MIG Update – August 8, 2022
No Obligation to Revisit Previous MIG Denials Post Removal?
In the July 25, 2022 issue of the MIG Monday, we reviewed a series of decisions wherein the Tribunal ruled that insurers are obligated to reconsider all previously denied treatment plans once removed from the MIG. As a result, the previously denied plans are subject to the reasonable and necessary test.
This week’s issue considers, a decision released last week wherein the Tribunal contradicts these previous decisions and rules they are prevented from reviewing a previously denied treatment plan. Is there an obligation to continuously adjust when a denial is made under ss 38(5) and 38 (6)?
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Factor: Section 38(5) and Section (38)(6)
In Galang v. Coseco Insurance Company (20-008382), Mary Queen Galang was involved in an automobile accident on April 30, 2018. She was removed from the MIG on August 24, 2018, due to a pre-accident diagnosis of ADHD and Depression.
As of April 7, 2022, $23,432.71 had been paid by the respondent for medical, rehabilitation, and attendant care benefits with $41,567.29 remaining under the policy.
One of the main issues in this dispute was entitlement to $3,696.50 for chiropractic treatment, recommended by Mackenzie Medical Rehabilitation Centre in a treatment plan (“OCF-18”) submitted on May 15, 2018. This was denied by Coseco pursuant to s.38(5) of the Schedule as Galang was entitled to treatment under the MIG during that time.
Further Coseco, submitted that pursuant to s.38(6), its decision is final and not subject to review by the Tribunal and relies on the authority of J.P. v. Allstate Insurance Company to support its position.
In J.P. vs. Allstate Insurance Company (18-008027) the Applicant was found not to be entitled to eight Treatment Plans, as the Respondent’s denials pursuant to s.38(5) of the Schedule were proper given that the subject OCF-18s (Treatment and Assessment Plans) were submitted while the Applicant was within the MIG and that the MIG limit had not been exhausted. Despite the Respondent’s repeated request, the Applicant failed to submit an OCF-23 (Treatment Confirmation Form) as required.
The Tribunal found:
- Coseco’s denial letter clearly advised Galang that the Treatment Plan was being denied pursuant to ss.38(5) and 38(6) of the Schedule. Also advising Galang that she was continuing to receive treatment under a May 14, 2018 Treatment Confirmation Form (OCF-23).
- The MIG was exhausted some time between September 7, 2018 and October 2, 2018, so Galang was still entitled to treatment under the MIG when the disputed Treatment Plan was submitted.
- Galang “failed to address ss.38(5) or 38(6) in her initial submissions. The applicant instead submits that the OCF-18s for issues 1 and 2 were wrongfully denied as it was clear that she should not be in the MIG due to the evidence listed in her submissions. The applicant failed to address when the evidence was provided to the respondent and the applicant was subsequently removed from the MIG on August 24, 2018” .
- Since finding that s38 (5) was applicable the Tribunal was prevented from reviewing the denial pursuant to s38(6) which sets out the insurer’s denial to be final regardless of the fact that the Galang was later removed from the MIG.
If you Have Read This Far…
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