Disputed Claim for continuing Income Replacement Benefits

In a 2016 civil action, Galloway v State Farm Mutual Automobile Insurance, State Farm Insurance Co. made a motion for summary judgement to dismiss the plaintiff’s claim for income replacement benefits, a catastrophic injury designation, as well as general damages due to the insurer’s mishandling of their claim.

The plaintiff claimed $5 million in general damages for breach of contract and negligence, for the insurer’s mishandling, deceptive and unfair practices in their managing of the plaintiff’s accident benefits claim. However, the defendant insurer argued that they dealt with the benefits based on available medical evidence and in accordance with legislation. Although payment of benefits was interrupted on a few occasions, it was reinstated until payments eventually stopped in November 2012. The motions judge concluded that there was no evidence to support the plaintiff’s claim for general damages, and no genuine issue for trial on this question.

With respect to the plaintiff’s assertion that their injury constitutes a catastrophic injury designation (CID), the judge again sided with the defendant and agreed that evidence did not support a CID.  Under the statutory accident benefits schedule (SABS), catastrophic impairment is strictly defined as: an impairment or combination of impairments that results in 55 per cent or more impairment of the whole person, including psychological and physical impairments; or an impairment that causes a marked or extreme impairment due to behavioural or mental disorder. The medical evidence of a team of assessors concluded that the plaintiff did not, in fact, exhibit a catastrophic impairment resulting from the collision.  Furthermore, the physicians and neurologist testifying on behalf of the plaintiff did not provide assessments referencing the specific catastrophic impairment criteria under SABS and/or fully explain how the plaintiff meets the legal definition of catastrophic impairment. The lack of facts and expert opinion to establish that the plaintiff meets the definition of catastrophic impairment led the judge to make a finding that the defendant insurer has established that there is no genuine issue for trial on this basis.

Ontario legislation states that an insurer is not required to pay income replacement benefits for longer than 104 weeks unless the insured person is entirely unable to engage in any employment for which they are reasonably suited, given their education, training or experience. In this case, the plaintiff had a grade 12 education and no other special training or education beyond that. At the time of the accident, he was employed as kitchen staff to deliver food to inmates, at Kingston Penitentiary. The plaintiff had suffered a seizure at the age of 12, and suffered two more seizures, one after another, two years after the accident. Prior to the accident, the plaintiff also received a diagnosis of hydrocephalus and as a result, had a shunt installed. 

The plaintiff’s mother testified that, after the seizures, she noticed that her son had substantial memory problems, difficulty focusing, headaches, difficulty conversing, and was easily confused and disorganized. She also stated that constant supervision was required to help him with his cognitive and behavioural difficulties, which had significantly diminished since prior to the accident.

Many medical experts testified on behalf of the plaintiff and most agreed that the accident is likely the cause of the plaintiff’s decline. One physician stated that before the collision, the seizures were only in the context of hydrocephalus but are now unprovoked, and there are many reports of patients with pre-existing epilepsy who suffered more frequent seizures after experiencing mild head trauma. A neurologist further testified that the motor vehicle collision undoubtedly caused head trauma, which led to his behavioural changes and headaches, which are often associated with post-concussion syndrome, and further exacerbated the plaintiff’s seizure problems.  It was asserted that the plaintiff’s cognitive difficulties result from the prolonged seizures, and his difficulties with memory and concentration would make it impossible to perform the essential aspects of his job. Another expert, a physiatrist, agreed that the patient’s condition completely prevents him from performing employment related activites as well as driving. A clinical psychologist stated a belief that the accident contributed to the plaintiff's onset of seizures.  One medical expert, a neuropsychologist disagreed with some of the previous opinions; he doubted that the plaintiff was suffering from significant psychological symptoms that were materially related to the accident and also stated that the plaintiff did not suffer impairments that impacted his daily living, social functioning and concentration.

The defendant insurer argued that the plaintiff’s condition does not meet the requirements under SABS and also, there is no evidence that his disabilities resulted from the motor vehicle accident rather than from his pre-existing condition.  One of the defendant’s medical experts stated that the mild head trauma that the plaintiff experienced in the collision would have entirely resolved and have little impact on his existing seizure disorder. He also surmised that the plaintiff was not entirely unable to engage in any employment for which he was reasonably suited.  Another physician testified that the plaintiff’s cognitive impairment resulted from brain injury due to the epilepticus; his post-accident seizures are not likely the result of the accident; and there is no clear evidence to support that the plaintiff’s behaviour or cognitive abilities resulted from the accident, whether due to psychological or physical trauma from an accident.

On the issue of income replacement benefits, due to the conflicting medical opinions on whether the plaintiff’s disabilities were caused by the collision, the judge determined that the summary judgement process cannot achieve a fair resolution.  As pointed out by the plaintiff, the defendant insurer did, in fact, pay income replacement benefits for a considerable period beyond 104 weeks, implying that they considered that the plaintiff met the qualifications for these.  It was concluded that this issue constitutes a genuine issue for trial, allowing fuller scrutiny of the medical evidence.