H.C. v. Certas Direct Insurance Company (16-001285)

The claimant sought entitlement to income replacement benefits along with two treatment plans, costs, and a special award. Adjudicator Bass reviewed the medical evidence, along with surveillance submitted by the insurer. It was found that the claimant’s reports were “overly pessimistic in light of the surveillance evidence from only a few months later.” As a result, it was concluded that the claimant did not sustain a substantial inability to perform the essential tasks of his employment. The treatment plans claimed were also denied as Adjudicator Bass found the claimant’s injuries to be minor.

J.S. v. RBC Insurance Company (16-000576)

The claimant sought entitlement to eight treatment plans. The insurer maintained a MIG position. Adjudicator Makhamra found the claimant failed to meet the burden of proof to warrant removal from the MIG. The claimant holds the onus to prove removal from the MIG is justified. In doing so, Adjudicator Makhamra distilled the analysis to three questions: i. Are the claimant’s injuries predominantly minor? ii. Does the claimant suffer from a pre-existing medical condition that prevents him from reaching maximal recovery if he is subject to the $3500 cap in the Minor Injury Guideline? and, iii. Are the treatment plans necessary and reasonable for the claimant’s treatment? Adjudicator Makhamra was satisfied with the notice letters and said the insurer “explained that the applicant’s injuries were within the MIG; it described the diagnosis, and advised of its intention to schedule an insurer’s examination where applicable.” The treatment plans were found not payable.

S.C.W.H. v. The Dominion of Canada General Insurance Company (16-000677)

The claimant sought entitlement to two chiropractic treatment plans and removal from the MIG. Adjudicator Makhamra concluded the claimant’s injuries fell within the MIG and therefore the treatment plans were not payable. The claimant did not submit medical evidence in support of the non-MIG injuries. It was noted that the pre-existing medical condition to warrant removal from the MIG must be supported by “compelling evidence.”

R.H. v. TD Insurance Meloche Monnex

The claimant sought entitlement to medical benefits and removal from the MIG. Adjudicator Leslie concluded that the insurer had not complied with section 38 of the SABS in the denial timeline, and that the insurer was therefore prohibited from taking the position that the MIG applied. One of the claimed treatment plans was awarded.

V.S. v. The Dominion of Canada General Insurance Company (17-001670)

The claimant sought entitlement to a number of medical treatment plans. The insurer asserted the claimant was governed by the MIG. The claimant raised an objection to the insurer’s notice letters. However, Adjudicator S.F. Mather determined the correspondence was compliant and that a medical reason was provided. On review of the medical evidence, Adjudicator Mather further concluded the MIG applied to the claimant and therefore the treatment plans sought were not payable as the MIG limits were exhausted.

Applicant v. Co-operators General Insurance Company (16-000714)

The claimant sought NEBs, medical benefits, and removal from the MIG. The adjudicator found that the claimant did not satisfy the burden of being removed from the MIG. There was a causation issue as the claimant was involved in two separate accidents and the alleged injuries from each accident were similar. NEBs were denied on credibility issues and the failure to provide sufficient evidence of the details of the claimant’s pre-accident lifestyle.

Applicant v. Aviva Insurance Company (16-000272)

The insurer sought reconsideration of the Tribunal’s decision on MIG because the claimant had been removed from the MIG two years prior. The Executive Chair rescinded the adjudicator’s decision regarding MIG because it was not an issue before the Tribunal in dispute.

N.E. v. Waterloo Regional Municipalities Insurance Pool (16-000066)

The claimant sought IRBs at a rate above the weekly rate paid by the insurer. The claimant also sought removal from the MIG. Adjudicator Gottfried dismissed the claim for increased IRBs as the claimant had not provided any documentation to support increasing the weekly quantum. The adjudicator also noted that entitlement to ongoing IRBs does not mean one’s injuries are non-MIG. The claimant was restricted to MIG-level medical benefits

N.C. v. RBC General Insurance Company (16-000282)

Following an accident, the self-employed claimant stopped operating his business in January 2016. Adjudicator Sewrattan concluded that the IRB calculation could not take into account business losses, as the claimant did not have business losses (as calculated by the Income Tax Act) after he ceased operations of his business. In terms of medical benefits, the adjudicator concluded that the claimant’s injuries did not fall in the MIG and wrote that pain reduction is a valid goal when assessing whether a treatment plan is reasonable and necessary.

M.M. v. Wawanesa Mutual Insurance Company (16-000642)

The claimant sought removal from the MIG, and entitlement to two treatment plans. Arbitrator Truong concluded that the MIG applied despite various pre-existing conditions, previous motor vehicle accidents, and earlier psychological injuries.