An insurer's own examiner found no formal diagnosis - but Ontario's tribunal used that report to remove a claimant from the MIG anyway.
The applicant was injured in an automobile accident on April 14, 2023, and sought statutory accident benefits from SGI Canada Insurance Services Ltd. The parties agreed that the $3,500 Minor Injury Guideline (MIG) limit had already been exhausted, so the applicant needed to prove her injuries fell outside the MIG to access further treatment funding. She argued a psychological impairment from the accident should take her out of the guideline. SGI Canada disagreed.
The applicant's own psychologist diagnosed her with Major Depression, Adjustment Disorder with mixed anxiety and depressive symptoms, and a specific phobia related to vehicles. SGI Canada's own examiner reached a different conclusion, but one that still worked against the insurer. He found the applicant had adjustment difficulties, writing that they were "not at a level or degree that they warrant a formal diagnosis" - while still attributing those difficulties to the accident.
Licence Appeal Tribunal Vice-Chair Julian DiBattista found that because both the applicant's assessor and the insurer's own examiner had linked a psychological condition to the crash, the applicant had proven, on a balance of probabilities, that she should be removed from the MIG.
The win was narrower than it looked. Removal from the guideline did not translate into payment for most of what the applicant was claiming. The tribunal denied a proposed psychological services plan worth $3,847.82 and a chronic pain program worth $16,113.73, finding in each case that the applicant had not identified the treatment goals or explained how they would be met. A separate $2,689.40 orthopaedic assessment was denied for lack of compelling contemporaneous medical evidence. Three disputed medication expense claims, totalling $117.81, were denied because the applicant made no submissions on them at all.
The applicant did secure one item: a psychological assessment plan, capped at $2,000 plus HST under section 25(5) of the Statutory Accident Benefits Schedule, plus interest under section 51. DiBattista rejected SGI Canada's argument that the assessment itself was unnecessary, pointing again to the same report from the insurer's examiner.
The applicant also sought a special award under section 10 of Regulation 664, which allows the tribunal to order an insurer to pay up to 50 per cent of benefits payable where it unreasonably withheld or delayed payment. That claim was dismissed too, with DiBattista noting the applicant had made no submissions to support it.
The result: SGI Canada lost the MIG argument but held the line on nearly every dollar in dispute, with the applicant's total recovery limited to the capped assessment fee and interest.
