Insured Fails to Prove Injuries Fall Outside MIG Guideline - GK v Wawanesa Mutual Insurance Company, LAT 16-004479

September 27, 2017, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

GK v Wawanesa Mutual Insurance Company, LAT 16-004479

Date of Decision: July 6, 2017
Heard Before: Adjudicator Chris Sewrattan

MINOR INJURY GUIDELINE: Insured takes position that injuries fall outside of MIG; pre-existing injuries preclude recovery from injuries if MIG used; Fails to make medical case; injuries fall within MIG

GK was injured in a car accident on January 30, 2015. She applied for accident benefits under the SABS from Wawanesa who denied payment for two treatment plans for physiotherapy because the MIG payment limit was been reached. GK appeals for payment to the LAT.

Issues:

1. Is GK entitled to $613.35 for a Treatment and Assessment Plan for physiotherapy dated September 1, 2015?
2. Is GK entitled to $520.00 for a Treatment and Assessment Plan for physiotherapy dated May 2, 2015?
3. Is GK entitled to interest on outstanding payments?

Result:

1. GK is not entitled to payment for any of the two treatment plans for physiotherapy services. Payment for GK’s treatment is subject to the Guideline, and the Guideline’s limit has been reached.

Discussion:

GK’s entitlement to the two physiotherapy treatment plans in dispute turns on the application of the Guideline. If the Guideline applies, GK is not entitled to either of the treatment plans. If the Guideline does not apply, GK may be entitled to both of the treatment plans.

GK has two arguments for why the Guideline does not apply:

1. She suffers from a pre-existing medical condition that prevents maximal medical recovery under the Guideline; and
2. As a result of the motor vehicle accident, she suffers from an injury that is not predominantly minor.

The Arbitrator reviewed the facts and the law. The Arbitrator determined that GK has not proven that her pre-existing back pain will prevent maximal medical recovery if payment for her benefits is subject to the Guideline. GK did not provide a medical opinion commenting on her ability to achieve maximal medical recovery under the Guideline. She has failed to prove her case on a balance of probabilities. On this basis, the Guideline applies in this case. 

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.