Lenworth Scarlett v. Belair Insurance Company Inc.

For the reported decision in its entirety please consult Lenworth Scarlett v. Belair Insurance Company Inc.

Summary

The applicant Mr. Lenworth Scarlett was injured in an automobile accident, and applied for accident benefits under the Statutory Accident Benefits Schedule. It was determined that because Mr. Scarlett’s injuries are classified outside the Minor Injury Guideline, he is eligible to receive accident benefits in excess of the $3500 limit set out in the guideline.

Review of Facts

– Mr. Scarlett was a passenger in a vehicle insured by Belair that was rear ended by another vehicle on September 10, 2010. As a result of the injuries he experienced, he applied for accident benefits.
– At the time of the accident, Mr. Scarlett was new to Ontario and consequently was not covered under OHIP or any other medical plan.
– Mr. Scarlett brought forth evidence from health practitioners that outlined the extent of his injuries, which suggested that the totality of them falls outside of the Minor Injury Guideline. According to the experts, he was suffering from mental health issues such as depression, anxiety and post-traumatic stress disorder as well as physical health conditions such as chronic pain and Temporal Madibular Joint Syndrome (TMJ).
– Belair sought out the opinion of experts who concluded that he suffered soft tissue injuries with no indication that they fall outside the scope of the minor injury guideline. And also concluded that based on his narrative Mr. Scarlett does not meet the criteria for any formal psychological diagnosis.

Key Issue

The issue to be determined in this case is whether or not the complainant Mr. Scarlett is able to recover accident benefits in excess of the $3500 limit set out in the Minor Injury Guideline.

Relevant Law

Minor Injury Guideline
Statutory Accident Benefits Schedule , O Reg. 34/10
The Insurance Act, R.S.O. 1990 c. I.8

Decision

To reach a decision, arbitrator John Wilson looked to the policy objectives and language used in the guideline and related law to determine if Mr. Scarlett’s injuries fall under the classification of the Minor Injury Guideline. It was first decided that the guideline though incorporated into SABS is non-binding and serves only as aid to help with interpreting the schedule. Subsequently the purpose of the superior legislation (The Insurance Act and SABS) was examined to ensure that the interpretation of the guideline was consistent with the intentions of the legislation. It was concluded that the guideline was to be interpreted at face value and in conjunction with the purposes that it specifically outlines. Because of this, the burden of proof was found to rest on the insurer to provide evidence on the balance of probabilities as to why there should be a limitation of coverage.

Based on the compelling evidence offered by the complainant through credible medical reports, and the single medical report lead by Belair, it was determined that Belair did not meet their burden in providing evidence that suggested the claim should be limited to the Minor Injury Guideline. Mr. Wilson accepted the evidence that Mr. Scarlett suffered from TMJ, chronic pain and psychological impairments, which he found to be separate, distinct and outside of the Minor Injury classification. Therefore Mr. Scarlett is able to recover accident benefits beyond the $3500 dollar limit set out in the Minor Injury Guideline.

Commentary

In the past many individuals have tried to dispute the Minor Injury Classification unsuccessfully. This is a precedent setting case because it marks the first time a decision has been made regarding accident benefits and the Minor Injury Guideline. It changes the future of legal claims regarding this area, because they will now be evaluated on an case by case basis because there may be other injuries or pre-existing conditions that can influence the classification.

Stephanie Hannah is a Paralegal student at Centennial College in Toronto studying professional communications with Omar Ha-Redeye.

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