An Ontario tribunal found a bare Minor Injury Guideline citation can itself satisfy an insurer's denial-letter reasoning duty under the Schedule.
The Licence Appeal Tribunal - Automobile Accident Benefits Service (LAT) dismissed a claimant's bid to escape the $3,500 Minor Injury Guideline (MIG) funding limit, finding she had not proven her accident-related injuries fell outside the MIG's scope.
The claimant was injured in an automobile accident on April 25, 2024, and sought statutory accident benefits from Certas Home and Auto Insurance Company. Certas denied a treatment plan for a psychological assessment, submitted July 23, 2024 and valued at $2,144.93, on the basis that the claimant's injuries were minor and fell within the MIG.
The claimant argued that Certas's denial letter did not comply with section 38(8) of the Statutory Accident Benefits Schedule, which requires insurers to notify claimants within ten business days of receiving a treatment plan of what they will and will not pay for, and the medical or other reasons why. She contended that this non-compliance should have removed her from the MIG.
Adjudicator Nadia Mauro disagreed, finding that Certas's denial letter, dated July 25, 2024, was compliant with section 38(8). The letter referenced the claimant's family doctor records, stated there was no compelling evidence of psychological injury, and described her injuries as "minor and within the Minor Injury Guideline."
Mauro found that citing the MIG itself qualified as a medical reason, since minor injury is a defined medical term under the Schedule, and that the letter gave the claimant enough information to decide whether to accept or dispute it.
Even setting aside the compliance question, the adjudicator noted that non-compliance with section 38(8) does not automatically remove a claimant from the MIG - it only prevents an insurer from relying on the MIG as a denial reason for that specific treatment plan, citing prior case law.
On the substantive MIG question, the claimant pointed to psychological symptoms listed in the treatment plan, including isolated phobia, headache, nightmares, nonorganic sleep disorders, irritability, and anger. But Mauro found she had not provided any corroborating evidence, medical opinion, or documentation beyond the treatment plan itself to support those claims. Relying solely on a treatment plan, the adjudicator held, is not sufficient to meet a claimant's onus of proving entitlement to be removed from the MIG.
As a result, the Tribunal ordered that the claimant remains subject to the MIG and its $3,500 funding limit, that the psychological assessment treatment plan is not payable, and that she is not entitled to interest. The claimant had also sought an award under section 10 of Regulation 664, alleging Certas unreasonably withheld or delayed payment, but with no benefits found owing, Mauro ruled no award was payable either. The application was dismissed in full.
For claims professionals, the decision indicates that a denial letter's own reference to the Minor Injury Guideline can qualify as a sufficient medical reason under section 38(8), and that a claimant cannot rely on a treatment plan alone to prove entitlement to be removed from the MIG.
