MIG Update – April 14, 2025
MIG Valid Medical Reason
In contrast to last week’s issue of MIG Monday, the Tribunal, in another noteworthy trend, does not deal with the merits of the MIG but rather the technical issues regarding the notices and what constitutes a sufficient medical or other reason.
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Factor: MIG Valid Medical Reason
In Sharon v. Pembridge (23-006003), Egidjia Sharon was involved in an accident on February 16, 2022 and sought entitlement to six Treatment Plans outside of the MIG limit, for psychological, orthopedic and chronic pain assessments as well as self-directed exercise, physiotherapy and aqua therapy totaling $12,860.99.
Sharon submitted that Pembridge failed to comply with the notice requirements pursuant to s.38(8) of the Schedule, as it did not provide meaningful and adequate reasons for the denial of the disputed Treatment Plans. Further, the notice of examination dated August 2022, also did not meet the requirements of s.44(5) of the Schedule, as Pembridge failed to provide any specifics of her medical condition.
Pembridge on the other hand submitted that its denial notices complied with s.38(8), as they advised Sharon of its determination that her injuries fell within the MIG. It relied on the Tribunal decisions in 17-001670 v. The Dominion and 19-011900 v. Royal & Sun, as they supported its position that denying a Treatment Plan based on a belief that the MIG applied constituted sufficient medical or other reasons. The Respondent also submitted that despite its numerous requests for medical documentation pursuant to s.33 of the Schedule, to assist with its determination of Sharon’s entitlement to medical and rehabilitation benefits, she consistently failed to provide the same.
On the issues of the Notice of Examination, the letter was compliant with s.44(5) of the Schedule as the proper medical and other reasons were provided, along with the names, professions/designations, and specialties of the assessors as well as the date, time and location of the examinations.
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The Tribunal found:
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- Although MIG was listed as an issue in dispute in the CCRO, Sharon did not address this issue in her submissions nor did she provide any medical evidence to support her removal from the MIG. As such, she was held within the MIG.
- The notice requirements were satisfied and as such the Treatment Plans were not payable.
- The explanations provided by Pembridge were clear and sufficient reasons to allow Sharon to make an informed decision to either accept or dispute the denials.
- In each of the explanations, Pembridge indicated that it was unable to approve the goods, services and/or assessments on the basis that Sharon sustained a minor injury as a result of the accident.
- The explanation notes that based on the medical documentation on file and the injuries listed on the treatment plans, Sharon’s injuries are predominantly soft tissue injuries that can be treated within the MIG.
- Pembridge asked for supporting medical documentation relied upon to determine that the injury is excluded from the MIG.
- “I find that standing within the MIG is a medical reason because it indicates that the applicant’s impairments are minor, which is a medical definition in the Schedule.”
- Similarly, the notice of examination dated August 2022 provided a clear and sufficient reason, pursuant to s.44(5) of the Schedule.
- Pembridge advised Sharon that it required IEs to determine whether her impairment was predominantly a minor injury.
- Standing within the MIG is a medical reason because it indicated that Sharon’s impairments were minor, which is a medical definition in the Schedule.
- In addition, Pembridge provided the names, professions/designations, and specialties of the assessors as well as the date, time and location of the examinations.
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!