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  MIG Update – April 20, 2026

No ‘Splitting the Determination’

This week we review a MIG escape where the Tribunal weighed a consistent clinical history supported by a prescription history against the failed malingering tests in an IE.

Once the psychological impairment removed the Applicant from the MIG, the Tribunal turned to the pending physiotherapy plans. Applying the precedent in Co-operators v. Bennett, the ruling confirms that an insurer cannot “split the determination” by acknowledging a MIG escape while simultaneously trying to keep physical injuries capped. Because the Respondent relied solely on the MIG and offered no alternative reasons for why the treatment plans were not “reasonable and necessary,” the plans became payable by default the moment the psychological threshold was met.

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In Farooq v. Unifund Assurance Company (24-003029), Umar Farooq was involved in an accident on July 20, 2021, and sought entitlement to five Treatment Plans for physiotherapy and psychological services and a psychological assessment, and prescription expenses, totalling $15,422.41. He sought removal from the MIG based on a psychological impairment.

Farooq submitted that his complaints to his treating providers and his prescription history were consistent, which demonstrated the genuine nature of his impairments. He relied on GP Dr. Babatope’s September 2021 diagnosis of high-level anxiety. He pointed to GP Dr. Babatope’s January 2022 notes documenting depressed mood, sleep disturbance, and impaired concentration, and his recommendation for psychotherapy.

He relied on psychiatrist Dr. Robertson-Moore’s March 2022 report, which diagnosed him with PTSD, major depressive disorder, and moderate to severe insomnia. He also relied on psychologist Dr. Aghamohseni’s April 2022 report, documenting cognitive concerns, avoidance, and trauma symptoms, and opining that he suffered substantial psychological trauma. He explained that the lack of OHIP-funded treatment records after February 2023 was due to the expiry of his health card and work permit.

Regarding the physiotherapy Treatment Plans, Farooq submitted that they were denied solely because Unifund classified his injuries within the MIG. He argued that if he were removed from the MIG, these plans should be payable under s.38(8) and s.38(11) of the Schedule because the stated reason for denial would no longer be valid. He relied on Co-operators v. Bennett to argue that an insurer cannot continue to apply the MIG to some injuries once an insured is removed from it. He submitted that the Respondent’s notices failed to meet the requirements of s.38(8).

Unifund submitted that Farooq’s providers accepted his self-reporting at face value without validity testing or considering secondary gain. It sought an adverse inference because he failed to produce OHIP summaries and CNRs for certain periods. It argued that psychologist Dr. Aghamohseni’s April 2022 report should receive less weight because she did not review medical records. It relied on psychologist Dr. Harris’s March 2022 IE report, which indicated that Farooq failed two malingering tests, preventing a definitive diagnosis. It further relied on psychologist Dr. Harris’s October 2022 addendum, noting that psychologist Dr. Aghamohseni did not test for malingering.

Regarding the Treatment Plans, Unifund argued that Farooq bore the onus of proving they were reasonable and necessary and that he failed to make substantive submissions on this point. It submitted that the MIG limits were exhausted and no objective evidence warranted his removal.

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The Tribunal found:

• • Farooq’s psychological issues were documented by multiple practitioners, supported by prescribed medications, and were consistent over time.
  • Dr. Robertson-Moore’s March 2022 diagnosis of PTSD and major depressive disorder was significant. While noting that the psychological complaints to GP Dr. Babatope arose several months post-accident, this was explained by symptom progression.
  • While Dr. Aghamohseni’s April 2022 did not review medical records, her standardized testing used validated tools and her results matched other clinical findings.
  • Dr. Harris’s malingering concerns were not definitive and did not outweigh the consistent diagnoses from multiple practitioners.
    
  • There was no adverse inference drawn for the lack of OHIP records and CNR’s as Farooq’s explanation that his OHIP coverage ended when his work permits expired reasonably accounts for the absence of OHIP-funded treatment after February 2023.
  • “I have found that the applicant has been removed from the MIG due to psychological impairments. The insurer denied the physiotherapy plans solely on the grounds that the applicant was subject to the MIG at the time of denial. Section 38(8) requires insurers to provide medical and other reasons when issuing a denial so that the applicant understands the basis for the decision and can take steps to challenge it. This obligation applies at the time the denial is made; it does not require the reasons to remain accurate indefinitely. While the insurer’s MIG-based reasons were valid for notice purposes when given, they are no longer relevant to determining entitlement now that the applicant has been found to fall outside the MIG. In these circumstances, the insurer’s stated reason for denial does not justify the continued refusal of the plans. I also note the Divisional Court’s decision in Co-operators v. Bennett, which confirms that an insurer cannot “split the determination” and continue to apply the MIG to some injuries once the insured is removed from it”.
  • The December 2021, March 2022, and September 2023 physiotherapy plans are payable because Unifund failed to provide any alternate reasons beyond the MIG position for the denials.

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