untruthful or that he was able to return to his employment. Adjudicator Gosio also awarded fifteen months of ACBs and held that the insurer had unreasonably withheld payment. Services were deemed incurred in accordance with section 3(8). Finally, Adjudicator Gosio issued a special award against the insurer in relation to ACBs due to the manner in which it denied ACBs and mislead the claimant on the IE physician’s opinion.

Applicant v. Pembridge (17-005544)

The claimant sought removal from the MIG and entitlement to four medical benefits. Adjudicator Purdy concluded that the claimant did not suffer chronic pain or psychological impairments as a result of the accident, and that such injuries arose from an unrelated workplace incident.

M.C. v. Aviva Insurance Company of Canada (17-002614)

The claimant sought entitlement to treatment outside of the MIG, attendant care benefits, six treatment plans, and a special award. Adjudicator Truong found that the claimant was entitled to treatment outside of the MIG, the cost of an attendant care assessment and assistive devices, interest, and a special award. Adjudicator Truong found that the claimant was not entitled to attendant care or the cost of the remaining treatment plans. She noted that the claimant had not incurred any attendant care services following the accident. Adjudicator Truong held that the MIG did not apply to the applicant’s impairments pursuant to section 38(11) because the insurer had failed to respond within 10 days. Adjudicator Truong found that the attendant care assessment was payable for the same reason. The treatment plan had been denied on HCAI, but no denial letter was sent by the insurer. Adjudicator Truong also held that the applicant was entitled to the special award largely due to the insurer’s continued denial of the cost of the attendant care assessment despite its failure to provide a denial letter. Adjudicator Truong stated that once the insurer became aware it had breached section 38(8) with respect to providing notice, it should have immediately provided notice and/or paid the benefit.

Applicant v. Unifund Claims Inc. (17-005698)

The claimant sought removal from the MIG, entitlement to ACBs, and entitlement to various medical benefits. Adjudicator Watt concluded that the claimant’s injuries fell within the MIG. He noted that the claimant had essentially returned to his pre-accident life shortly after the accident. He also held that the claimant’s self-reporting contradicted the statements in the section 25 reports regarding ongoing impairments.

R.P. v Aviva Insurance Canada (17-003500)

The claimant appealed Aviva’s MIG determination and sought medical benefits for chiropractic services, the completion of numerous OCF-3s, a social work assessment, and an orthopaedic assessment. The claimant also sought IRBs. Aviva opposed the claimant’s request to have a treating chiropractor qualified as an expert. Adjudicator Hines held that the claimant’s injuries were within the MIG and none of the OCF-18s or OCF-3s were reasonable and necessary. The adjudicator further held that the claimant was not entitled to IRBs. The adjudicator also held that the treating chiropractor was not qualified as an expert witness, but could give evidence in his capacity as a treating chiropractor. The adjudicator held that the claimant sustained soft-tissue injuries, which fell within the MIG. The adjudicator held that the chiropractor’s diagnosis of post-concussion syndrome/concussion was outside the scope of his expertise, and the adjudicator also found inconsistencies in the claimant’s evidence with respect to “loss of consciousness”. The adjudicator preferred Aviva’s IE report from a psychologist over the claimant’s report from a social worker with respect to psychological injuries. The adjudicator also held that the rates charged on the OCF-18s exceeded the amounts payable under the FSCO Guideline. The OCF-3s were not payable as particulars were not provided with respect to the claimant’s change in condition and updated OCF-3s were not requested by Aviva. Lastly, the adjudicator preferred Aviva’s multi-disciplinary report over the claimant’s evidence (OCF-3s) with respect to IRBs, and held that the claimant did not suffer a substantial inability to perform the essential tasks of a material handler or casino dealer.

Applicant v. Aviva Insurance Company (17-002973)

The claimant sought entitlement to IRBs, ACBs, and medical benefits. The insurer argued that the claimant failed to attend an IE assessment contrary to the SABS. Adjudicator Maedel agreed with the insurer in regard to most of the claimed benefits, and held that the IEs were not requested inappropriately. In terms of the MIG and a psychological treatment plan, the adjudicator held that the claimant failed to prove that she suffered a psychological injury as a result of the accident. He preferred the IE opinions over that of the claimant’s assessors, which appeared to be boilerplate. He also commented that the family physician’s records did not show any connection between the accident and the claimant’s psychological impairments.

Applicant v. Aviva Insurance Company (17-002638)

The claimant sought entitlement to ongoing IRBs, various medical benefits outside of the MIG, and a special award. The claimant submitted that psychological impairments and chronic pain took him outside of the MIG. Adjudicator Boyce found that the claimant’s impairments were predominantly minor injuries, holding that in the absence of evidence of a full or partial tear, the claimant’s shoulder tendonitis was within the MIG. The claimant was found not to have a psychological diagnosis. Adjudicator Boyce held that the claimant had not proven that he had missed work as a result of the accident and was therefore not entitled to IRBs. A special award was denied.

Applicant v. Aviva Insurance Company (17-003600)

The claimant sought entitlement to medical benefits outside of the MIG and a special award. Adjudicator Victor found that the claimant was outside of the MIG because of the extent of her psychological symptoms, and she was entitled to the cost of a psychological assessment, plus interest. The claimant was not found entitled to a special award.

Applicant v. Co-Operators Insurance Company (17-006513)

The claimant sought medical benefits outside of the MIG and interest on the overdue payment of benefits. Adjudicator Ferguson held that the claimant’s injuries fell within the MIG and dismissed the claimant’s application. Adjudicator Ferguson relied on the claimant’s self-reporting to conclude that the claimant did not have a credible psychological injury arising from the accident. Adjudicator Ferguson noted that the claimant’s own words in examination were “powerful evidence” in determining whether the claimant’s claimed psychological issues were credible. Adjudicator Ferguson also concluded that the claimant had failed to prove that she suffered from chronic pain syndrome because her self-reports were contradictory and non-credible.

B.A. v Certas Direct Insurance Company (17-004796 and 17-004801)

The claimant was involved in two motor vehicle accidents and appealed Certas’ MIG determination for each accident. The claimant also sought medical benefits for physiotherapy for the first accident and chiropractic services for the second accident. Adjudicator Cavdar held that the claimant’s injuries for each accident fell within the MIG. The claimant suffered soft-tissue injuries as a result from the first accident. While the claimant argued that she suffered a psychological injury, her only evidence was a note of emotional disturbance by a physiotherapist, and her self-report to an IE physiatrist that she had a fear of driving. The adjudicator further held that the claimant suffered soft-tissue injures as a result from the second accident, and there was no evidence of a psychological injury except for the claimant’s self-report of anxiety. The adjudicator also held that the claimant did not submit compelling medical evidence to detail how a pre-existing condition would remove her from the MIG for the second accident.

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