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Posts Tagged ‘toronto personal injury law’

Perspectives on Chronic Pain

Tuesday, January 29th, 2013

One in every five people in Canada suffers from chronic pain.

Chronic pain sufferers may find and do find relief with prescription medication. Often strong medications, such as opoids are prescribed, but many physicians are hesitant to prescribe them, or are unable to prescribe them and only specialists can prescribe them.

There is a polarization between pain and addiction. Doctors do not want to prescribe medication for pain, because of fears that patients will become addicted to the medication.

Chronic pain can develop as a result of injuries from a motor vehicle accident and can lead to the short term disability claims and long term disability claims.

Many people in Ontario who suffer from chronic pain are left floundering, struggling to find someone who will help them to manage their chronic pain. Pain specialists are in short supply in Ontario. Chronic pain sufferers are facing an uphill battle: there is a lack of understanding with respect to chronic pain among doctors and health professionals, and a growing stigma with respect to opoid medications, which the government has cracked down on- making treatment less available to those in need.

The Canadian Pain Coalition recognizes that strong medications such as Oxycodone and morphine need to be carefully monitored, but the opoids are an important part of pain management. Having a pain specialist or physician who can prescribe the medication and monitor its use is an important part to treating chronic pain, especially when physiotherapy and/or massage therapy is not an available option. When medication is difficult to get, chronic pain patients are out of luck.

Both the government of Ontario and the federal government have taken steps to oversee how painkillers such as Oxycontin, Oxycodone, morphine, methadone and codeine are dispersed in the wake of the rising number of accidental deaths. Ontario has introduced a tracking system to monitor these narcotics to identify patients who are getting multiple prescriptions, the doctors prescribing them and the pharmacists dispersing them.

Chronic pain affects not just the individual in pain, but his or her family.

 

 

A Depression Gene, Stigma, Psychotherapy, Relationship between Concussions and Depression

Monday, January 21st, 2013

The search for a depression gene came up empty. A group of 86 researchers were hoping to discover genetic influences linked to depression while studying approximately 34,500 volunteers. Since depression runs in families, many experts believe that there must be a genetic connection. Research failed to demonstrate any specific genes that cause depression. After raising the number of study subjects to over 51,000, only one spot in the whole genome was tied to depression, but it was not close to any genes. The study had focused on patients with symptoms of depression. The study’s authors are considering trying again on a larger scale, this time focusing on patients who have a confirmed diagnosis of depression.

What prevents people from seeking treatment for depression and mental health treatment? Psychotherapy takes time and effort. There is stigma attached to seeking treatment for mental illness. People are hesitant to admit that they attend therapy sessions. Society places illogical taboos and stigmas around mental illness, therefore many people feel ashamed about their diagnoses or symptoms. Another factor that can prevent someone from seeking treatment is severity- he or she may not realize how severe the symptoms are and may feel that therapy is not warranted. The will to get started and knowing how and when to start is another factor.

Research has shown that, in some instances, there are legitimate biological scenarios that cause secondary illnesses that would not exist in individuals otherwise. Researchers in Denmark at the University of Copenhagen were able to isolate an enzyme called C-Reactive Protein (CPR), that when present in high concentrations can cause depression, using a blood test to isolate a specific protein in the bloodstream. It was through this line of research that they found a relationship between depression and arthritis. It was noted in the past patients with inflammation or arthritis may have been simply “written off” by their doctors as upset due to the physical pain and limitations.

This new research has showed that those patients with higher levels of the CPR protein (which is released by inflammation/inflammatory conditions), were 2-3 times more likely to develop depression. It is not clear though, whether inflammation causes depression or the other way around.

An article released on the Time.Com website concerning the link between concussions and depression explains how sustaining a concussion can make one more vulnerable to depression. Two studies were conducted on  retired NFL players.  The first study, which has already been released found that the former players who are depressed or cognitively impaired have abnormal findings in a specific area of the white matter of their brains.  White matter is critical for transmitting signals. The American Academy of Neurology reports that a higher number of concussions equates to a higher likelihood of depression. Neurologist, Dr. John Hart, who was active in both studies, said that these studies apply to everyone who is affected by concussions, not just professional sports players. He said anyone who has suffered a concussion should be monitored for signs of depression. Depression is manageable, but only if doctors know how to diagnose and treat it properly.

 

Aaron Waxman and Associates is a Toronto Personal Injury Law Firm that focuses solely on the rights of injured persons. We advocate for your rights. We provide a free initial consultation.

 

Developments in the field of Brain Injury Awareness

Monday, January 14th, 2013

When a brain injury occurs, it is crucial to go to a hospital or diagnostic imaging clinic to have a CT Scan or MRI test completed right away to assess what has happened.

A recent study found that , however, that CT scans can miss minor bleeds on the brain. Individuals with mild traumatic brain injuries may have normal CT Scans. It may take more sophisticated scans to see abnormalities. MRIs are of course, more expensive.

The study tracked patients with mild TBI for 3 months. Researchers found that over a quarter of patients with normal CT Scans on the day of injury had positive findings on their MRIs when tested a week later. Further testing showed that full recovery had not taken place after 3 months.

An MRI study is a more comprehensive study and is better able to show a comprehensive picture of damage.

This is why it is so important for patients to tell their doctors exactly how they are feeling and if they are experiencing any problems after a head injury.

The study showed that MRIs are able to show focal lesions, which are areas of microscopic bleeding in the brain.Researchers can use the presence of focal lesions to predict which patients are more likely to have ongoing neurological problems.

MRIs are better indicators of the course of injury and recovery.

A brain injury can cause long term damage to the brain. A traumatic brain injury can lead to inflammation and slow regeneration of brain cells. A study from the University of South Florida, found that even at the most chronic stage of injury, therapeutic intervention can help with the regeneration of brain cells. The study examined brain injuries to different areas of the brain and found that TBIs caused a second wave of cell death that impairs cell proliferation and impedes that brain’s ability to regenerate cells.

The study’s researchers found that microglia cells at the injury site and distant sites were activated around 8 weeks after injury. The researchers feel that therapeutic intervention may help prevent some long term damage to the brain.

According to the Centre for Disease Control and Prevention (CDC), 1.7 people sustain a traumatic brain injury per year and of that number, 75% are concussions or some other form of mild TBI.

Aaron Waxman & Associates is a Toronto Personal Injury Firm that advocates for the rights of its clients. Contact us today for a free consultation.

Developments in the Field of Chronic Pain/Pain Management

Monday, January 7th, 2013

Yoga is not just for relaxation. Yoga breathing and relaxation techniques can ease chronic pain according to an assistant professor, Neil Pearson, at the University of British Columbia. Pearson is offering free online information sessions (webinars) for those interested in learning more. Pearson explains that pain changes everything in a person’s life from thoughts to movement to relationships.

A step forward for pain management is to move beyond finding a simple remedy for pain. By the time most people accept that their pain condition is long term, their nervous system has already become “locked in” to a pattern of pain. This pain pattern leads to shallow breathing, tight muscles and spasms. This pain pattern causes a “hyper-vigilant” nervous system.

Yoga can help reset the system and break away from stiffness. Chronic pain is common amongst Canadians of all ages and can stem from a variety of causes including car accidents, falls, sports injuries, arthritis, digestive disorders and back problems.

If you are in constant pain, you should blame your genes, says a new scientific study. Scientists have identified genes that interact with each other to regulate pain in humans. They found that differences in these genes may influence people’s sensitivity to pain. The method used to study and target these genes is called “exome sequencing”- a strategy used to sequence genetic coding.

The study notes that chronic pain is a significant burden on individuals and on the economy. Exome sequencing could be used to find important pathways in other common conditions. The results showed different patterns of genetic variants in each group, the pain sensitive people had less variation of DNA compared to those who were less sensitive to pain.

It is known that people who are most sensitive to pain in general, are those who are most likely to develop chronic pain. Understanding the underlying genetic factors of chronic pain can help researchers understand the biology of pain and new areas to target for therapy. Research for chronic pain is important because current treatments can be expensive, have limited efficacy or significant side effects.

It turns out that Morphine can actually cause pain in some people. Research from the Universite Laval in Quebec City has shown that there is a molecular pathway by which morphine can actually increase pain, but at the same time, provides insight for how morphine can be effective for more patients.

The research team includes representatives from Quebec, Ontario, the U.S. and Italy.

The research identifies a target pathway to suppress morphine-induced pain, and was able to distinguish the pain hypersensivity caused by morphine from tolerance to it. Previously it was thought that pain hypersensitivity and tolerance were caused by the same mechanisms.

The study demonstrates that cellular and signalling processes for morphine tolerance are markedly different from those of morphine-induced pain. This research is important, because the usual line of thinking is that when morphine doesn’t reduce pain, a higher dosage is needed, but sometimes increasing the dosage has a paradoxical effect.

Decisions released in Cornie v. Security National & Younis v. State Farm today

Thursday, November 29th, 2012

In the late summer, the appeal was heard in Leone v. State Farm and State Farm’s appeal was dismissed. The decision concluded that mediation was deemed to have failed because it did not occur within 60 days of the application being filed and the parties could not extend the time limit on consent once the 60 days had expired.

Director’s Delegate Evans stated that “I agree with the arbitrator that Mr. Leone did not need to attach the report of mediator to his application for arbitration where mediation has failed by statutory definition, but no report of mediator is available…Mr. Leone should not be prevented from proceeding to arbitration where through no fault of his own, s.280(8) has not been complied with.”

Today, a decision was released in Cornie v. Security National (this case is also listed as Hurst v. Aviva Insurance Company) where 4 plaintiffs commenced litigation against their insurers after the 60 day period had passed. All 4 insurers appealed the decision in Cornie (“the appellants”).

All 4 plaintiffs (“the respondents”) suffered serious injuries as a result of motor vehicle accidents and filed for mediation as a result of disputes against their accident benefits providers. All of the respondents waited at least 60 days after filing for mediation for FSCO to appoint a mediator and for a mediation to take place. No mediator was appointed and no mediation took place in any of the 4 cases.  They took the position that mediation had failed because the prescribed time for mediation had expired. Each wrote a letter to FSCO requesting a mediator’s report declaring that the time for mediation had elapsed and that mediation had failed according to s. 281(2) of the Insurance Act.

Subsection 281(2) of the Act prevents insured persons from resorting to court actions against their insurers unless they first sought mediation and mediation failed.

FSCO refused to issue a report of mediator, taking the position that the time limit for conducting mediation did not commence until an application had been assessed and found to be complete. Each of the respondents then commenced a court action. Each insurer brought motions to strike or stay the actions, arguing they were barred by s. 281(2), and all motions were heard by Sloan (J) who dismissed the motions.

The respondents took the position that mediation must be completed within 60 days of their applications to FSCO, relying on the Act, the SABs and the Dispute Resolution Practice Code.

Rule 19 of the DRPC states that “mediation must be concluded within 60 days” of the filing of a properly completed application for mediation, unless the parties agree otherwise.

At paragraph 26, R.G. Juriansz J.A. writes,

[26]The appellants support their argument by examining the functioning of FSCO. FSCO’s services resolve some 75% of cases mediated. FSCO also eliminates from the system claims that are incomplete, vexatious, or barred by statutory limitation periods. Fresh evidence tendered by the IBC indicates that FSCO received a total of 36,492 applications for mediation in 2011. As of April 1, 2012, 21,023 of 26,240 active applications that had not yet been referred to mediation were more than 60 days old. Dismissing the appeal would allow these disputes to proceed in court or arbitration, when 75% of them would have been resolved by mediation before FSCO. The resulting costs could be immense.  Insurers pay a filing fee of $500 for mediation, and $3,000 for arbitration. If all of the claims that would have otherwise gone to mediation are forced into arbitration, the cost to the insurance industry from the additional filing fees alone could amount to $83 million.  When one considers the additional costs of court proceedings and legal fees, which are not so easily calculated, it is inevitable that there would be upward pressure on insurance premiums.

And at paragraph 38:

[38]       I do not accept that the 60-day clock does not begin to run until FSCO has assessed an application as complete. Such an interpretation, which would allow FSCO to accumulate a backlog of any length, would ignore the legislative purpose of providing a speedy mediation process. As noted in s. 10 of the regulations, a mediator is required to attempt to effect a settlement of a dispute within 60 days after the date on which the application for the appointment of a mediator is filed. Rule 6 of the DPRC provides that a document that is required to be filed “must be delivered to the Dispute Resolution Group” by one of several methods of delivery permitted under Rule 7. Clearly, the word “filed” is used in the legislative scheme in its ordinary sense.

And the conclusion:

[56]       The legislative scheme for resolving disputes about statutory accident benefits requires that insured persons resort to a mandatory mediation process before commencing a court proceeding or submitting their disputes to arbitration. The Act, the regulations and the DRPC make it clear that this process is intended to be completed within 60 days from the filing of an application for mediation with FSCO, unless the parties agree to an extension of time. The scheme postpones the right of insured persons to commence civil actions against their insurer in order to allow the mediation process to be completed within the time prescribed, but leaves them free to commence actions once that period has expired.

The appeals were dismissed and costs were awarded in favour of the respondents in the amount of $10,000 against the appellants (the insurers) and against the Insurance Bureau of Canada in the amount of $6,584 including disbursements and costs.

A decision was also released in Younis v. State Farm where the plaintiff commenced litigation shortly after an application for mediation was filed. State Farm brought a motion to stay the proceedings in Younis until an actual mediation was held. The motion was heard in February 2012, which was more than 60 days after the application for mediation was filed. The motion judge followed the decision of Cornie v. Security National and concluded that s. 281(2) of the act allowed an insured person to commence a civil action if mediation was sought and not completed within 60 days of filing an application.

The motion judge considered the circumstances and declined to stay the proceedings. The Court of Appeal, however, allowed the appeal and determined that the circumstances differed from Cornie as the plaintiff had brought a civil action a week after filing for mediation.

At paragraph 12 & 13, R.G. Juriansz J.A. states,

[12] I would allow the insurer’s appeal. The motion judge evidently approached the motion as one that called upon the court to exercise its inherent jurisdiction to stay an action. However, the insurer’s motion called upon the court to apply a statutory bar to the commencement of an action. The terms of s. 281(2) of the Act are clear. No person may bring a proceeding until mediation has failed. The respondent jumped the gun and brought this proceeding before that had occurred.

[13]       I appreciate that by the time the motion to stay came before the court the 60-day time period had expired. From the practical perspective adopted by the motion judge, there would seem to be no reason to require the respondent to start again. However, the respondent commenced his action in contravention of the statute and the statute must be applied. Insured persons cannot commence civil actions until mediation has failed. To conclude otherwise would allow all insured persons to immediately commence civil actions knowing that the insurers’ motions to stay are not likely to be heard until after the expiration of the 60 day time period. The statute does not permit this stratagem.

The Court of Appeal also ruled that as the commencement of the action was statute-barred, it is quashed. No costs were awarded.

 

 

Cars with Wifi, Beware of Wildlife and Road Rage: An Update on the Wonderful World of Driving

Tuesday, November 20th, 2012

In-car technology has come a very long way in recent years. Auto makers have installed radar devices and cameras to help drivers maintain safe distances from other cars, keep vehicles in their lane and even alert drivers of impending accidents. There is in-car technology that even goes as far as automatically breaking and stopping the car as necessary.

How about if your car could have a bird’s eye view of the road, and see other vehicles, pedestrians and bicyclists? A special form of Wi-Fi is being developed that will allow cars to communicate with each other through special sensors. It would be vehicle to vehicle Wi-Fi.

This system is being piloted by the University of Michigan, eight automakers and the Department of Transportation. It is being tested on 3,000 vehicles in Michigan with sensors. Participating automakers include GM, Ford, Toyota, Honda, Nissan, VW, Hyundai/Kia and Mercedes. Data from the trial will ultimately help determine whether or not the National Highway Traffic Safety Administration should pursue this technology.

Collisions between wildlife and vehicles are often unpredictable. Collisions tend to spike during the fall, when it is breeding season for deer. In general, due to the earlier dusk and poorer visibility, more accidents are likely to occur. Drivers must obey wildlife signs and traffic signs.

It is better to think about and learn how to avoid an encounter with wildlife, than have to react to a dangerous situation when you are unprepared. Drivers and passengers should be on the lookout for wildlife on the road, in the ditch, on the shoulder. Driving at a slower speed may reduce the chances of having to swerve at all. Always reduce your speed in signed areas. The danger of swerving is that it can take you into the path of a ditch and take you off course.

However, if you are about to collide with a moose, experts say you should swerve as a collision with a moose carries a significant risk of injury or death to motorists and passengers.

Another threat on the roadway is distracted drivers. The popularity of smartphones and internet use while driving has made drivers even more distracted than ever.

State Farm conducted its annual research report on distracted driving, surveying 1000 US motorists. Texting and driving remains a concern, but there has been a noticeable increase in “webbing” while driving (internet use).

The study found that it is not just youth who are committing these distracted driving offenses, but motorists of all ages.

While the distracted driving focus has traditionally been on young people, the data indicate that motorists of all ages are using the mobile web while driving.

Another study says that young drivers are more likely to drive while tired. The AAA Foundation for Traffic Safety surved drivers aged 16-24 and found that 1 in 7 licensed drivers have admitted to falling asleep behind the wheel at least once in the past year.

Research shows that fatigue impairs a person’s driving ability, and causes them to behave in similar ways a person does while intoxicated. Most drivers underestimate the dangers of driving while fatigued. Driving fatigued can cause a person to miss exits and traffic signs,  drifting from your lanes and daydreaming.

A Canadian Study shows that 80% of Canadian drivers admit to road rage behaviour.   The poll, completed by Leger Marketing, suggests that about 80% of Canadians admit to aggressive behaviour such as using profanity, yelling or following other vehicles too closely. The most commonly reported aggressive behaviour was speeding.

Distracted drivers (including the use of mobile phones) were the most common trigger for road rage-like behaviour. Being cut off by other drivers, as well as tailgating behaviour were also causes of road rage. Other reasons for road rage included running behind schedule and having a bad day.

Aaron Waxman and Associates is a personal injury law firm located in Toronto. We handle various types of personal injury claims including automobile accident claims and disability claims.

 

Pastore v. Aviva Canada Inc. – Definition of Catastrophic Impairment broadens, victory for the plaintiff’s bar

Thursday, October 11th, 2012

The Ontario Court of Appeal finally released its decision in Pastore v. Aviva Canada Inc. It’s been referred to as a “landmark decision on chronic pain”.

The OCA ruled that chronic pain is a psychological condition that can produce a catastrophic impairment, thereby entitling accident victims to enhanced medical benefits.

The unanimous decision of the Court means will allow claimants with severe psychological impairments to access much-needed benefits beyond standard accident benefits.

The Court of Appeal overturned the lower court’s decision that would have denied the plaintiff, Anna Pastore access to extended benefits.

Pastore v. Aviva concerns a woman who was struck as a pedestrian in November 2002 and injured and broke her left ankle, which never healed properly, leading to numerous surgeries and an eventual knee replacement.

Prior to the accident, she was the primary caregiver to her husband of over 35 years, who was receiving chemo-dialysis.  The decision states that she is almost completely dependent on others for her most basis personal care needs.

Pastore applied for catastrophic determination in May 2005.

Pastore was assessed by a team of medical assessors to determine if she was catastrophically impaired. It was found that she had catastrophic impairment due to mental or behavioural disorder. She had class 4 or ‘marked impairment’ in terms of her activities of daily living and assigned her a class 3 (moderate impairment) with respect to social functioning, concentration, persistence and pace and deterioration or decompensation in work or work-like settings.

Aviva did not accept the findings of the assessment centre and this led to mediation and arbitration.

One major issue was whether marked impairment in one category was enough to lead to a catastrophic designation.

The arbitrator and the Director’s Delegate upheld the decision of the assessment centre and found that Pastore was catastrophically impaired. Aviva appealed this decision and the Divisional Court sided with Aviva, stating that the Guides portion of the Statutory Accident Benefits Schedule (SABS)  requires all four categories to be considered as marked impairments in order for a person to be deemed as catastrophically impaired.

The Ontario Court of Appeal disagreed and overturned the Divisional Court’s decision, siding with the original decision, stating that the American Medical Association’s Guides to the Evaluation of Permanent Impairment language did not specifically require all four categories to be considered marked impairments for a catastrophic impairment designation.

The role of pain was addressed within the context of the marked impairment test. The OCA concluded that a cumulative approach should be taken where it is not possible to factor out the impact of discrete physical impairment and associated pain limitations.

What the court is saying, is that pain can be considered within the marked test in cases where the pain is not cleared related to physical causes, but may be related to a mental disorder.

Aaron Waxman & Associates is a Toronto Personal Injury Law Firm that handles personal injury claims, including catastrophic cases.

Ontario Coroner’s Report on Pedestrian Deaths: No Jaywalking and Reduce Speed Limits

Thursday, September 20th, 2012

Ontario’s Deputy Chief Coroner, Dr. Bert Lauwers issued his report on pedestrian deaths on Wednesday, September 19, 2012, in collaboration with the Office of the Coroner.

The Report reminds us that we are all pedestrians.

According to the Coroner’s office, approximately 113 Ontarians die annually from pedestrian accidents.

The Coroner’s office suggested the following:

  1. Pedestrian deaths are more likely to occur during the months when daylight is shorter. (e.g. November to March).
  2. Pedestrian deaths are more likely to occur when a pedestrian and/or driver is using a mobile entertainment/communication device. (e.g. cell phone, ipod, etc.).
  3. Pedestrian deaths are more likely to occur when one or more persons involved in the collision are under the influence of alcohol and/or drugs.
  4. The vast majority of pedestrian deaths are preventable.

According to the Review on Pedestrian Deaths, in Canada, characteristics of pedestrian traffic are as follows:

  • 75% of pedestrian traffic fatalities occurred on urban roads;
  • 60% of pedestrians killed in traffic crashes were trying to cross the road;
  • 35% of fatally injured pedestrians were aged 65 or older even though they represent only 13% of the population;
  • 63% of pedestrians killed at intersections were 65 or older;
  • 6% of fatally injured pedestrians were under the age of 16 and of these, 20% ran out into the street;
  • 33% of fatally injured pedestrians acted in a manner which caused or contributed to the crash;
  • 33% of fatally injured pedestrians were struck by a driver who had committed a traffic infraction prior to the crash;
  • 60% of pedestrians were killed at night or during dim light conditions when they were not seen by drivers; and
  • 40% of fatally injured pedestrians had been drinking

The Coroner’s Office made 26 recommendations in the Report. Highlights of the recommendations include:

  • lowering speed limits in residential areas to 40 km/h
  • installing side guards on heavy trucks to help prevent people from falling beneath and getting crushed by the rear wheels
  • implementing a complete streets approach to guide the development of new communities and redevelopment of existing ones
  • creating an educational program for senior citizens and other adult pedestrians
  • creating an educational program for drivers

The Coroner found that 67% of pedestrian fatalities occurred on streets with a posted speed limit of above 50km/h.

Other significant factors for pedestrian deaths included jaywalking, inattentive motorists and distracted walkers.

It was found that nearly one third of pedestrians died while jaywalking.

The Report notes that in 14% of the deaths, driver inattention was noted.

Pedestrian distractions including dogs, smartphones and cellphones may have contributed to 20% of the fatalities.

Canada has a Road Safety Strategy according to the Report. The vision of the Strategy is to make Canada’s roads the safest in the world. Currently, Canada is ranked 10th in terms of fatalities per billion vehicle kilometers travelled compared to other member countries of the Organization for Economic Cooperation and Development.

The key elements of the Strategy are:

  • a downward directional trend in fatality and serious injury rates over the 2011 to 2015 period;
  • jurisdictions will adopt a holistic (Safer System) approach addressing the vehicle, the road infrastructure, and road users based on the primary risk groups;
  • an evidence-based Best Practice Framework will be adopted in choosing interventions;
  • a fluid and flexible approach will allow jurisdictions to adopt best practices appropriate to their situation; and
  • jurisdictions will own their road safety plans.

To achieve this, the Strategy seeks to target:

  • young drivers (16 to 24);
  • medically-at-risk drivers (e.g. those with heart disease or cognitive disorders such as Alzheimer’s Disease);
  • vulnerable road users (i.e. pedestrians, motorcyclists, bicyclists);
  • motor carriers (e.g. managers of carrier operations, truck and bus drivers);
  • high risk drivers (e.g. those who don’t wear seat belts or who speed, drive impaired, or drive without a valid license) and the general population.

Dr. Andrew McCallum, Chief Coroner for Ontario stated “A road safety paradigm shift will be necessary”, acknowledging that the rising cost of fuel will result in an increase in cyclists and pedestrians.

 

Aaron Waxman and Associates is a Toronto personal injury law firm. We handle various types of personal injury claims including motor vehicle accident, pedestrian, long term disability and critical illness claims.

Pre-existing conditions and Critical Illness Claims – Duke v. Clarica Insurance

Wednesday, September 5th, 2012

The Alberta case of Duke v. Clarica Insurance involves the denial of a critical illness insurance claim.

Mr. Duke was diagnosed with Parkinson’s Disease. He applied for critical illness through Clarica in 2001 and purchased a policy for critical illness coverage in the amount of $500,000. He submitted a critical illness claim on May 15, 2003, accompanied by an Attending Physician’s Statement. The Statement was completed by a neurologist.

He was advised that his claim was denied in September of 2003.

Parkinson’s Disease was a covered critical illness under the policy. Clarica stated that according to reports they had received, Mr. Duke’s medical history revealed symptoms of Parkinson’s Disease as early as 1997,  before the policy came into force, therefore they were denying the claim.

The Court was faced with the task of deciding two crucial issues, which can be applied to critical illness claims:

1. Is the Exclusion Clause Ambiguous?

2. Does the Plaintiff Qualify for Benefits?

The Court found that neither Mr. Duke or any of his treating physicians or assessors had associated his earlier symptoms with Parkinson’s disease prior to issuing the policy. The Court also found that the Plaintiff had no obligation to disclose these physical concerns at the time. They were generalized symptoms. The wording of the exclusion clause was found to be ambiguous and the Court found that it did not apply and that Clarica improperly denied the CI benefit.

With respect to the second issue, the Court deemed that Mr. Duke required substantial assistance in order to perform his activities of daily living and satisfied the criteria needed to require a critical illness benefit.

Mr. Duke was awarded damages in the amount $500,000, the amount of the critical illness insurance claim benefit.

Clarica appealed the decision and lost.

The judgement states: “Finally, it is agreed that the respondent was completely honest and forthright in his disclosure and did not in any way misrepresent or conceal his condition or his general state of health from the appellant, nor did he attempt to mislead the appellant.”

The full case can be found here: http://www.canlii.org/en/ab/abca/doc/2008/2008abca301/2008abca301.html

Aaron Waxman and Associates is a Toronto Personal Injury Law Firm. We handle critical illness insurance claims. If your critical illness insurance claim has been denied, contact us for a free, no obligation consultation.

FSCO Arbitrator upholds Leone decision: 60 day time limit for mediation elapsed

Friday, August 31st, 2012

On February 10, 2012, FSCO Arbitrator Jeffrey Rogers released a decision, Leone v. State Farm stating that mediation was deemed to have failed because it did not occur within 60 days of the application being filed and the parties could not extend the time limit on consent once the 60 days had expired.

Director’s Delegate David Evans upheld the decision and dismissed State Farm’s appeal, and found that mediation was deemed to have failed.

Leone had submitted an Application for Mediation, which was received by FSCO on October 8, 2010 and no mediator had been appointed by March 14, 2011. Leone then submitted an Application for Arbitration. State Farm argued that he needed to attach the Report of Mediator to his application.

Arbitrator Evans states “I agree with the arbitrator that Mr. Leone did not need to attach the report of mediator to his application for arbitration where mediation has failed by statutory definition, but no report of mediator is available…Mr. Leone should not be prevented from proceeding to arbitration where through no fault of his own, s.280(8) has not been complied with.”

S.280(8) is the requirement to issue a Report of Mediator if the mediation fails.

What is the impact of the decision?

FSCO has notified all lawyers, law clerks and paralegals who have submitted applications for mediations of the decision, provided them with a mediation file number and stated that the following two options continue to be available for those files waiting in the queue:

1. Complete a Consent To Fail Form

2. Complete an Extension Form

Both forms must be completed jointly with the insurer, and require the signature of the client.

The appeal of several court decisions,  Cornie v. Security National (and the other 3 cases heard with it) and Younis v. State Farm regarding the 60-day time limit issue was heard on July 19, 2012 at the Court of Appeal.

The Court of Appeal has reserved judgment and as a result, FSCO felt it was not yet time to change the dispute resolution processes without having heard the results of the Court of Appeal decision.

For those Applications for Arbitration where no Report of Mediator was issued, FSCO is holding them in abeyance pending the Court of Appeal decisions.

According to the FSCO website the current wait time for a pre-hearing date is 6-8 months.

FSCO is looking at outsourcing its mediations to private mediators to assist with clearing up the mediation backlog. It is hoping to have a contract in place by early September. FSCO hopes to hand off 2,000 mediation files monthly to private mediators.

The mediation backlog is frustrating for claimants. By the time the mediation takes place, their circumstances may have changed dramatically. They may have been forced to find work due to financial stress, or their condition may have worsened due to lack of treatment. Treatment needs to be delivered in a timely fashion, in order to be beneficial.

It is not in an insurer’s best interest to have a continued backlog in mediations. Insurers pay 2% interest on claims per month. The longer an application sits in the queue, the more interest accrues.

There are various consequences of Leone v. State Farm and Cornie v. Security National if the original decision is upheld.

In Leone, the arbitrator noted that State Farm did not receive an Application for Mediation from FSCO until a mediator had been appointed. Generally, plaintiff’s counsel sends 2 copies of the application to FSCO, the second copy to distribute to the insurer. If FSCO is backlogged, the insurer does not know until months down the road that there is a pending application.

If the Court of Appeal upholds the decisions in Cornie and finds that 60 days begins to run when the application has been filed, insurers may not know about the application or the dispute until they receive a statement of claim.