Expert assessments by medical and health practitioners play an important role in personal injury law. However, it is not unusual for expert assessments to differ or conflict on certain points. In a recent case, the Ontario Superior Court addressed the issue of how to treat conflicting expert assessments.

In Personal Insurancev. Hoang [1], the claimant was a young child who had been struck by a motor vehicle. A few years after the accident, on the recommendation of the child’s attendant health practitioners, the insurer was asked to pay for certainrehabilitation services. Several expert assessments substantiated this claim.

In response, the insurer conducted its own independent expert assessment. This assessment concluded that the requested services were unnecessary. The insurer relied on these findings in its decision to turn down the claimant’s request. The claimant disputed the decision and the issue was decided in the claimant’s favour. It was later appealed by the insurer to the Ontario Superior Court, which upheld thedecision in the claimant’s favour.

The court ordered the insurer to pay the claimant for the services requested, as it found them to be reasonable. The court also ordered the insurer to pay extra compensation to the youth because it found the insurer had acted unreasonably in denying the claim. The insurer acted unreasonably in two ways.

First, in its over-reliance on its independent assessment, against the advice and opinions of the claimant’s experts advocating for additional treatment. The insurer’s reliance on its assessment “in the face of the overwhelmingly consistent opinions and reasoning of [the claimant’s experts] … amounts to an unreasonable disregard of the available information.”[2]

Second, the insurer’s behavior in this instance was considered even more unreasonable as the circumstances demanded extra care. The insurer was, or should have been aware, of the significant negative impact of its decision to deny the claim on a child still in their “developing years”.

The outcome of the case is not particularly surprising. The courts want insurers and claimants to work together, with all available information, to find a reasonable solution. They will not uphold an insurer’s decision that takes only some information into consideration.

 

[1]Personal Insurance Company v. Hoang, 2014 ONSC 81 (CanLII).

[2] Ibid, at para 46.