2014 QCCQ 6625, 2014 QCCQ 6625

Mancini c. Standard Life du Canada 2014 QCCQ 6625 COURT OF QUEBEC Small Claims Division CANADA PROVINCE OF QUEBEC DISTRICT OF MONTREAL Civil Division No: 500-32-128076-116 DATE: July 3, 2014 ______________________________________________________________________ PRESIDED BY THE HONOURABLE DAVID L. CAMERON, J.C.Q. ______________________________________________________________________ JOSIE MANCINI […] Côte St-Luc, Montréal, Québec, […] Plaintiff v.

STANDARD LIFE DU CANADA 2045 Stanley, 7 th floor Montréal, Québec, H3A 2V4 Defendant ______________________________________________________________________ JUDGMENT ______________________________________________________________________ [ 1 ] The Plaintiff, Josie Mancini, sues Standard Life du Canada ("Standard Life") in relation to a dental claim she filled under a group health insurance policy, in respect of alleged accidental injury to natural teeth for her husband Giuseppe Mancini. [ 2 ] The claim was filled on August 23, 2010 and it related to an incident that allegedly occurred when Mr Mancini was being intubated during a surgical procedure and its aftermath in August 2009. [ 3 ] In its written contestation, Standard Life defends the matter on various technical grounds relating to the application of the group insurance policy.

Firstly, under the coverage for “dental care required as a result of accidental injury to natural teeth”, Standard Life pleads that the treatments have not been provided within 12 months of the accident and no benefit is therefore payable under that coverage. Alternatively, it pleads that the cost of treatment foreseen would be $1,944 and not the $6,900 alleged. [ 4 ] Secondly, and alternatively, Standard Life pleads that, under the "dental care" benefit

section of the policy, only reimbursement of expenses actually incurred can be reimbursed, not prospective treatments. [ 5 ] Mrs Mancini's response to this defence is to state that her husband could not undergo the treatments required to correct his dentition immediately, because the work could only be carried out gradually as his muscles, which had become weakened, were rehabilitated.

Therefore, she maintains that the strict time limits of the policy should not be applied in this case. [ 6 ] It became obvious at the hearting, because of the oral argument of Standard Life and the correspondence that had been exchanged between the parties, that Standard Life presents a defence of a more fundamental nature considering the claim for damages costs by an accident. This defence consists in asserting that the medical file does not contain adequate documentation of damages occurring to Mr Mancini’s dentition during an intubation in 2009 to establish that an accident occurred.

Therefore there is no coverage for accidental damage to the teeth. [ 7 ] The Court agrees, essentially, with Standard Life’s position concerning accidental damage. The medical records in the file do not establish the occurrence alleged, where, during an intubation, Mr Mancini’s teeth were damaged.

There is a difference between repairs being necessary because of deterioration of the dentition, as opposed to damages directly related to a mishap that occurred during intubation. [ 8 ] There is a note by Dr Sam Shuldiner of January 25, 2011, stating that Giuseppe Mancini suffered serious damage to his teeth when he was intubated in October 2009, and there is a note of October 29, 2010 from the attending physician Patricia McMillan. Dr McMillan writes: "he [Giuseppe Mancini] sustained inadvertent damage to his dentition at that time during this prolonged intubation and now requires repair of same.

[ 9 ] The declarations do not clearly state a causal relationship between an unforeseen event and specific damage. Apart from these declarations of physicians, which are not contemporaneous, with the events, there is absolutely no indication in any of the hospital records made at the time of the surgery and the following convalescence to suggest that there was any accident causing damage to Mr Mancini’s dentition during the intubation process. No such damage is diagnosed. [ 10 ] If in fact his teeth had been damaged during these procedures, the medical records would have indicated this in some way.

There would have been an intervention, notes taken, and treatment provided. [ 11 ] It is not impossible that such damage occurred, but in a civil action such as this one, probative evidence is required, and in this case, there is a total absence of evidence of an occurrence. [ 12 ] The doctors' declarations have no probative value because there is no medical file to support them and they are not made within a period that would permit accurate memory of the events, assuming that these doctors were even present at the time. [ 13 ] The policy also has coverage for dental treatment generally, that is to say, not necessarily relating to an accident.

Although Mrs Mancini does not make her claim in the present file on this basis, Standard Life accepts nonetheless that if any of the repairs that were contemplated to Mr Mancini’s teeth, because of what they consider to be a pre-existing condition, were in fact carried out in 2009, 2010 and 2011 before the policy lapsed, these treatments would be recoverable in the normal way, up to $1,000 per year, on an 80% basis. [ 14 ] Standard Life states that some of the repairs which, in Mrs Mancini’s first claim amount to $1,836, were in fact carried out during those three years. [ 15 ] Mrs Mancini pointed out that the Ombudsman of Standard Life stated Standard Life's final position for reimbursement, for a dental treatment plan proposed by Mr Mancini's dental professional, at $1,740. [ 16 ] The Ombudsman’s letter of April 4, 2011, pointed out that the predetermination approval was valid until August 3, 2011, but subject to the policy still being in force at the time of the repairs. [ 17 ] Mrs Mancini states that she did eventually carry have carried out a number of treatments to repair her husband’s teeth, but much of this fell outside the policy periods in which she was covered after she retired from her employment.

Again, she expresses that the treatments could only be carried out gradually as her husband's muscles became sufficiently rehabilitated. [ 18 ] In a note she sent to the Court on March 3, 2014, Mrs Mancini states that she in fact received $248 in respect of work concerning this predetermination approval. [ 19 ] In testimony however, Mrs Linda Emond, representing Standard Life, consulted her records and indicated that approximately $1,000 was claimed and that this was recognised paid at 80% for approximately $800. [ 20 ] The Court’s estimation of the testimony provided by Standard Life as to the amounts actually paid is more reliable that provided by Mrs Mancini.

Mrs Mancini shows evidence that she received $240 but it is not possible for her to establish that this is the only amount she received. [ 21 ] Be that as it may, Mrs Mancini’s claim for an accidental benefit cannot succeed because the medical record of the hospital provides no trace of an accident of the type alleged. The doctors’ declarations are not contemporaeous with the events and refer to no supporting records nor are they descriptive or detailed in any way. [ 22 ] Mrs Mancini was entitled to make claims from year to year until the policy expired so long as her claims met the requirements of the policy.

She did claim some amounts under the ordinary dental coverage and received payments in accordance with the policy for the claims she actually made. [ 23 ] It is unfortunate that Mrs Mancini’s claim cannot be maintained in full, but this is a function of the technical limitations on the policy coverage that was put in place by her employer. If a medical accident could truly have been demonstrated through proper evidence, her claim might have been allowable but, sadly the medical records simply do not support these conclusions. [ 24 ] There will no award against Mrs Mancini for costs.

FOR THESE REASONS, THE COURT: DISMISSES the Plaintiff's application. WITHOUT COSTS. __________________________________ DAVID L. CAMERON, J.C.Q. Date of hearing: March 3, 2014