Any person who has sustained injuries in an auto accident or certain relatives or defendants of an individual involved in an auto accident may be eligible for receiving accident benefits. In Toronto, we practice what is known as a no-fault system with respect to payment of accident benefits. This means that a Toronto standard insurance policy will provide claimants with accident benefits regardless of who is found at fault for the collision. These accident benefits and their payment are defined and regulated by the Statutory Accident Benefits Schedule (SABS), under Ontario's Insurance Act . Recently changes were made to the SABS. The New SABS came into effect on September 1, 2010.
Effective September 1, 2010, with respect to medical/rehab and assessment/examination accident benefits, the Minor Injury Guideline (MIG) replaced the previous Pre-Approved Framework Guideline for Grade I and II Whiplash Associated Disorders (WADs) in the SABS and are to be applied to injuries sustained in collisions on or after September 1, 2010.
The MIG imposes a $3500.00 cap on medical and rehabilitation benefits as well as assessment and examination expenses for Grade I and II WADs as well as other minor injuries as defined in the body of the Guideline. Within this $3500.00 cap, the Guideline provides for a pre-approved $2200.00 limit for assessments, treatments, supplementary goods and services and discharge reporting.
What Is Considered a "Minor Injury"?
The Guideline defines a minor injury as:
a sprain, strain, whiplash associated disorder, contusion, abrasion, laceration or subluxation and any clinically associate sequelae.
If an injury falls within the above definition, insurers will impose a $3500.00 limit on the assessment and treatment of the injuries. However, if an injury sustained in a motor vehicle collision falls outside of the MIG then the $3500.00 does not apply.
However, as per s. 18(2) of the Guideline, the maximum limit may not apply when:
based on compelling evidence provided by his or her health practitioner, the insured person has a pre-existing medical condition 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.
However, MIG continues to state that:
the existence of any pre-existing condition will not automatically exclude a person's impairment from this Guideline. It is intended and expected that the vast majority of pre-existing conditions will not do so.
What this means is that once the $3500.00 limit is exhausted, the insurer will only cover the cost of additional treatments if there is "compelling evidence" from a health provider of a pre-existing condition that would prevent the claimant from achieving full recovery. However, the Guideline goes on to state that this will only happen in limited instances.
What Injuries Fall Outside of the MIG?
Given how minor injury is defined in the Guideline, personal injuries such as partial (but not complete) tears to ligaments, tendons and muscles can be considered to be minor injuries.
Some examples of injuries and impairments that are outside of the MIG are:
If not a "minor injury" then:
If the injuries sustained are not deemed to be minor injuries but also are not considered catastrophic (physical or psychological) then medical and rehabilitation benefits for the claimant will be subject to a $50,00.00 maximum for up to 10 years.
If the injuries are found to be catastrophic (a subject which we will further discuss in upcoming blog postings) the benefits will be subject to a $1,000,000.00 maximum over the claimant's lifetime.
Contact JEWELL RADIMISIS JORGE LLP for more information on minor injuries and injury claims.