Avril A. Farlam

The applicant sought dispute resolution at the Licence Appeal Tribunal after the respondent insurer denied various medical and rehabilitation benefits following a motor vehicle accident.

The Tribunal dismissed the application, finding that the applicant was barred from proceeding with several claims due to her unexcused failure to attend scheduled insurer's examinations.

Furthermore, the Tribunal held that the applicant failed to meet her burden of proving that the proposed physiotherapy, assessments, and additional psychological therapy were reasonable and necessary as a result of the accident.

The applicant sought income replacement benefits (IRB) following a motor vehicle accident.

The respondent insurer denied the benefits and sought repayment of previously paid IRB, arguing the applicant was excluded under s. 31(1)(a)(i) of the Schedule because he knew or ought reasonably to have known he was operating the vehicle without valid insurance.

The Tribunal found the applicant's testimony that he believed he had purchased valid insurance from a 'broker' to be not credible, given his prior experience with insurance and the suspicious circumstances of the transaction.

The Tribunal dismissed the applicant's claims for IRB, interest, and a special award, and ordered the applicant to repay $19,177.60 in IRB to the respondent.

The applicant was injured in a motor vehicle accident and sought an income replacement benefit (IRB).

The respondent insurer denied the claim on the basis that the applicant was driving with a suspended licence at the time of the accident.

The applicant argued he was unaware of the suspension and raised a defence of due diligence.

The Tribunal held that s. 31(1)(a)(ii) of the Schedule clearly bars an IRB claim if the driver did not hold a valid licence, regardless of whether they knew or ought to have known of the suspension.

The applicant's claim for an IRB was therefore barred.

The applicant requested a reconsideration of a Licence Appeal Tribunal decision regarding entitlement to payment for three treatment plans.

The applicant argued the Tribunal erred in law and fact by finding that the insurer's notice was valid and by requiring the applicant to prove the treatment plans were incurred despite the insurer's non-compliance with section 38(8) of the Statutory Accident Benefits Schedule.

The Vice Chair dismissed the reconsideration request, finding no errors of law or fact in the original decision's interpretation of section 38(11) or its conclusion that the insurer is only liable for incurred expenses during the period of non-compliance.

The applicant sought statutory accident benefits following a motor vehicle accident.

The respondent denied various benefits and required the applicant to attend s. 44 insurer's examinations, which she failed to attend.

The respondent requested a preliminary issue hearing to determine if the applicant was barred from proceeding with her application.

The Tribunal found that the applicant failed to provide a reasonable explanation for missing six insurer's examinations.

The Tribunal also struck portions of the applicant's submissions on the basis of settlement privilege.

The applicant was barred from proceeding with the disputed medical benefits issues.

The applicant requested a reconsideration of a previous decision that denied his claim for a higher quantum of income replacement benefits (IRB), disputed treatment plans, and an award.

The applicant argued the adjudicator violated procedural fairness and made errors of law and fact by relying on the respondent's in-house accounting report, rejecting the applicant's self-employment source documentation, and misapplying the law regarding a psychotherapist's hourly rate.

The Vice Chair dismissed the request for reconsideration, finding no breach of procedural fairness or errors of law or fact that would have changed the result.

The Vice Chair held that the applicant was attempting to reargue his case and had failed to meet his onus of proof regarding his self-employment income.

The applicant, a pedestrian injured in a 2010 motor vehicle accident, sought payment for a catastrophic impairment assessment totaling $26,919.25.

The respondent denied the claim.

The Licence Appeal Tribunal found that the applicant failed to provide sufficient objective medical evidence to suggest a reasonable possibility of catastrophic impairment.

The Tribunal held that the assessment was not reasonable and necessary, noting evidence of symptom amplification and a lack of support from treating physicians.

The application for the assessment costs, interest, and a special award was dismissed.

The applicant sought attendant care and housekeeping benefits following a motor vehicle accident.

The parties agreed on the quantum of benefits owed for services provided by the applicant's daughters.

The Tribunal ordered the respondent to pay the agreed amounts, plus interest on any overdue payments.

The applicant's request for a special award was dismissed, as the Tribunal found no evidence that the respondent unreasonably withheld or delayed payment.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits, including income replacement benefits (IRB) and treatment plans outside the Minor Injury Guideline (MIG).

The respondent insurer determined the injuries were minor and subject to the $3,500 MIG limit.

The Licence Appeal Tribunal found that the applicant's injuries were predominantly minor soft tissue injuries and that she failed to prove she suffered from chronic pain caused by the accident.

The Tribunal also found the applicant was not entitled to IRBs, as she continued to work post-accident and failed to establish a substantial inability to perform the essential tasks of her employment.

The application was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident.

The respondent denied certain treatment plans on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 funding limit had been exhausted.

The applicant argued that pre-existing back and shoulder issues, psychological impairments, and chronic pain removed him from the MIG.

The Tribunal found insufficient medical evidence to establish that any pre-existing condition would prevent maximal recovery within the MIG limit, or that the applicant suffered from accident-related psychological impairment or chronic pain.

The Tribunal concluded the injuries were predominantly minor and subject to the MIG limit.

As the limit was already reached, the disputed treatment plans and interest were denied.

The applicant was involved in a motor vehicle accident in Alberta while driving a vehicle registered and insured in Alberta.

She subsequently moved to Ontario and sought statutory accident benefits under the Ontario Schedule, arguing she could elect Ontario benefits because the insurer has offices in both provinces.

The Licence Appeal Tribunal held that the applicant was not an 'insured person' under section 3(1) of the Schedule, as she was not a resident of Ontario at the time of the accident and the vehicle was not operated in Ontario.

The application was dismissed.

The respondent insurer requested a reconsideration of a Tribunal decision that found the applicant entitled to $877.93 for the cost of a psychological assessment.

The insurer argued the Tribunal erred in law and fact by not requiring the cost to be justified by the hourly rates of the service providers and by relying on the cost of the insurer's own examination.

The Vice Chair dismissed the request, finding no errors of law or fact in the original decision that would have likely led to a different result.

The applicant sought statutory accident benefits following a motor vehicle accident.

The respondent denied certain treatment plans on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 funding limit had been exhausted.

The Tribunal found that the applicant suffered predominantly soft tissue injuries and failed to provide compelling medical evidence of pre-existing conditions, psychological impairment, or chronic pain that would remove her from the MIG.

As the funding limit was already reached, the disputed physiotherapy treatment plan was not payable.

The claim for medication costs was dismissed as already paid.

The applicant, who suffered catastrophic injuries as a pedestrian in a motor vehicle accident, sought a medical benefit for a physiotherapy treatment plan.

The respondent insurer denied the plan, relying on its expert assessors who opined that home-directed exercises were sufficient and that the applicant's neurological impairment was fixed.

The Tribunal preferred the evidence of the applicant's treating multidisciplinary team, finding the professionally directed physiotherapy reasonable and necessary to manage and prevent regression of the applicant's conditions.

The treatment plan was approved with interest.

The applicant sought income replacement benefits (IRBs) following a motor vehicle accident, claiming a substantial inability to perform his pre-accident employment as a hazardous material worker due to exacerbated chronic back pain and psychological symptoms.

The respondent denied the IRBs after December 1, 2019.

The Licence Appeal Tribunal dismissed the application, preferring the evidence of the respondent's medical assessors over the applicant's family physician.

The Tribunal found no objective findings to support the subjective complaints and concluded the applicant did not suffer a substantial inability to perform the essential tasks of his employment.

Claims for a special award and interest were also dismissed.

The applicant insurer brought a preliminary issue hearing to determine if the respondent was involved in an 'accident' as defined under s. 3(1) of the Statutory Accident Benefits Schedule.

The respondent alleged he was struck by a vehicle while riding his bicycle.

The Tribunal preferred the evidence of an independent police officer and the driver, finding that the vehicle was stationary and the respondent simply lost his balance and fell.

The Tribunal concluded the incident did not meet the purpose test, as the injuries did not arise out of the use or operation of an automobile.

The respondent was found not to have been involved in an accident.

The applicant sought statutory accident benefits after tripping and falling on a raised ledge near a displayed vehicle at an auto show.

The respondent denied the benefits, arguing the incident was not an 'accident' under s. 3(1) of the Statutory Accident Benefits Schedule.

The Licence Appeal Tribunal held a preliminary issue hearing and found that the applicant's injuries did not arise out of the ordinary use or operation of an automobile.

The Tribunal concluded the purpose test was not met, as the display of a vehicle at an auto show does not constitute ordinary use or operation, and dismissed the application.

The applicant sought statutory accident benefits following a motor vehicle accident, claiming entitlement to psychological treatment, physiotherapy treatment, a chronic pain assessment, and a driving reintegration assessment.

The Licence Appeal Tribunal dismissed the application, finding that the applicant failed to prove on a balance of probabilities that the disputed treatment plans and assessments were reasonable and necessary.

The Tribunal gave little to no weight to the applicant's expert reports, noting they were completed years after the accident and were inconsistent with the clinical notes and records of the applicant's family physicians, which showed minimal complaints and primarily degenerative changes.

The applicant sought statutory accident benefits following a motor vehicle accident.

The insurer determined the injuries fell within the Minor Injury Guideline (MIG) and denied a treatment plan for chiropractic services.

The Licence Appeal Tribunal found that the applicant's injuries were predominantly minor and that he failed to provide compelling evidence of a pre-existing right ankle condition or psychological injury that would remove him from the MIG.

The Tribunal also concluded that the disputed treatment plan was not reasonable and necessary, as it lacked support from the applicant's treating physicians.

The application was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident.

The respondent denied income replacement benefits (IRB) and various medical and rehabilitation benefits, arguing the applicant failed to comply with requests for information under s. 33 of the Schedule.

The Tribunal found the applicant adequately complied with the s. 33 requests and was procedurally entitled to the IRB.

The Tribunal also found that a proposed mattress and chiropractic treatment were reasonable and necessary, preferring the evidence of the applicant's treating practitioners over the respondent's assessors.

The applicant was awarded the disputed benefits with interest.