Injuries Fall Within MIG - Applicant Limited to $3500 in Benefits

April 02, 2017, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

16-000575 v RBC: Entitlement to medical benefits; MIG guidelines; pre-existing conditions; medical documentation of pre-existing condition;

Date of Decision: February 2, 2017
Heard Before: Adjudicator Samia Makhamra

This matter involves a claim arising from a car accident that happened when the applicant was the driver. He applied for and received benefits under the SABS. The applicant applied to the LAT) seeking payment for medical benefits that were denied by RBC.

The parties disagree on the severity of the applicant’s injuries because of the accident, and whether the treatment plans for which funding is sought are warranted. The applicant believes that he is entitled to the treatment plans on two grounds: his injuries are not minor in nature; and he suffers from pre-existing medical conditions that entitle him to access additional funds for treatment. RBC disagrees. Its position is that the applicant has suffered predominantly minor soft tissues injuries, and that it has paid the maximum amount allowed of $3500 for treatment of minor injuries.

Issues:

1. Is the applicant entitled to receive a medical benefit in the amount $3,371.32, partially approved for $2,200.00, submitted on a Treatment and Assessment Plan (OCF-18) dated August 4, 2014 for physiotherapy?
2. Is the applicant entitled to receive payment in the amount $1646.80 submitted on a Treatment and Assessment Plan (OCF-18) dated March 31, 2015, recommended a physiatry assessment?
3. Is the applicant entitled to receive a medical benefit in the amount $1989.46 submitted on a Treatment and Assessment Plan (OCF-18) dated June 23, 2015, for a psychology assessment?
4. Is the applicant entitled to receive a medical benefit in the amount $1406.80 submitted on a Treatment and Assessment Plan (OCF-18) dated October 23, 2015, for a physiatry assessment?
5. Is the applicant entitled to payments for the cost of examinations in the amount of $200.00 for a psychology pre-screen?
6. Is the applicant entitled to payments for the cost of examinations in the amount of $1,229, for an attendant care assessment?
7. Is the applicant entitled to payments for the cost of examinations in the amount of $1,855.39 for a psychological assessment?
8. Is the applicant entitled to payments for the cost of examinations in the amount of $2,000.00 for a physiatry assessment?
9. Is the applicant entitled to interest for the overdue payment of benefits?

To determine the applicant’s entitlement to the claimed benefits there are three questions: i. Are the applicant’s injuries predominantly minor? ii. Does the applicant 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 (the “MIG”)? And, iii. Are the treatment plans necessary and reasonable for the applicant’s treatment?

The applicant must establish that his injuries are not predominantly minor, or that he has a pre-existing medical condition.

The Arbitrator reviewed the medical evidence, the law, and the definitions of ‘minor injury’. Based on the evidence provided, the Arbitrator determined that the applicant is not entitled to the treatment plans in dispute. He suffered predominantly minor, soft tissue injuries as a result of the accident, and he did not put forward the medical evidence necessary to establish that he suffers from a pre-existing medical condition that would take his treatment outside of the cost limits for minor injuries. As there are no benefits owing, the applicant is not entitled to interest.

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.