16-001226 v. State Farm Mutual Automobile Insurance Company, 2018 CanLII 13155

Overview

1The applicant was involved in a motor vehicle accident on January 3, 2014 and sought benefits pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 2010 (the "Schedule"). In July 2015, the applicant applied to the respondent for a determination that her accident-related impairments met the definition of a catastrophic impairment under the Schedule. The respondent conducted a series of assessments and determined that the applicant's accident-related impairments did not meet the definition of a catastrophic impairment.

2The applicant disagreed with the respondent's decision and submitted an application to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the "Tribunal"). The matter proceeded to a case conference but the parties were unable to resolve this dispute.

Issues

3Did the applicant sustain a class 4 (marked) or class 5 (extreme) mental or behavioural impairment in accordance with the American Medical Association's Guides to the Evaluation of Permanent Impairment, 4th edition, 1993 (the "Guides") that qualifies as a catastrophic impairment under section 3(2)(f) of the Schedule?

4Did the applicant sustain an impairment or combination of impairments under section 3(2)(e) of the Schedule that, in accordance with the Guides, results in 55 per cent or more impairment of the whole person?

Result

5The applicant sustained a catastrophic impairment under section 3(2)(f) of the Schedule because she has a marked impairment in the functional categories known as activities of daily living, concentration, persistence and pace and adaptation according to the descriptive criteria set out in Chapter 14 of the Guides. As this is sufficient to meet the catastrophic threshold under section 3(2)(e) of the Schedule, I do not need to determine whether the applicant meets the 55% WPI threshold under section 3(2