The Case Overview: Why Catastrophic Impairment Benefits Were Denied?
In the case of Sarah Syed v. Security National Insurance Company and Licence Appeal Tribunal, the Ontario Superior Court of Justice Divisional Court upheld the denial of catastrophic impairment benefits, highlighting the stringent criteria required under Ontario law.
The Claim:
On November 4, 2018, an accident occurred involving Sarah Syed and her husband’s vehicle. Since the accident, Ms. Syed has complained of numerous health concerns including neck pain and headaches, pain behind both eyes, motor cycle personal injury and sensitivity to light (photophobia). When she went to her family doctor after her accident, she was diagnosed with a severe concussion. In her family’s quest for answers, she underwent a variety of medical examinations, including an MRI and a SPECT brain scan, which eventually allowed a neuropsychologist to diagnose her in 2021 with mild complex TBI. Ms. Syed was also found to have persistent cognitive impairments and psychiatric problems which were significantly interfering with her functioning throughout the day.
Following these diagnoses and after exhausting the $65,000 in benefits available for non-catastrophic injuries, Ms. Syed sought a determination under section 45 of the SABS to classify her impairment as catastrophic (CAT). If she had been successful in receiving this designation, she would have been entitled to more benefits such as attendant care and medical/rehab expenses which could go up to a total of $1 million.
The Insurer’s Denial:
Ms. Syed applied for catastrophic impairment status which Security National Insurance Company denied, claiming her impairments did not meet the definition under sections 3.1(1) 7 and 8 of the SABS relating to the classification of catastrophic impairments. This led Ms. Syed to bring her case in front of the Licence Appeal Tribunal, LAT, challenging this denial.
The Tribunal’s Decision:
After a two-week hearing conducted via videoconference in January 2023, LAT Adjudicator Christopher Evans ruled against Ms. Syed. The decision, released on April 4, 2023, concluded that Ms. Syed had not sustained a catastrophic impairment as defined by the SABS. Specifically, the adjudicator found that:
Criterion 7: The combination of Ms. Syed’s physical and mental impairments had resulted in a Whole Person Impairment (WPI) rating of only 42%, below the required minimum level of 55% to be considered catastrophic.
Criterion 8: According to the adjudicator, Ms. Syed has not suffered from a marked Class 4 or Class 5 extreme impairment in one or more areas that would prevent her from effectively functioning.
The after-effects of this decision meant that Ms.Syed was not able to obtain the increased benefits for a catastrophic impairment. Without that determination, her benefits were capped with standard coverage, which severely limited her ability to obtain the required medical and rehabilitation assistance.
What are the Legal Standards for Catastrophic Impairment?
The Ontario Statutory Accident Benefits Schedule (SABS) sets out strict criteria that must be met for an injury to be classified as catastrophic. This classification is crucial because it determines the level of benefits available to accident victims. According to SABS, the following conditions are considered catastrophic impairments:
Complete or partial paralysis of the limbs (paraplegia,quadriplegia).
A serious amputation, especially where the limb lost has a large effect on what things victim helps do day-to-day.
Permanent, serious brain injury if it causes memory loss or difficulty concentrating (even reading), or significant changes to behaviour and personality.
Total blindness or severe visual impairment, e., with the best correction in either eye, but unable to read 18 -point print.
In addition to these conditions, the SABS also considers other severe impairments, such as injuries leading to a Glasgow Coma Scale (GCS) score of 9 or lower or injuries causing a marked impairment in daily living activities or in social and occupational functioning.
How to proof that an injury meets ‘Catastrophic’ criteria?
Proof of a traumatic injury meeting these criteria typically necessitates a detailed medical examination from subspecialists who can prepare the relevant records and provide expert testimony. Such evidence shall clearly demonstrate that the injury has led to a permanent, serious impact on the victim’s quality of life.
Even with hefty evidence, insurance companies usually have a rebuttal for a claim. Often, they rely on the outcome of an independent medical examination, which is likely to return different levels of impairment. This is where many lawsuits arise, as it is incumbent on the claimant to prove they meet the declared thresholds of catastrophic impairment. This shows the effect of rigorous documentation and, as such, possible legal representation to effectively deal with all these intricacies.
Need to talk to a personal injury lawyer? Call us now for experienced guidance and support in securing the benefits you deserve.
The Court’s Final Verdict
Ontario Superior Court of Justice upheld a ruling, by the LAT to reject Sarah Syeds claim for impairment benefits based on principles and the assessment of evidence. The Divisional Court supported the Adjudicators conclusions. Endorsed his preference for the evidence presented by the Respondents Experts, which was deemed more in line with findings and the AMA Guides criteria. Furthermore, the court affirmed that the adjudicator conducted a thorough examination of all evidence with his decision being clear and well founded. The court also noted that the adjudicator’s observations of Ms. Syed’s cognitive functioning during testimony contributed to his conclusion, further affirming the reasonableness of the decision.
How Nanda & Associate Lawyers Can Assist You?
This ruling serves as a cautionary tale for those relying solely on the severity of their injuries to secure compensation. Victims must be prepared to navigate a legal process that is often adversarial and requires a deep understanding of both medical and legal standards.
If you or a loved one has been denied catastrophic impairment benefits, the legal team at Nanda & Associate lawyers are here to help. Our experienced personal injury lawyers will work tirelessly to ensure you receive the compensation you are entitled to.
Call us now at 905-405-0199!