MIG Update – April 7, 2025
Four OCF 18’s Payable Despite MIG Hold
This week a MIG hold case where several treatment plans were considered by the Tribunal from a notice sufficiency perspective. Ultimately 4 out of 7 plans were found to have deficient notices. How often is the Tribunal adjudicating this ancillary issue?
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Factor: Notices
In Sediqi v. BelairDirect Insurance Company (23-000344), Khaleda Sediqi was injured in an accident November 13, 2021 and sought entitlement to seven Treatment Plans for physiotherapy treatment and chronic pain, orthopedic and psychological assessments totalling $14,554.29 as well as removal from the MIG on the basis of psychological injury and chronic pain.
Sediqi was held to the MIG because she did not prove she sustained a psychological injury or chronic pain with functional impairment as a result of the accident. The Tribunal found, based on records of family doctor Dr. Al-Hellawi, there was only one mention of ‘chronic pain’ in August 2022 and ‘depressed mood’ was noted on four occasions over two years post-accident, which was insufficient to prove a psychological injury caused by the subject accident, in light of pre-accident references to anxiety, stress and prescription to Cipralex. Furthermore the Tribunal accepted the April 2022 findings of both IE assessors. First, IE psychologist Dr. Saunders, who also acknowledged the complaints but testing did not rise to the level of a diagnosis. Second IE GP, Dr. Silver who confirmed non-organic signs and a good prognosis for musculoskeletal injuries.
The Tribunal having determined the injuries were within the MIG did not need to address the disputed plans on the test of ‘reasonable and necessary’ rather in this instance compliance with the notice provisions set out in s 38(8).
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The Tribunal held:
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- Four Treatment Plans, 3 for physiotherapy and a chronic pain assessment totaling $9,403.73 were granted as BelairDirect’s notices were non-compliant with s.38(8) of the Schedule.
- Sediqi was entitled to $2,227.73 for physiotherapy dated July 2022 and the plan was payable from the 11th day following the notice if incurred as the denial letter of August 2022 did not contain a valid medical reason rather a general assertion that “there is no medical documentation support removal from the MIG”. Moreover this was an unsupported conclusion, nor did BelairDirect point to specific medical documentation and the relevant points for their decision to go to IE. There was also no follow up to provide Sidiqi with a copy of the paper review and their decision as set out under s.38(13) and s.38(14) of the Schedule.
- Sediqi was also entitled to the $1,690.81 for physiotherapy dated September 2022 and the $2300 chronic pain assessment as the notices did not give any details of Sediqi’s condition but rather that the goods and services were similar to the treatment plan proposed by Dr. Bruni dated July 2022 which was denied by Dr. Silver’s IE. This denial letter would leave an unsophisticated person wondering what condition formed the basis of the denial.
- Likewise Sediqi was entitled to $3,185.19 physiotherapy dated April 2022, as the denial letter dated May 2022 was outside of the 10 business day notice requirement and the reasons provided used boilerplate language and did not make any reference to Sediqi’s particular condition and request for additional documentation was not clear.
- BelairDirect did not point to any notices that cured the deficient notices, as such the Treatment Plans were payable plus applicable interest upon proof that they were incurred after the 11th business days from which they were submitted pursuant to s.38(11)2.
Our MIG Monday series discusses the multitude of factors to consider when evaluating a risk position on MIG cases. The Tribunal has ruled on the MIG in 33% of the decisions so far. Each case is nuanced, but with similar factors.
Inform your position & present persuasive arguments. Include an Outcome Analysis Report (OAR) in your case evaluation complete with For/Against cases. Get an OAR!