An auto injury falling outside of Ontario’s $3,500 Minor Injury Guideline (MIG) cap is no longer a ‘minor injury’ for the purpose of imposing funding limits on certain medical goods and services, Ontario License Appeal Tribunal (LAT) has ruled.
“There is no provision under the [Statutory Accident Benefits] Schedule (SABs) that separates a ‘minor injury’ from the MIG,” LAT adjudicator Derek Grant wrote in a May 11 decision. “While appreciating Co-operators’ argument that these are separately defined terms, the practical reality is that they are intertwined.
“Therefore, when an insurer provides notice that its insured is no longer under the confines of the MIG, this also confirms that the insurer is no longer considering that its insured’s injuries are minor.”
Co-operators asked Grant to reconsider his previous decision in favour of the claimant, whose injuries sustained in an accident took her outside of the MIG. The driver was found to have had a pre-existing medical condition that would have affected her recovery if she had been confined to the province’s $3,500 cap on minor injuries.
Section 4 of the Minor Injury Guideline states:
“An insured person’s impairment does not come within this Guideline if the insured person’s impairment is predominantly a minor injury but, based on compelling evidence provided by his or her health practitioner, the insured person has a pre-existing medical condition that was documented by a health practitioner before the accident and that will prevent the insured person from achieving maximal recovery from the minor injury if he or she is subject to the $3,500 limit…”
Co-operators interprets this to mean injuries can still be considered ‘minor’ even if they fall outside of the MIG. For instance, under the wording above, you could still have an impairment that is “predominantly a minor injury,” but nevertheless falls outside the MIG because of a pre-existing condition. Therefore, Co-operators concluded, limits to payments described in the SABS (i.e., attendant care, in-home assessments) can still apply to ‘minor injuries’ that fall outside MIG’s $3,500 cap.
Grant observed that Co-operators’ attempt to treat ‘minor injuries’ defined in the SABs as separate and distinct from the minor injuries covered by the MIG would lead to an ‘absurd’ result.
“I agree with [the claimant] that the removal from the MIG, as a result of having a pre-existing condition (or meeting any other exception that warrants removal from the MIG), is a ‘removal of all constraints found within the MIG, including limits as well as goods and services.’
“I further agree that the MIG’s purpose would be rendered meaningless if the MIG was interpreted to mean that one can be removed from the MIG, but still be determined to suffer minor injuries, and therefore be subject to the MIG’s limit on funding and goods and services.”
Feature image courtesy of iStock.com/Pheelings Media