Applicant has no pre-existing medical conditions - benefits limited by MIG: E.F. v RBC Insurance Company

May 17, 2017, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

E.F.  v  RBC Insurance Company                   Tribunal File Number: 16-001038/AABS

Date of Decision: March 28, 2017
Heard Before: Adjudicator:  Khizer Anwar

Entitlement to benefits: MIG? Do injuries fall outside of MIG? Injires fall squarely within MIG guidelines; failure to establish entitlement to benefits

E. F. was injured in a car accident on December 6, 2015, and sought benefits pursuant to the SABS. He applied for physiotherapy services and a functional abilities evaluation which were denied by RBC, as it held that E.F. had suffered predominantly minor injuries and that treatment fell within the MIG. When the parties could not resolve their disputes, E.F. applied to the LAT.

ISSUES TO BE DECIDED

1. Is E.F. entitled to a medical benefit in the amount of $3,427.52, for physiotherapy services, as outlined in the Treatment and Assessment dated April 8, 2016?
2. Is E.F. entitled to a medical benefit in the amount of $2,152.00, for chiropractic services, as outlined in the Treatment and Assessment plan dated April 29, 2016?
3. Is E.F. entitled to interest on overdue payment of benefits?

RESULT

Based on the totality of evidence the Arbitrator found that:

1. E.F. suffered predominantly minor injuries as defined under the Schedule.
2. Neither party provided evidence with respect to any amounts that have already been paid out to E.F. within the MIG limit of $3,500 (“the Cap”). E.F. is entitled to receive treatment up to the Cap limit, minus any amounts already paid, in accordance with the guidelines under the Schedule.
3. Based on the findings above, there is no need to assess the disputed treatment plans for reasonableness and necessity.
4. E.F. is not entitled to interest on overdue payment of benefits.

ANALYSIS

The MIG designation is the primary point of contention. Both parties have made extensive submissions on the nature of E.F.’s injuries sustained as a result of the accident.

The MIG establishes a framework for the treatment of minor injuries. It also clearly lays out the eligibility guidelines and maximum benefits. The onus is on the applicant to prove their injuries fall outside the MIG. The Schedule makes provision for some injured persons who have a pre-existing medical condition to receive treatment in excess of the Cap. To access the increased benefits, the injured person’s healthcare provider must provide compelling evidence that the person has a pre-existing medical condition, documented prior to the accident, which will prevent the injured person from achieving maximal recovery if benefits are limited to the MIG cap. In this matter, E.F. carries the onus of establishing his entitlement to a higher level of coverage than the $3,500 stipulated under the MIG.

The Arbitrator reviewed the medical evidence and the law. He noted that E.F. was diagnosed with soft tissue injuries suffered as a result of the accident. The diagnosis falls within the very definition of minor injuries under the Schedule.

Post accident E.F. underwent treatment for sprains and strains, post traumatic headache, sleep disorder, and nervousness. Upon review of these assessments the Arbitrator concluded that E.F.’s accident related injuries continue to fall within the MIG and he has failed to establish entitlement beyond the Cap limits.

The Arbitrator reviewed the evidence to determine whether there is compelling evidence that E.F. suffered from a pre-existing condition, documented by a healthcare practitioner before the accident, which prevents him from achieving maximal recovery under MIG.

E.F. outlined in his submissions that he does not suffer from any pre-existing medical conditions, and despite being involved in various accidents, his resulting injuries had fully healed. He has asthma.

Based on the evidence the Arbitrator found that E.F. does not suffer from any pre-existing conditions documented by any health practitioner that would prevent him from achieving maximal recovery under the MIG. Hence, E.F. is not entitled to treatment beyond the Cap limit.

About Deutschmann Law

Deutschmann Law serves South-Western Ontario with offices in Kitchener-Waterloo, Cambridge, Woodstock, Brantford, Stratford and Ayr. The law practice of Robert Deutschmann focuses almost exclusively in personal injury and disability insurance matters. For more information, please visit www.deutschmannlaw.com or call us at 1-519-742-7774.

It is important that you review your accident benefit file with one of our experienced personal injury / car accident lawyers to ensure that you obtain access to all your benefits which include, but are limited to, things like physiotherapy, income replacement benefits, vocational retraining and home modifications.