Insured sustained soft tissue injury to his neck and lower back from a motor vehicle accident
The Saskatchewan Court of Appeal has denied an insured’s entitlement to additional rehabilitation benefits beyond those capped by a discharge report.
In Zunti v Saskatchewan Government Insurance, 2023 SKCA 82, Jacob Zunti was involved in a motor vehicle accident where he sustained a soft tissue injury to his neck and lower back. After the accident, Zunti applied to Saskatchewan Government Insurance (SGI) for no-fault benefits under The Automobile Accident Insurance Act.
SGI initially agreed to provide Zunti with rehabilitation benefits. However, it later decided to deny him any further benefits because the medical documentation did "not support more investigation or treatment for accident-related conditions, as there is no indication of medical necessity."
Zunti disagreed with SGI's decision, so the parties resolved their differences through mediation, which led to an agreement where Zunti would undertake a multi-disciplinary assessment funded by SGI and, further, that would abide by any treatment recommendations arising from that process.
Discharge report
Zunti completed an eight-week secondary treatment program with the LifeMARK Health Centre. LifeMARK issued a discharge report. Zunti disagreed with the report and later raised the matter to the Automobile Injury Appeal Commission. The issue before the commission was whether Zunti was entitled to additional rehabilitation benefits beyond those capped by the recommendations in the LifeMARK discharge report.
Zunti sought reimbursement for various treatments between 2013 and 2017, arguing that he needed further care until complete recovery. SGI argued that his symptoms were unrelated to the accident and that they were not obligated to provide benefits until he became pain-free. The commission accepted SGI's position, stating that without medical evidence linking the treatments to the accident, they could not conclude that the treatments were necessary for his rehabilitation. The commission denied Zunti's appeal.
Zunti brought the matter to the Saskatchewan Court of Appeal. The court acknowledged that an insurer's decision to grant rehabilitation benefits is discretionary. Additionally, the court noted that the criteria guiding the insurer's decision to fund rehabilitation benefits turn on whether the treatment is medically necessary and contributes to rehabilitation or lessens a disability.
Onus of proof
Zunti argued that the commission improperly placed the burden of proof on him to establish that SGI was wrong to discontinue his rehabilitation benefits. He also argued that insureds are entitled to continue receiving rehabilitation benefits until they achieve the state of health enjoyed before the accident.
The court noted that an insured bears the burden of proof concerning entitlement to benefits, but SGI bears the burden when benefits are terminated. The court found nothing in the commission's decision to suggest that it approached Zunti's appeal from the perspective that he bore the burden of proof. Instead, the court pointed out that the commission assessed Zunti's appeal in light of the evidence both parties had put before it.
The court noted that the commission considered that Zunti did not call evidence about whether the treatments he had received from health care providers were medically necessary. While the commission did not reject Zunti's evidence, it gave little weight due to a lack of context and because it seemed to consist of Zunti's unsupported subjective opinion about his state of health and his argument that further treatments were required.
Furthermore, the court noted that the commission was left with only SGI's medical evidence, resulting in the commission's decision that "There was no medical opinion or evidence indicating the LifeMARK discharge report treatment recommendations were inappropriate or that an increased number of treatments were required for the injuries sustained in the MVA."
Accordingly, the court concluded that there was no error in how the commission dealt with the burden of proof.
Zunti argued that he was entitled to ongoing rehabilitation benefits until he achieved his pre-MVA health status. He said, "SGI's obligations end when I am returned to the health, I was in prior to my… accident, not my completion of a LifeMARK program".
The court acknowledged the commission's decision that without medical evidence linking the treatments to the injuries sustained in the MVA, the commission could not conclude that the treatments were necessary or advisable to contribute to Zunti's rehabilitation or to facilitate his recovery from the MVA. Further, Zunti cited no jurisprudence to support his position that benefits must continue until an insured fully recovers from injuries sustained in a motor vehicle accident.
The court found that the commission considered the question of medical necessity based on the parties' evidence. However, it did not find any medical opinion or evidence indicating the LifeMARK discharge report treatment recommendations were inappropriate or that more treatments were required for the injuries sustained in the MVA. Ultimately, the court decided to dismiss Zunti's appeal.
