Category: Minor Injury Guideline

M.V. v. Aviva General Insurance Company (18-011523)

The claimant sought entitlement to IRBs and removal from the MIG. Vice Chair Farlam concluded that the claimant was not entitled to IRBs and that his injuries fell within the MIG. The medical evidence provided showed only soft tissue injuries, and insufficient objective evidence was led regarding chronic pain or psychological impairment. There were also multiple inconsistencies with the claimant’s reporting that called into question the medical opinions based on the claimant’s self-reported symptoms. Regarding IRBs, the claimant himself said during IE assessments that he was not disabled from working from a psychological perspective, and no evidence from the family physician was submitted regarding the claimant’s ability to return to work.

C.G. v. The Guarantee Company of North America (17-007300)

The claimant had a number of pre-accident injuries and impairments. She suffered an exacerbation of her conditions in the accident. She sought entitlement to NEBs, removal from the MIG, and two assessment costs. The insurer argued that the claimant’s impairments were not caused by the accident. Adjudicator Johal accepted that the accident did cause an exacerbation of pre-existing injuries that would otherwise have not occurred. She also concluded that the claimant suffered chronic pain as a result of the accident given that her pain persisted for more than six months, and her injuries therefore did not fall within the MIG; this conclusion was made without a specific diagnosis of chronic pain. The claimed psychological assessment was awarded, but the denied in-home assessment was not as the medical evidence suggested that the claimant remained independent with personal care. The claim for NEBs was also dismissed. The claimant failed to provide evidence that her post-accident life was significantly different than her pre-accident life.

C.G. v. The Guarantee Company of North America (17-007300)

The claimant had a number of pre-accident injuries and impairments. She suffered an exacerbation of her conditions in the accident. She sought entitlement to NEBs, removal from the MIG, and two assessment costs. The insurer argued that the claimant’s impairments were not caused by the accident. Adjudicator Johal accepted that the accident did cause an exacerbation of pre-existing injuries that would otherwise have not occurred. She also concluded that the claimant suffered chronic pain as a result of the accident given that her pain persisted for more than six months, and her injuries therefore did not fall within the MIG; this conclusion was made without a specific diagnosis of chronic pain. The claimed psychological assessment was awarded, but the denied in-home assessment was not as the medical evidence suggested that the claimant remained independent with personal care. The claim for NEBs was also dismissed. The claimant failed to provide evidence that her post-accident life was significantly different than her pre-accident life.

S.S.L. v. Certas Direct Insurance Company (19-004473)

The claimant sought removal from the MIG and entitlement to IRBs, two treatment plans for chiropractic services, and cost of examination. Prior to the hearing, the claimant withdrew her claims for the medical benefits and the costs of examinations. Adjudicator Norris held that the claimant could not dispute the MIG if no medical or rehabilitation benefits were in dispute. Adjudicator Norris concluded that the claimant was not entitled to IRBs because there was no compelling evidence to support her claim that she was disabled from working as an event planner. The evidence was clear that the claimant did not suffer physical or psychological impairment that would prevent her from completing her essential tasks of employment.

J.R. v. Aviva Insurance Company (19-006160)

The claimant disputed his MIG determination, as well as entitlement to attendant care benefits in the amount of $138.09 per month and various medical benefits. Adjudicator Boyce found the claimant to be unsuccessful on all of the disputed issues. The claimant’s argument for removal from the MIG centred around his psychological impairments, relying on a psychological pre-screen interview report. Adjudicator Boyce did not find the pre-screen report compelling because it included no preliminary diagnosis or suggestion that the claimant met DSM-V criteria. Further, the claimant’s family doctor records made no reference to accident-related psychological complaints. As the claimant’s injuries fell within the MIG, he was not entitled to attendant care benefits or the disputed non-MIG treatment plans.

F.S. v. The Dominion of Canada General Insurance Company (19-007563)

The claimant sought removal from the MIG and entitlement to four medical benefits. Adjudicator Johal found that three of the four medical benefits were barred by the limitation period. The denials were clear and unequivocal. Section 7 of the LAT Act did not apply because the claimant failed to show a bona fide intention to dispute entitlement within the limitation period or an explanation for the delay. Regarding the remaining disputes, Adjudicator Johal concluded that the claimant’s injuries fell within the MIG.

B.N. v. The Co-Operators Insurance Company (19-006455)

The claimant sought removal from the MIG and entitlement to three treatment plans for psychology services and chiropractic treatment. This case also raised the issue of whether an insurer can properly deny medical benefits for a psychological assessment and psychological treatment without requiring the claimant to attend an in-person IE for a psychological assessment. With respect to the MIG, the claimant did not provide the required evidence from his health care providers to support that he had pre-existing conditions that would prevent him from achieving maximum recovery. In addition, the treatment plans and psychological report lacked credibility and the claimant’s psychological complaints were not medically supported. The adjudicator ruled that the claimant did not sustain more than predominately minor injuries. For this reason, the treatment plans were not reasonable or necessary. In determining whether the insurer provided proper medical reasons for denying the disputed treatment plans, Adjudicator Mather was satisfied that the insurer had made it clear to the claimant what medical evidence it was looking for to substantiate the claim. Adjudicator Mather held that the insurer provided a valid medical reason for denying the benefits for the psychological assessment and psychological treatment.

C.W. v. Aviva Insurance Company (19-002426)

The claimant sought removal from the MIG and entitlement to various medical benefits. Adjudicator Farlam found that the claimant sustained minor injuries in the accident. While the disability certificate noted COPD, mild stroke, right sciatica, low back pain, they appeared to be self-reported by the claimant, and there was no pre-accident medical records documenting the alleged pre-existing medical conditions. Adjudicator Farlam also considered the claimant’s arguments that section 38 of the SABS entitled him to payment of incurred medical benefits. The adjudicator accepted that one of the disputed treatment plans was responded to 10 days late. However, the claimant had not incurred any of the proposed treatment during that time frame, so the insurer was not liable to pay anything.

Z.X.C. v Belair Insurance Company (19-000314)

The claimant disputed her MIG determination, as well as entitlement to various medical benefits and IRBs. Adjudicator Shapiro concluded that based on the medical evidence, the claimant suffered predominantly minor physical injuries – strains and sprains – as a result of the accident, and her injuries thus fell within the MIG. Adjudicator Shapiro also determined that the claimant was not entitled to IRBs as she had not proven the rate of the benefit, nor had she proven her basic entitlement to IRBs after March 24, 2017. While the claimant submitted that she provided ample documentation to calculate the rate of IRBs, Adjudicator Shapiro found that the claimant’s records conflict as to what her employment earnings were, and when she earned it, and that her hearing testimony lacked credibility to fill in the gaps. He also felt that the claimant sustained minor strains and sprains, as above, which did not cause her a substantial inability to perform her pre-accident position in any event.

R.E. v Aviva Insurance Company (19-000303)

The claimant disputed his MIG determination, as well as entitlement to various medical benefits and IRBs. Adjudicator Boyce concluded that the claimant sustained predominantly minor injuries as defined by the SABS that were properly treated within the MIG, noting that the medical evidence relied upon was “incredibly underwhelming”. Adjudicator Boyce further concluded that the claimant was not entitled to IRBs, as he had not demonstrated a substantial inability to perform the essential tasks of his pre-accident employment and had not furnished evidence that his income qualifies under section 4(5) of the SABS. The claimant made no reference to any medical evidence confirming that he was incapable of performing the essential tasks of his pre-accident work, aside from the insurer’s IE reports, which were unhelpful to him as they determined that he did not meet the IRB test. More problematically, the claimant did not produce any financial documentation or even identify for the Tribunal what his pre-accident employment constituted, how many hours he worked per week, or what his tasks were.