MIG Update – June 13

MIG Escape 8 Years Post Accident

This week a MIG escape where an Applicant’s ongoing pain from a pre-existing knee injury sustained as a teen, was exacerbated and continued for 8 years following the accident. The surgical repair and ongoing intervention led to the Tribunal’s decision that maximum medical recovery could not be achieved within the MIG limits.

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Factor: Pre-Existing Injury

In Almonte v. Wawanesa Mutual Insurance Company (20-000204), Robert Almonte was injured in an accident on December 11, 2014 claiming that his pre-existing knee pain was exacerbated by the accident in which he had struck his knee amongst other injuries. Further diagnostic imaging by way of an MRI revealed complex lateral meniscal tears and a complete ACL tear, which was found to be chronic in nature that ultimately required surgical repair.

At issue were 7 treatment plans for both treatment and assessments in dispute between August 2017 and December 201, totalling $14,200.

Wawanesa submitted that Almonte did not meet his burden in proving the pre-existing injuries prevented maximal recovery under the MIG. They also submitted any treatment or assessments beyond the August 2017 surgery were caused by degenerative knee changes unrelated to the accident.

The Tribunal found:

• On the medical evidence submitted, Almonte’s right knee was already compromised at the time of the accident due to the pre-existing athletic injury suffered as a teen.
• In the months following the accident Almonte reported on more than one occasion that he struck his right knee at the time of the collision.
• Between March 9, 2015 and December 19, 2019 there are numerous records of knee pain complaints and pain medication prescriptions. All of which were documented as accident related.
• In September 2017 Almonte underwent knee surgery due to the ACL tear and lateral meniscal tear.
• The accident exacerbated Almonte’s pre-existing right knee pain to such an extent it would prevent maximum medical recovery if remained in the MIG.
• The treatment plans for physical therapy were reasonable and necessary. The knee pain complaints were consistent both prior to and after the surgery and the treatment plans helped with symptom control and goals met to a reasonable degree.
• Prior to the accident Almonte was able to engage in full-time work and sports activities, and after the accident, he required knee surgery and is no longer able to engage in full-time work or his various pre-accident sports activities. As such, “there are reasonable grounds to support an investigation by way of an orthopaedic assessment”.
• Wawanesa’s argument that Almonte failed to meet the criterion set out in the AMA Guides for a chronic diagnosis was not a valid position against the assessment request which was to determine if there was a chronic pain diagnosis.

If you Have Read This Far…

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