Security National defeats catastrophic impairment claim as surveillance sinks Ontario bid

A no-show applicant and a repair-shop video told the real story

Security National Insurance Company has defeated a catastrophic impairment claim at Ontario's Licence Appeal Tribunal, with surveillance footage and insurer assessments proving decisive. The applicant, injured in a June 19, 2019 automobile accident, sought a catastrophic impairment designation under the Statutory Accident Benefits Schedule, along with monthly attendant care benefits of $1,460.15 dating back to June 9, 2021 and funding of $12,743.00 for further catastrophic assessments. The Tribunal denied all of it.

The adjudicator found the applicant did not meet the 55 per cent whole person impairment threshold required under Criterion 7. Combining the accepted ratings, the adjudicator arrived at 40 per cent - well short of the mark. The fight came down to two contested areas: the applicant's spine and his psychological condition.

On the mental and behavioural disorders, the applicant's psychiatrist assigned a 30 per cent rating; the insurer's assessor put it at 10 per cent. The adjudicator preferred the insurer's figure, finding the higher scores "inflated" and unsupported by the wider record. Surveillance evidence was central.

The applicant's psychiatrist had scored him as seriously impaired socially, relying on reports that he stayed home and saw no friends. But surveillance video showed him spending hours socializing at a repair shop, and he acknowledged seeing friends once or twice a week, maintaining relationships with his parents and adult children, and starting a new relationship after the accident. The adjudicator found those facts pointed to moderate, not severe, impairment.

The insurer's psychiatrist had also flagged numerous inconsistencies in the applicant's reporting - about past accidents, substance use, relationships and driving habits - and the adjudicator gave that analysis weight. By contrast, the applicant's expert was found to have relied heavily on self-reports that clashed with the evidence. Under Criterion 8, the adjudicator found the applicant had a mild impairment in social functioning and moderate impairments in concentration and adaptation - not the marked impairment in three of four areas that the test demands.

The attendant care claim failed on similar grounds. The applicant relied on a registered nurse's December 2020 assessment recommending $1,460.15 in monthly care. The insurer relied on an occupational therapist's June 2021 assessment recommending zero hours.

The adjudicator preferred the insurer's report as more detailed and contemporaneous with the disputed period, and noted the applicant had not shown he actually incurred the costs claimed. The $12,743.00 treatment plan for additional catastrophic assessments, submitted in March 2023 and denied days later as a duplication of the insurer's existing reports, also fell. The applicant made no submissions supporting it.

Notably, the applicant did not attend the rehearing; his counsel advised he had been detained by police. The parties proceeded on transcripts from an earlier hearing.