MIG Update – September 20, 2021

MIG Escapes Achieving ‘Reasonable’ Treatment Goals

In the two MIG escape cases reviewed this week, the Tribunal addresses the factors in concluding their finding of “reasonable and necessary”. A MIG escape doesn’t necessarily mean automatic approval of treatment plans in dispute. What are the common factors considered?

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Factor: Reasonable Treatment Goals

In Koufis v Intact (20-002237), an April 2017 accident, the Tribunal agreed with Koufis’ in finding that her pre-existing physical impairments, primarily in her lower back, right arm and shoulder areas, prevent her from recovering from her post-accident injuries within the 12-week recovery period as contemplated by the MIG. Koufis’s pre-existing lower and upper back complaints continued for more than two years post-accident. There were consistent visits to her physician who referred her for massage therapy and physiotherapy.

The insurer maintained that Koufis merely sustained mechanical back pain and that her accident related injuries had healed within the MIG timeframe.

The Tribunal found the four Treatment Plans for physiotherapy proposed between April 2018 and August 2019 to be reasonable and necessary:

1. Evidence of multiple medical consultations regarding common complaints established Koufis had yet to achieve maximum medical recovery during the period of Treatment Plans submitted April and September 2018
   
2. The duration of the September treatment would have lasted to approximately January 2019. The proposed treatments for the February and August 2019 plans were equally reasonable and necessary for ongoing, pain relief treatment.
3. Duration of the latter Treatment Plans are reduced, reflecting a reasonable measure of the effectiveness of the treatment, over time.
   

In Gharibo v. Aviva (19-008841), injured in a January 2018 accident, the Tribunal found Gharibo’s injuries were not minor as she suffered psychological impairment as a result of the accident. However, Gharibo failed to show how the Treatment Plan for physical treatment was reasonable and necessary when there had been no improvement in reducing her pain from her previous treatment.

The Tribunal held that Gharibo must submit compelling contemporaneous evidence to prove that any proposed treatment and devices are reasonable and necessary:

1. CNRs from the treatment facility leading up to the submission of the disputed treatment plan show Gharibo herself reported she was not receiving any benefit from her ongoing physical treatment.
   
2. On September 11, 2018, the same date of the proposed treatment plan, Gharibo reported no improvement and that her pain was worse.
3. The treatment facility’s CNRs again show that Gharibo was not obtaining pain reduction, noting on the Treatment Plan a 0% improvement since the last treatment plan/span>

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