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MIG is Unconstitutional: FSCO

A recent arbitration decision by the Financial Services Commission of Ontario (FSCO) has ruled that the Minor Injury Guidelines within the Statutory Accident Benefits Schedule (SABS) are unconstitutional. In the decision, Abyan and Sovereign General [FSCO A16-002657], Arbitrator Benjamin Drory was asked to consider whether Sections 3 and 18 of the SABS unjustifiably infringe upon Sections 7 and/or 15 of the Canadian Charter of Rights and Freedoms. Arbitrator Drory noted that the Applicant has to first demonstrate that a Charter right has been infringed, and then it is up to the government to justify the infringement under Section 1 of the Charter. It was noted that it was unfortunate that no one from the government attended the hearing. In this particular case the Applicant suffered from chronic pain. The insurer, Sovereign General, had taken the position that, since the chronic pain was an "associated sequelae" from a minor injury, the MIG applied and the insured was, therefore, limited to a maximum of $3,500.00 in medical and rehabilitation benefits. The arbitrator decided that Section 7 of the Charter was not violated by the MIG, as it does not threaten his security of person, without accordance to the principles of fundamental justice. With respect to Section 15 of the Charter, Arbitrator Drory stated the following:

The New Dispute System for Accident Benefits Claims: You Lose Before You Even Begin

It is a common legal principle in civil law that the party that loses a case must pay at least some of the winner's costs, which can include legal fees and disbursements. This is based on the tenant of access to justice, which allows anyone regardless of economic resources to advance a claim against a party that has wronged him or her. In the context of the accident benefits system, it means that an injured person can advance a dispute against an insurance company and, if they are successful, their legal costs will be paid. They are not hindered in advancing a claim because they cannot afford to do so. On April 1, 2016, all disputes for accident benefits from motor vehicle accidents in Ontario were moved into a new system through the License and Appeals Tribunal (LAT) through the Ministry of the Attorney General. With a new system came new rules. One of the most concerning is Rule 19, which deals with costs.  A recent LAT decision with respect to this rule deemed that costs can only be claimed if a party has acted unreasonably, frivolously, vexatiously or in bad faith within the dispute resolution process.  In other words, as long as both parties have acted well within the dispute resolution process, costs will not be awarded, no matter how egregious an insurer might have been in denying benefits. In our view, this is totally unjust and unfair. At Smitiuch Injury Law we fully intend on appealing any adverse decisions on costs and will raise the access to justice principle in order to declare the current Rule 19 void.

Neuropsychological Assessments and the $2,000 AB Cap

In September of 2010, the Statutory Accident Benefits Schedule (SABS) were amended with respect to Costs of Examinations.  A cap of $2,000.00 was placed on each assessment completed, either for the insured or the insurer. This cap has proven difficult for some more complex assessments, including neuropsychological assessments.  In order to obtain a reliable assessment the cost is well beyond $2,000.00. Many in the accident benefits community (plaintiff lawyers acting on behalf of injured victims, as well as insurers) have been getting around this cap by dividing up the assessment into two distinct assessments; normally a "psychological" assessment and a "neuropsychological" assessment.  For the most part this has been widely accepted as a way to comply with the statutory limit while getting a fairly reliable assessment report.  There have been a few insurers who have not agreed with this approach. A recent FSCO arbitration decision, Breadner and Co-operators [FSCO A15-005120] has challenged this approach. A Treatment and Assessment Plan (OCF-18) was submitted on behalf of Ms. Breadner with the following breakdown of costs:

The New Dispute System for Accident Benefits Claims: You Lose Before You Even Begin

On April 1, 2016, all disputes for accident benefits from motor vehicle accidents in Ontario were moved into a new system through the License and Appeals Tribunal (LAT) through the Ministry of the Attorney General. With a new system came new rules on the dispute resolution process. One of the most concerning is Rule 19, which deals with costs. It is a common legal principle in civil law that the party that loses a case must pay at least some of the winner's costs, which can include legal fees and disbursements (things that have been paid to third parties to advance the matter). This is based on the tenant of access to justice, which allows anyone regardless of economic resources to advance a claim against a party that has wronged him or her. In the context of the accident benefits system, it means that an injured person can advance a dispute against an insurance company and, if they are successful, their legal costs will be paid.

Catastrophic Impairment Denial Not Subject to Limitation Period

Because a catastrophic impairment designation is not a "benefit", as defined under the Statutory Accident Benefits Schedule (SABS), there is no time limitation for disputing an insurer's denial. On January 6 2009, Zofia Machaj submitted an Application for Determination of Catastrophic Impairment (OCF-19) to RBC Insurance.  After conducting insurer's examinations, RBC responded on May 25, 2009, stating that, "the assessors have formed the consensus opinion that you have not sustained a catastrophic impairment and therefore you do not qualify for the increased benefits." In order to dispute RBC's denial, an Application for Mediation was submitted by Ms. Machaj on July 18, 2011, which was almost two months beyond the two year limitation period that the Insurance Act stipulates is required.  Section 281.1 of the Insurance Act establishes a limitation period, provides that a mediation proceeding, "...shall be commenced within two years after the insurer's refusal to pay the benefit claimed" (emphasis added). In 2015, Whitten J. issued a decision on a Summary Judgment Motion in the matter of Machaj v RBC General Insurance Company [2015 ONSC 4310], wherein he found in favour of RBC Insurance and ruled that the two-year limitation applied, because the denial, "...flushed out the consequences of the denial of the status of catastrophic impairment; namely, the enhanced benefits were not available." Ms. Machaj appealed.  The Ontario Court of Appeal disagreed with Judge Whitten's decision, noting that, "In our opinion, by adding the words, "and you therefore you do not qualify for the increased benefits", the respondent insurer was doing nothing more than telling the appellant that she lacked status to claim increased benefits. The additional words did not convert what was, in substance, a denial of a catastrophic determination into a denial of the specific benefits that would trigger the commencement of the two year limitation period." RBC Insurance sought leave to appeal to the Supreme Court of Canada, but it was dismissed with costs. As such, under the current legislation, an insured person is not bound to dispute an auto insurance company's denial of catastrophic impairment determination within two years, unlike a denial of an actual "benefit" under the SABS. If you have been injured in an automobile accident and your insurance company has denied anything, it is always best to consult with a lawyer to ensure that your interests and entitlements are protected.

Providing Attendant Care in the Course of Employment, Occupation or Profession: Economic Loss Not Required

If an individual who is involved in a motor vehicle accident is incapable of self-care as a result of their injuries they are eligible to claim Attendant Care Benefits through their own insurance company.  The insurer is only obligated to pay the benefit if the insured person has received the goods or services, has paid or promised to pay the expense, and if the person who provided the goods and services either (A) "did so in the course of the employment, occupation or profession in which he or she would ordinarily have been engaged, but for the accident", or (B) sustained an economic loss as a result of providing the goods or services to the insured person.  In the case of "B", the amount payable has been limited to the amount of the economic loss sustained as a result of providing the attendant care. The first option is normally interpreted as obligating an insurer to pay for a professional service to come into the injured person's home to provide attendant care, such as a personal support worker.  The second option is normally interpreted as requiring an insurer to pay for any economic loss sustained by a "non-professional" (family member or friend) who provides attendant care to an injured individual.  But what if the family member or friend is a professional personal support worker? In the Financial Services Commission of Ontario (FSCO) decision, Michael Walsh and Echelon General Insurance Company [FSCO A15-007448], Arbitrator Benjamin Drory confirmed that, if a family member or friend who is a personal support worker provides attendant care to an injured individual, they do not need to sustain an economic loss as a result of providing the attendant care and the amount of attendant care payable is not limited to the amount of any economic loss. Arbitrator Drory made the following comments in this decision:

Proposed Amendments to Ontario Automobile Insurance Dispute Resolution System

The Ontario Government has released its proposed amendments to the Insurance Act regulations regarding the Ontario Automobile Insurance Dispute Resolution System (AIDRS). Effective April 1, 2016, an individual who wishes to dispute a denial by an insurance company for statutory accident benefits will go through the Ministry of the Attorney General's License Appeal Tribunal (LAT) and not the Financial Services Commission of Ontario (FSCO). The proposed amendments include the following:

Costs for Examination for CAT Assessment, Form 1 Completion and Disability Certificate Not Out of Med-Rehab Limits

A recent decision by the Financial Services Commission of Ontario (FSCO) confirms that the costs for completion of a catastrophic assessment are not subject to the medical and rehabilitation benefit limits. In Lee-Anne Henderson and Wawanesa Mutual Insurance Company [FSCO A14-001758], Arbitrator Patrick Bowles was asked to consider whether or not this was the case.  The Applicant, Ms. Henderson, had requested that the costs for the completion of a catastrophic assessment be paid by the insurer.  Wawanesa denied payment, stating that Ms. Henderson had reached the maximum payable for medical and rehabilitation benefits in the amount of $50,000.00, therefore there was no further benefits available to fund the assessments. Arbitrator Bowles accepted Ms. Henderson's argument that the only assessments that are subject to the medical and rehabilitation benefit limits are ones for the purpose of claiming a medical and rehabilitation benefit.  Since a catastrophic determination is not for the purpose of a benefit per se (rather, it is for a determination on the amount of benefits available), it is not subject to the limits, and should properly be allocated as a claims expense by the insurer. While it was not directly considered in this decision, it follows that the costs for completion of an Attendant Care Needs Assessment (Form 1), as well as a Disability Certificate (OCF-3) are also not subject to payment under the medical and rehabilitation benefits, as they are for an attendant care benefit and for specified benefits, respectively. If an insurer is claiming that the medical and rehabilitation benefits have reached the limits, it is helpful to obtain an itemized listing of all payments made to determine if any payments have been incorrectly allocated.  This could free-up additional funds that may be needed by an insured for treatment. This decision can be read in its entirety by clicking on the link below. Henderson, Lee-Anne and Wawanesa - COE for CAT not in MR benefit limits

New FSCO Decision Limits Timelines for Examination Under Oath for Specified Benefits

NOTE: This arbitration decision was overturned on appeal.  A petition for Judicial Review was filed, but later abandoned. The Financial Services Commission of Ontario (FSCO) has released an arbitration decision that limits an insurer's ability to request an Examination Under Oath in certain cases. In the decision Neil Williams and State Farm Mutual Automobile Insurance Company [FSCO A14-001463], Arbitrator Maggy Murray considered whether or not an insurer was prohibited from providing a notice of an Examination Under Oath more than 10 business days after receiving an application and completed disability benefit for a specified benefit. A specified benefit is an income replacement benefit, caregiver benefit, non-earner benefit, or housekeeping and home maintenance benefit. Section 36(4) of the Statutory Accident Benefits Schedule (SABS), reads as follows (emphasis added):

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