ACCIDENT BENEFITS UPDATE: INSURER CAN’T RELY ON PRIOR MIG REPORT

In Applicant v. Aviva Insurance Canada (2018 CanLII 110921), a recent Licence Appeal Tribunal (LAT) decision, the applicant was struck by another car while making a left hand turn on June 30, 2016.  Within two days of the accident, he reported back and left leg pain and began receiving physiotherapy. His employer provided accommodation for his injuries that allowed him to continue working.  He received accident benefits coverage from his insurer, Aviva subject to the $3500 cap under the Minor Injury Guideline (MIG). Subsequent treatment plans for physiotherapy, chiropractic and massage were denied and the applicant commenced a LAT proceeding to challenge the MIG designation and seek payment of the disputed plans.

Goals of the disputed treatment included: pain reduction. chronic pain prevention and functional restoration.  Aviva denied the plan based on the opinion of Dr. Auguste, an Orthopedic Surgeon, who felt that the MIG applied to the applicant’s injuries and there was no evidence that suggested he should be treated outside of its limits.  

After the denial, the applicant was notified that he had been removed from the MIG for psychological impairments, based on a report by Dr. Pilowsky (partially funded by Aviva).

At the hearing, Aviva argued that although the applicant was no longer in the MIG, his physical impairments were still minor.  As a result, the denial of ongoing physical therapy was justified. It claimed that the status of the applicant’s physical injuries was not a factor in its decision to remove him from the MIG.

Adjudicator Go highlighted the contradiction inherent in Aviva’s position.  Denial of the disputed treatment plans was based solely on Dr. Auguste’s report. However, by March 2017, Aviva had already acknowledged that the applicant’s injuries were not covered under the MIG.  Aviva no longer accepted its expert’s opinion regarding the MIG yet continued to rely upon it for purposes of this dispute.

Adjudicator Go observed that merely stating an applicant is non-MIG for "psychological reasons" does not give an insurer the right to ignore his ongoing physical complaints.  In fact, psychological well-being is intertwined with the speed and quality of physical recovery. As a result of these considerations, she held in favour of the applicant, and approved the treatment.

If you have been seriously injured in a car accident, and have questions about this decision, the Minor Injury Guideline or your accident benefits generally, please contact us for a free consultation.  At Campisi LLP, we run our practice "Clients First, Excellence Always".  Put us to work for you.

In Applicant v. Aviva Insurance Canada (2018 CanLII 110921), a recent Licence Appeal Tribunal (LAT) decision, the applicant was struck by another car while making a left hand turn on June 30, 2016.  Within two days of the accident, he reported back and left leg pain and began receiving physiotherapy. His employer provided accommodation for his injuries that allowed him to continue working.  He received accident benefits coverage from his insurer, Aviva subject to the $3500 cap under the Minor Injury Guideline (MIG). Subsequent treatment plans for physiotherapy, chiropractic and massage were denied and the applicant commenced a LAT proceeding to challenge the MIG designation and seek payment of the disputed plans.

Goals of the disputed treatment included: pain reduction. chronic pain prevention and functional restoration.  Aviva denied the plan based on the opinion of Dr. Auguste, an Orthopedic Surgeon, who felt that the MIG applied to the applicant’s injuries and there was no evidence that suggested he should be treated outside of its limits.  

After the denial, the applicant was notified that he had been removed from the MIG for psychological impairments, based on a report by Dr. Pilowsky (partially funded by Aviva).

At the hearing, Aviva argued that although the applicant was no longer in the MIG, his physical impairments were still minor.  As a result, the denial of ongoing physical therapy was justified. It claimed that the status of the applicant’s physical injuries was not a factor in its decision to remove him from the MIG.

Adjudicator Go highlighted the contradiction inherent in Aviva’s position.  Denial of the disputed treatment plans was based solely on Dr. Auguste’s report. However, by March 2017, Aviva had already acknowledged that the applicant’s injuries were not covered under the MIG.  Aviva no longer accepted its expert’s opinion regarding the MIG yet continued to rely upon it for purposes of this dispute.

Adjudicator Go observed that merely stating an applicant is non-MIG for "psychological reasons" does not give an insurer the right to ignore his ongoing physical complaints.  In fact, psychological well-being is intertwined with the speed and quality of physical recovery. As a result of these considerations, she held in favour of the applicant, and approved the treatment.

If you have been seriously injured in a car accident, and have questions about this decision, the Minor Injury Guideline or your accident benefits generally, please contact us for a free consultation.  At Campisi LLP, we run our practice "Clients First, Excellence Always".  Put us to work for you.