When SGI Refuses to Provide a Decision Letter

SGI is governed by the Automobile Accident Insurance Act.

Section 189 of the Act requires that when SGI is making a decision about a claimant’s entitlement to no-fault insurance benefits, SGI must:

• send the claimant a written decision with reasons for the decision and

• provide notice of the claimant’s right to appeal the decision or request a mediation.

Unfortunately, this isn’t always the way it happens.

Sometimes SGI refuses to approve benefits, treatments or assessments, but does not provide a decision letter that allows the individual to appeal their decision. This can leave an injured person in limbo, with reassurance from their Personal Injury Representative that the matter is under review and they will receive a decision in due course. Sometimes, a decision letter is never received.

We see this happen in several types of situations. I’ll focus today on cases when the care provider makes a referral for an escalated level of treatment or assessment. 

Multidisciplinary Assessment Denials

SGI has developed internal policies and agreements with care providers outlining how treatment should progress for people injured in motor vehicle accidents. The policies are not public, but they provide that if a client is not healing/recovering from primary-level care, that care provider should recommend the individual attend a multidisciplinary assessment (MDA) after a certain number of weeks. 

The multidisciplinary assessment involves a care team including a doctor and physiotherapist who will assess symptoms and provide a treatment plan. The team can assess a person’s symptoms and limitations, confirm MVA-related diagnoses, and alert SGI to “red flag” issues if people’s symptoms aren’t matching up with their initial injuries.

This approach can prevent injured people from having all of their symptoms assessed and documented. MDA teams are trained in the assessment and treatment of MVA-injuries, and can provide information to SGI in an unbiased manner.

Why is SGI Avoiding MDAs?

In cases where an injured person’s symptoms last longer than expected, detailed assessments can create accountability for SGI. The better those symptoms are documented, the harder it can be for the insurer to terminate benefits relating to those symptoms. With SGI’s practice of sending files to a consultant for a paper file review, SGI gains an advantage: the consultant can provide an opinion that it’s most likely that the MVA symptoms “would have resolved” within a certain post-MVA period, or that the symptoms in question were not caused by the MVA. Then, even if the injured person does eventually attend an MDA, SGI can provide the care team with the guidance that SGI will not be compensating the team for any assessments or tests related to the non-accepted symptoms.

Why Decision Letters Matter

A decision letter and the opportunity to appeal is very important in these situations. Often, even though the consultant opinion that SGI relies on to justify denying treatment, it is not enough to legally justify SGI’s refusal. When individuals are able to appeal the decision that they receive to the Automobile Injury Appeal Commission, SGI is often quick to realize that they are not able to substantiate their denial without collecting a lot more information.

What You Can Do

If SGI is refusing to provide a decision letter about benefits, treatment, or assessments, here are some recommended steps:

📩 1. Request a Decision Letter in Writing

Email your Personal Injury Representative and clearly state that you are requesting a decision letter from SGI. Ask that any phone communication be followed up in writing.

🩺 2. Follow Up With Your Doctor

If your physiotherapist or chiropractor has recommended an MDA and you haven’t heard back, book an appointment with your family doctor. Ask if they agree with the recommendation and request that they communicate their opinion to SGI.

📝 3. Appeal the Non-Decision

Even when SGI doesn’t provide a formal decision, that doesn’t mean you have no right of appeal. You can file an Application for Appeal with the Automobile Injury Appeal Commission, including:

• A copy of your care provider’s recommendation, and

• Any related correspondence from SGI.

A lawyer can assist you with the specifics of this approach.

Final Thoughts

SGI has a legal obligation to issue written decisions with reasons when it denies benefits, treatments, or care recommendations. If they are not accepting a treatment plan, they must explain why—and they must give you the opportunity to appeal.

If this is happening to you or someone you know, we want to hear from you.