To determine this, the government created the Minor Injury Guidelines (the “MIG”) to help the industry decide what injuries fall within the MIG and what injuries fall outside of it. Typically, soft tissue injuries, such as partial muscle or ligament tears, bruising, dislocations, strains and sprains will automatically fall within the MIG. So if you are one of those unlucky people who have suffered injuries as a result of a car accident, the current accident benefits legislation sadly almost makes you wish your partial ligament tear was a full tear, or that a small bone has fractured, because we often see that $3,500.00 of medical and rehabilitative expenses is simply not enough. Once you hit this limit, the Insurer puts up a fight if you want more, and they have every right to do so under the current accident benefits legislation.
Having said that, it is not hopeless for those who have suffered soft tissue injuries to get more than $3,500.00 in funding for medical expenses. If you have a pre-existing condition which arose before the accident, that is one way to pull your claim out of the MIG. You would need to show that your pre-existing condition prevents you from achieving maximal medical recovery from your accident-related injuries with only $3,500.00. Another way to get out of the MIG is if your accident-related medical condition continues to deteriorate to the point that your primary injury is no longer minor in nature. For example, we see some claimants with soft tissue injuries go on to develop a psychological disorder or chronic pain disorder as a result of their accident-related injuries. This requires supporting medical documentation from your healthcare provider and often means a trip to a medical assessment arranged by your Insurer.
For those whose claims are taken out of the MIG, you now have available to you $50,000.00 in medical and rehabilitation expenses. However, this is not without restriction. For any medical and rehabilitative expenses you claim for or seek, the Insurer must be satisfied that the expenses are reasonable and necessary. For the most part, early on in the claim, the Insurer will approve traditional therapy expenses (e.g., physiotherapy, massage, etc.) without questioning the reasonableness and necessity of these expenses. However, if you are week or months post-accident, or if your healthcare team has recommended more unique treatment (e.g., aqua therapy, driver rehabilitation, psychological counselling, neuropsychological assessment, etc.), an Insurer may require that you undergo an Insurer’s medical assessment to determine whether the therapy or assessment is reasonable and necessary.
As you can see, there are different checkpoints in the legislated accident benefits scheme for an Insurer to send you for a medical assessment to determine your entitlement to medical and rehabilitative expenses, even if you have the support of your family doctor and/or treating specialists. These obstacles are unavoidable should an Insurer choose to use these tools available to them. There are steps you can take to make these obstacles easier to overcome:
- Follow up regularly with your family doctor to discuss any symptoms or difficulties you are experiencing – the notes your family doctor makes becomes a running documentary of your life after the car accident and the severity of your injuries;
- Attend therapy regularly to show that you are doing your part to recover;
- Listen to medical advice from your treating healthcare team and ensure you make time to attend follow up appointments;
- Be thorough about your symptoms and difficulties when you do attend a medical assessment arranged by the Insurer – this is your opportunity to show the Insurer what difficulties and symptoms you encounter on a day to day basis;
- Be honest to your healthcare team and the medical assessors hired by the Insurer – credibility is of utmost importance; and
- Speak to your legal team – we are here to help guide you through the accident benefits process to ensure you get access to the benefits you are entitled to.