Our client came to us after suffering a concussion and other injuries in a motor vehicle accident. Their injuries affected their ability to work and participate in regular daily activities. At the same time, they were attempting to navigate Ontario’s accident benefits system and obtain funding for necessary treatment.
Despite our client’s concussion and continuing limitations, the insurance company had placed their claim within the Minor Injury Guideline, commonly referred to as the “MIG.” This classification restricted the medical, and rehabilitation benefits available to them.
Our client needed assistance understanding the insurer’s decision and presenting the evidence required to challenge the MIG classification.
When Is a Concussion More Than a “Minor Injury”?
The Minor Injury Guideline (MIG) provides a treatment framework for impairments that are predominantly minor injuries, such as certain sprains, strains and whiplash-associated disorders.
For someone recovering from a straightforward soft-tissue injury, the treatment available through the Minor Injury Guideline (MIG) may be sufficient. However, the classification can become a significant barrier where an injured person requires:
- further assessments,
- concussion rehabilitation,
- psychological treatment,
- occupational therapy or
- a longer period of recovery.
A concussion may affect:
- concentration,
- memory,
- sleep,
- balance,
- energy and
- tolerance for physical/mental activity.
It is important to note that, these symptoms are not always visible. This being said, they can significantly interfere with a person’s employment, household responsibilities and normal daily function.
An insurer will look into:
- medical records,
- reported symptoms,
- functional limitations,
- recovery progress and
- recommended treatment.
The challenge was to demonstrate that our client’s impairment and treatment needs could not be properly addressed within the insurer’s original classification.
Building the Medical Evidence
When our client first reached out to our firm, it was clear for us to see that the insurance company did not have a complete picture. The insurance company did not fully understand how the concussion was affecting our client.
Our legal team obtained and reviewed the relevant medical records. Those records documented the concussion diagnosis, continuing symptoms, work limitations, changes to daily activities and recommendations for further treatment.
This was important for us to do because medical information does not always reach an insurance adjuster automatically. Records may be held by several healthcare providers, and individual medical notes may not clearly communicate the overall effect of an injury when viewed in isolation.
Our legal team organized the available evidence and considered how the medical findings related to our client’s continuing functional limitations. The goal was to provide the insurer with more than a diagnosis. The evidence needed to demonstrate how the concussion was affecting our client’s life and why additional treatment was required.
Challenging the Insurer’s Decision
After reviewing the records, our legal team provided the relevant medical evidence to the insurance adjuster. We also prepared correspondence explaining why our client’s injuries should not remain within the Minor Injury Guideline (MIG).
The submissions connected the concussion diagnosis to their continuing symptoms, functional limitations and treatment needs. This gave the insurer a more complete account of our client’s condition than had been available when the original classification was made.
An insurer’s initial classification is not necessarily final. Where the medical evidence supports a different conclusion, that decision can be challenged. The strength of the challenge will often depend on whether the records clearly document the diagnosis, the effect of the injuries and the need for further treatment.
Medical Evidence Changes the Claim
After reviewing the medical records and our correspondence, the insurance company agreed to remove our client from the Minor Injury Guideline (MIG).
Our client was no longer restricted to the limited treatment framework available under the Minor Injury Guideline (MIG) and could pursue additional medical and rehabilitation benefits within the non-catastrophic category.
Removal from the Minor Injury Guideline (MIG) did not mean that every future treatment plan would automatically be approved. Proposed treatment still had to be supported by the evidence and satisfy the applicable accident benefits requirements. However, the decision allowed our client’s ongoing treatment needs to be considered within a substantially broader funding framework.
Most importantly, the claim could now proceed based on our client’s actual injuries and recovery needs rather than the insurer’s initial understanding of the claim.
Helping Clients Access the Benefits Available to Them
Accident benefits claims can involve much more than submitting an initial application to the insurance company.
Our legal team can review the available insurance coverage, determine whether a client has been placed in the appropriate injury category, obtain supporting medical records and communicate with adjusters and treatment providers.
The objective is to identify and pursue the accident benefits available under the applicable policy and supported by the medical evidence. In this case, gathering and presenting the medical evidence changed the course of our client’s claim and opened the door to additional treatment funding.
Early legal advice can help ensure that important evidence is preserved, the insurer’s decisions are properly reviewed, and an injured person pursues the benefits that may be available.
To discuss an accident benefits claim, contact Bergeron Clifford Injury Lawyers for a free consultation.
