Minor Injury Guideline Explained
- March 20, 2015
- Lisa Morell
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What is the Minor Injury Guideline?
The Minor injury guideline is a series of regulations about the amount of treatment you are entitled to if your insurance company has made the determination that your injuries are of such minor extent that they need not meet their full obligation to you.
According to everyone’s standard auto insurance policy is medical treatment of 50,000 over 10 years if its reasonable and necessary to help you recover from an automobile accident. The minor injury guideline reduces that to 3,500 and any insurance assessments that are done come out of that $3,500 so quite often you see people getting maybe 2,000 worth of treatment and the insurance company charging them on their own insurance $1,000 to have insurance exams that say they shouldn’t be getting any more treatment.
Read the feature article in the brant advocate
Morell Kelly on The Minor Injury Guideline
How is the minor injury guideline affecting people injured in motor vehicle accidents in Ontario?
Except in the clearest of cases, for example if there is a case where somebody has multiple fractures or is unconscious at the scene. The majority of people in accidents are being placed in the minor injury guideline. This happens when they visit a treatment centre. If the treatment provider completes an OCF 23 rather than an OCF 18 which is a treatment plan, the claim is automatically placed in the minor injury guideline and the treatment facility is automatically paid for their work up to $3,500 which includes their assessments.
On the other hand if an OCF 18 is completed to do a full assessment to determine what treatment may be reasonably required, the insurance company only has to pay for the OCF 18 if they agree. This causes many of the treatment providers to avoid OCF 18’s which means they are only doing a very summary assessment and the person injured in the motor vehicle collision is being left with less than $3,500 in treatment at the time when they need it the most to obtain maximum medical recovery.
The responsibility is on the person that is hurt in the accident to convince the insurance company that their injuries should not fall within the minor injury guideline. From the outset this has been made more difficult by treatment providers by completing the OCF 23’s and placing them in the minor injury guideline.
The other way to provide compelling evidence that their claim should not be in the minor injury guideline would be through their family physician.
There is a couple of things here we need to remember. The science is incontrovertible, early treatment prevents the development of chronic problems. We all know this. Limiting them to the $2,000 can virtually ensure a certain percentage of those people will go on to have chronic conditions. The other point is, in terms of their own rules and practice, a phisio therapist is not competent to put somebody into a minor injury guideline. But they are the ones selecting which forms to send in and it is outside of their scope of practice.
The minor injury guideline is based on a review of a persons health pre-accident and post accident to determine if there are issues that make barriers to recovery which would make it inappropriate for a person to be in the minor injury guideline. Often people are visiting a treatment facility shortly after the accident. The person completing the OCF 23 hasn’t seen a complete copy of the injured person’s clinical notes and records and does’t make the the inquiries to determine if their are barriers to recovery. They also are not qualified to make that determination. Instead the OCF 23 is simply submitted.
How should the minor injury guideline be applied?
According to the rules governing insurance in Ontario, I think everyone should know this. Automobile insurance and financial interests all are governed by the financial services commission of Ontario known as FISCO. When you hear about automobile insurance changes, it’s FISCO that decides what the insurance policies will look like. FISCO mandates that the minor injury guideline is only to be applied at the acute (immediately after the accident) and the sub-acute (the period of healing that normally comes shortly after the accident) phase of the injury, which means within weeks. If you are still having a problem a month or two down the road, you are past the acute and sub-acute and you are starting to move towards a chronic condition. The insurance company are not looking at that part of the regulation, so they are leaving people in the minor injury guideline. They are saying you’ve used up your money, bye bye.
The regulation specifically talks about the $3,500 cap they have set out in the minor injury guideline and should not be applied where it will not be sufficient to allow someone to make an optimal recovery. This is being completely ignored by the insurers. When the $3,500 is used up, if you haven’t provided compelling evidence or shown that there is a fracture or mri result that shows a complete tear, not just a partial tear. The are just leaving people subject to the minor injury guideline where they are virtually unable to find a way out until they seek counsel who are experience in dealing with accident benefits.
What to do if your insurance company has put you in the minor injury guideline?
One of the most important things to do is to talk to your family doctor as soon as possible after an accident. Make sure your doctor takes notes of all of your complaints related to the accident. For example if you are experiencing symptom consistent with a concussion, that should be noted down as it may be sufficient to get you out of the minor injury guideline. The easiest way to get out of the minor injury guideline is to have some compelling evidence from you family doctor, send it to your insurance adjuster, the insurance adjuster ideally reads it and agrees and removes you from the minor injury guideline. Unfortunately there is no case law on the minor injury guideline so that’s not happening as frequently as it should. When that doesn’t happen the only other option is to issue a state of claim against your own insurance company. The financial services commission of Ontario is taking a position that they do not mediate the applicability unless there is treatment plans in dispute and there are not going to be any treatment plans in dispute unless you decide to pay 600-700 per treatment plan to a treatment provider to submit them. The next step if insurance company doesn’t agree with you that there is medical evidence that would warrant you being removed from the minor injury guideline, its imperative that you find counsel to assist you in suing your insurance company. Otherwise you might be left without treatment during the time where you can get the maximum benefit from that treatment and make an optimal recovery.