The Test for Catastrophic Impairment

A recent decision by the Divisional Court in Ontario provides a plaintiff-friendly interpretation of the test for catastrophic impairment under the SABS.

In Security National Insurance Co. v Hodges, 2014 ONSC 3627 (Div. Ct.), GCS scored administered within 30 minutes of the accident were 11.  He underwent surgery the day after the accident and scores fell to 3 while he was intubated, but rose to 10 once the trachea was removed. Roughly three days following the accident – and while still under the influence of medication – several GCS tests were administered and resulted in scores of 9.  MRI and CT scans done at the time suggested that, while Mr. Hodges had suffered a brain injury from the accident, the extent of the injury was quite limited. GCS tests administered over the following days showed continuing improvement and the final GCS test indicated no impairment in consciousness.

The insurer denied the plaintiff's application for catastrophic impairment.  The arbitrator found that the plaintiff met the test for catastrophic impairment and this finding was affirmed under appeal to FSCO.  The insurer appealed to the Divisional Court. 

In upholding the FSCO decision, the Divisional Court stated that what constitutes a reasonable period of time to conduct the GCS test should be determined on a case-by-case basis. It found that, in this case, the test was conducted within a reasonable period of time, given that the injured individual was still experiencing fluctuating levels of consciousness at the time of the test. The court rejected the argument that the GCS score had to have “prognostic value,” saying that this would turn the legal test for catastrophic impairment into a medical test. The court also rejected the argument that the statute required that the brain injury be the sole cause of the score of 9 or less, saying: “It is sufficient that the person claiming catastrophic impairment had any brain injury causing anyimpairment….”

It will be interesting to see if Hodges results in a greater number of applications for a CAT designation.  Of course, the claimant still needs to show entitlement to benefits even if successful.

Catastrophic Impairment: Aviva v. Pastore

The Court of Appeal has released an important decision relating to catastrophic impairment:

Aviva Canada Inc. v. Pastore, 2012 ONCA 642 (C.A.)

The insured was injured in a 2002 motor vehicle accident as a pedestrian and sustained an ankle injury. She alleged her gait had been altered and was diagnosed with a pain disorder.  A DAC found her to be catastrophically impaired in 2005 due to a marked mental or behavioural impairment under s. 2(1.1)(g) of the SABS.  An assessment under s. 2(1.1)(g) is carried out with reference to the AMA Guides, which provide for an assessment of function in four categories:

(1)              Activities of daily living (ADL);

(2)              Social functioning;

(3)              Concentration, persistence and pace; and

(4)              Deterioration or decompensation in work or work-like settings.

Pastore was diagnosed with a number of psychological disorders and the DAC concluded that she had a class 4 marked impairment in activities of daily living.  The DAC concluded she was catastrophically impaired on the basis of the one class 4 impairment.  The insurer did not agree with the assessment and the matter proceeded to mediation then arbitration.

At arbitration, the arbitrator agreed with the DAC assessors and held that one marked impairment was enough to comply with the Guides approach to impairment.  In addition, it was appropriate to consider physical pain in assessing mental disorder, as it was not possible to factor out all physically based pain since it was intertwined with mentally based pain. The Director's Delegate upheld the decision, but the Divisional Court overturned the arbitrator.

The Court of Appeal allowed the appeal and reinstated the arbitrator`s decision.  The conclusion that only one marked impairment is sufficient to meet the definition of catastrophic impairment was a reasonable one. In addition, it was not an error for the DAC assessors to consider both physical and mental pain.

Pastore appears to have lowered the bar for catastrophic impairment based on a mental disorder and more claimants may be able to fit themselves into a catastrophic designation than prior to this decision.