A Belair Insurance policyholder's bid for catastrophic impairment status collapsed after a tribunal rejected her medical assessors' ratings as inflated.
The applicant was injured in a car accident on February 8, 2021, and sought statutory accident benefits from Belair Insurance Company Inc., including a catastrophic impairment (CAT) designation, attendant care benefits and several treatment plans. Belair denied the claims, and the dispute went before Ontario's Licence Appeal Tribunal for resolution by written submission.
The applicant's case rested on a whole person impairment (WPI) rating of 62 percent from her assessors, well above the 55 percent threshold required for CAT status under Criterion 7 of the Statutory Accident Benefits Schedule. Belair's assessors put the figure at 15 percent.
Adjudicator Lisa Holland sided almost entirely with the insurer's experts. She rejected nearly every rating the applicant's neurologist and pain specialist had assigned, from spine and shoulder impairment to headaches and nerve damage, finding each one unsupported by objective medical evidence or accident causation. On the left shoulder specifically, Holland preferred the applicant's family physician's note that the symptoms had resolved over a later report claiming ongoing impingement. “I find the ratings assigned by the applicant’s assessors inflated,” she wrote.
The psychological side fared no better. The applicant's psychiatrist had scored her at a 20 percent WPI and diagnosed major depressive disorder, somatic symptom disorder and features of post-traumatic stress disorder. Holland found several of the underlying scale scores did not match the applicant's actual functioning, including a severe travel impairment rating despite evidence she continued driving herself to work, appointments and errands for years after the accident. Holland preferred the insurer's psychologist, who rated the impairment as mild and found it unclear whether any mental health impairment was accident-related at all.
The applicant also failed on Criterion 8, which requires three marked impairments across four functional domains. Holland found the applicant's activities of daily living impairment was, at most, mild - not marked - largely because a pre-accident medical history, a subsequent workplace repetitive strain injury and two years of continued employment after the accident complicated the causation picture.
With no catastrophic designation, the applicant's related claims fell away. Holland found Belair's initial denial of $2,322 in monthly attendant care benefits was compliant with the Schedule's notice requirements, and that the applicant had not shown the benefit was reasonable and necessary. Multiple occupational therapy, case management and assessment plans, including proposals from two rehabilitation providers, were dismissed for the same reason, with one attendant care assessment plan rejected outright because neither the plan nor Belair's denial had been put into evidence.
Holland also declined to order interest or a special award under section 10 of Regulation 664, finding no benefits had been unreasonably withheld. The application was dismissed in full.
