An Ontario tribunal kept a claimant's treatment inside Intact Insurance's $3,500 minor injury cap after its examining psychologist rebutted five psychological tests.
The Licence Appeal Tribunal - Automobile Accident Benefits Service dismissed the applicant's bid to escape the Minor Injury Guideline (MIG) following a July 13, 2022 motor vehicle accident. The applicant had sought statutory accident benefits after Intact denied funding for four disputed treatment plans, arguing psychological impairments and a chronic pain condition took his injuries outside the MIG's scope.
For claims professionals, the decision turns on how a detailed, test-by-test insurer examination outweighed a claimant-side psychological assessment built on the same battery of standardized tools.
The applicant's psychological assessor diagnosed adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, and noted probable post-traumatic stress symptoms, based on a battery that included the Beck Depression Inventory, the Beck Anxiety Inventory, the Pain Patient Profile, the PCL-5 and the Accident Fear Questionnaire. The applicant scored 42 on the depression measure and 36 on the anxiety measure, both described as reflecting severe symptoms, and 65 out of 80 on the PTSD-focused tool.
The insurer's examining psychologist addressed each test individually rather than issuing a blanket denial. He attributed the applicant's sleep issues to working night shifts rather than the accident, put the applicant's avoidance of driving down to not owning a car, and read the Pain Patient Profile results as below average rather than elevated. His own testing flagged a subtle pattern suggesting the applicant may have been presenting himself in an unfavourable light. He concluded no diagnosis was warranted under the DSM-5TR.
The adjudicator preferred that examination, together with the family physician's contemporaneous clinical notes, which recorded no psychological complaints in the five months following the accident, over the applicant's own assessment. In the adjudicator's words, any post-accident symptoms amounted to "mere psychological sequalae, and not a psychological condition" that would justify removal from the MIG.
The chronic pain argument fared no better. A functional abilities evaluation found the applicant had normal range of motion across his cervical, lumbar and shoulder regions with 80 to 90 per cent improvement, and the insurer's examining general practitioner classified the injuries as a whiplash-associated disorder and soft-tissue sprains and strains - all within the minor injury definition. The applicant was also back to working regular hours and full duties, no longer taking pain medication, and more than 90 per cent improved.
With the applicant kept inside the MIG, the tribunal did not need to assess whether the four disputed chiropractic and psychological treatment plans, totalling $11,535.12, were reasonable and necessary. No interest was awarded, since no benefits had gone unpaid or overdue.
For claims teams, the takeaway is in the method: a point-by-point rebuttal of a claimant's own test results, backed by the family doctor's contemporaneous notes, outweighed a psychological assessment built on the same tools.
