In Hamid v. Intact Insurance, 2023 CanLII 103792 (ON LAT), the Adjudicator made it abundantly clear that evidence from qualified medical professionals is necessary for the Tribunal to rule on issues that involve medical determinations.
In Hamid, the Applicant’s husband was involved in an accident in 2015 when he lost control of his vehicle on the Gardiner Expressway and collided with a guardrail. Police noted that the man likely lost control of the vehicle due to a medical incident that occurred while he was driving. At the hospital, doctors concluded that the man suffered from a stroke. Some days later, the man went into cardiac arrest and fell into a coma, and remained in a coma until he passed away in 2019. The Applicant applied for benefits from the Respondent but the application was denied.
The issue before the License Appeal Tribunal (LAT) was narrowly framed: whether the Applicant – the man’s wife – could be properly considered an “insured person” as that term is defined in Section 3(1) of the Statutory Accident Benefits Schedule (SABS). Subsection 3(1)(a)(ii) of the SABS sets out that, as it pertains to a policy of motor vehicle insurance, ‘insured person’ includes, inter alia, the named insured and the named insured’s spouse. It provides for benefits coverage “if the named insured, specified driver, spouse or dependant is not involved in an accident but suffers psychological or mental injury as a result of an accident in or outside Ontario that results in a physical injury to his or her spouse.”
The insurer argued that the Applicant was not an insured person because there was no evidence that her husband sustained a physical injury as a result of the motor vehicle accident. The Applicant argued that she was an insured person and entitled to benefits because she claimed that she had suffered a psychological injury as a result of her husband being involved in the accident. However, the Applicant did not lead any medical evidence to prove her alleged psychological injuries, and she did not produce evidence to substantiate that her husband sustained a physical injury as a result of the accident. The Adjudicator held that even if the LAT were to have accepted the Applicant’s contentions regarding her alleged psychological injuries, the greater issue was whether the Applicant ’s had proven that her husband sustained any physical injuries in the accident that would then create the opportunity for the Applicant to claim benefits based on consequent psychological injury. The medical evidence that was filed detailed that the Applicant’s husband had a mild right sided facial droop, right sided neglect and paralysis, and that he was soft and non-tender in all quadrants. The police field notes listed the injuries as stroke. The Adjudicator noted that the Applicant submitted medical literature and referenced the medical documents from the hospital during her husband’s treatment to argue that her husband suffered the stroke and soft-tissue musculoligamentous injuries a result of the accident. However, the Applicant did not provide any evidence from a qualified medical practitioner that could properly opine on the cause of her husband’s medical condition. Further, the Applicant did not provide evidence that she even attempted to acquire such evidence. Accordingly, the Adjudicator found no basis to hold that the Applicant’s husband suffered physical injuries as a result of the accident, and, for that reason, the Applicant could not be an insured person under Subsection 3(1)(a)(ii) of the SABS.
This decision underlines the requirement for expert medical evidence to prove both the nature of the psychological or mental injury that is being claimed, and the link between underlying physical injury to the insured person involved in the accident and the consequent psychological or mental injury that is being claimed. In Hamid, the absence of such evidence resulted in the dismissal of the claim based on the Adjudicator’s finding that the claimant was not an insured person under the SABS.
Jordan Hochman is an articling student at the firm and the author of this blog. If you have a question about this decision, or a similar file, please contact Jordan at [email protected] or Bill Sproull at [email protected].
