Minor Injury Guideline Does Not Apply If Insurance Company Has Breached Their Obligations Under the Statutory Accident Benefits Schedule
If an individual is injured in a car accident and has suffered from a minor injury, their insurance company will classify them as falling within the Minor Injury Guideline. In certain situations, an individual may be “taken out” of the Minor Injury Guideline. This means that they will be able to access more money for treatment. This article will explain what the Minor Injury Guideline is and will look at a recent case showing how an accident victim can be taken out of the Minor Injury Guideline.
Minor Injury Guideline explained:
When an individual is injured in a motor vehicle accident, they may make a claim for accident benefits from their insurance company. The Minor Injury Guideline is a framework for providing treatment and benefits to motor vehicle accident victims who have suffered from minor injuries. In other words, if the injured party only suffers from a minor injury as a result of the accident, their claim falls within the Minor Injury Guideline. “Minor injury” can include, for example, a sprain, strain, or whiplash injury that has resulted from the accident. It is important to note that under the Minor Injury Guideline, medical and rehabilitation benefits are limited to just $3,500.
Minor Injury Guideline does not apply if insurer does not meet their obligations:
The injured person will submit a treatment plan to their insurance company, which specifies treatment they are seeking for their injuries. When the insurance company receives the treatment plan, the insurer must follow certain steps that are specified in the Statutory Accident Benefits Schedule (SABS). For example, when the injured party sends their insurance company a treatment plan, the insurer must respond within 10 business days, amongst other requirements. If they do not, this may take an individual out of the Minor Injury Guideline classification; it will thus allow them to be able to access more money for treatment.
In a recent FSCO Arbitration decision, Ferawana v. State Farm (FSCO A13-005319, August 29, 2016), the consequences of not following these steps in the SABS once a treatment plan is received from the injured party were highlighted. In this case, the insurer, State Farm, did not provide a proper response to the treatment plan within the ten-day time period.
Since State Farm did not follow the procedural requirements in the SABS, the Arbitrator held that State Farm could not argue that the Minor Injury Guideline applied to the injured party. This applied to all treatment plans under the claim; not just the treatment plan that the insurance company did not properly respond to. This interpretation was found to be consistent with the rest of the subsection and the purpose of the Minor Injury Guideline. As a result, since State Farm breached their procedural obligations, they were prohibited from taking a Minor Injury Guideline position on the claim.