MIG Update – January 10, 2022

Obligation to Re-evaluate MIG Denials

In this first edition of 2022 the Tribunal considers an insurer’s obligation to re-evaluate previously denied treatment plans once the insurer has removed an Applicant from the MIG.

In an earlier decision, 16-000872 v Certas Home and Auto Insurance Company the Tribunal held at para 16 – “Firstly, in the spirit of the overall benefit scheme, and at least as of the date the insurer found the applicant’s injuries no longer met the MIG classification, it was obligated to re-consider the submitted treatment plans under the non-MIG regime. To do otherwise, or to maintain its denial of the treatment plans based on its initial belief of the classification of the applicant’s injuries and in light of proof to the contrary, would undermine the purpose of the benefit scheme to allow access to appropriate treatment.”

In the case reviewed here the insurer did provide notice that they were maintaining their denial in the absence of compelling evidence. What does “revisit” intend or imply?

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Factor: Re-evaluating Previous MIG Denials

In Jaweed Noori v Certas Home and Auto Insurance Company (20-003507), Noori was injured in an December 28, 2018 accident and removed from the MIG in July 2019 following an Insurer’s Examination that confirmed that due to a pre existing “Ganu Varum” deformity, that the left knee injury would require additional treatments outside of the $3500 Medical limits. However, Certas held the position that all other motor vehicle accident related impairments were minor.

Noori succeeded on 3 disputed treatment plans for physiotherapy services that followed the removal from the MIG dated February 5, April 23, and July 7, 2020. The Tribunal found that Noori had still reported significant levels of pain in his neck, knee and head in July 2020 and that there was no support for Certas’ position that maximal medical recovery was reached. As such the incurred treatment ($3403.57) between February 5 and July 28 2020 was payable.

However Noori argued the denials on the 3 assessments that were submitted prior to the Noori having been removed from the MIG, for psychological, orthopaedic and neurological were not re-evaluated by the insurer.

The Tribunal held:

• • Certas did provide an explanation as to why removal from the MIG did not alter their opinion in a letter dated May 7, 2020 namely:“It remains our position that you sustained minor injuries as a result of this accident, and have not provided any compelling evidence to support that additional assessments are required as a direct result of this accident, therefore, we are maintaining our denial of the following OCF18s as there is no compelling evidence to support the requested assessments are reasonable and necessary…”
  • Noori had established that assessment requests for psychological and orthopedic were reasonable and necessary.
    
  • On the orthopedic assessment it was logical that Noori would want his own treatment team to assess in light of the IE findings regarding the left knee.
  • There were consistent complaints and physical findings from the date of loss up to the date (May 2019) of the completion of the orthopedic assessment request.
  • No issue on causation as the family doctors records indicate in a ‘general check-up’ several months prior to the accident found no health concerns. Discussion in the IE on functional changes lends creedence as to causation.
  • On the psychological assessment, the evidence of psychological distress following the accident was documented in the OCF-3 Disability Certificate as well as the psychological pre-screen in January 2019

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If you Have Read This Far…

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