Avril A. Farlam

The applicant sought statutory accident benefits following a motor vehicle accident, including treatment plans for physiotherapy, a psychological pre-screening, and a chronic pain assessment.

The respondent denied the benefits.

The Licence Appeal Tribunal found that the applicant failed to meet her burden of proving the disputed treatment plans were reasonable and necessary, noting a lack of persuasive medical evidence and reliance on reports that did not support the requested treatments.

The claims for the disputed treatment plans and interest were dismissed.

The applicant sought dispute resolution at the Licence Appeal Tribunal after the respondent insurer denied certain statutory accident benefits following a motor vehicle accident.

The core dispute involved the calculation of the applicant's pre-accident self-employment income for Income Replacement Benefits (IRBs).

The applicant relied on bank statements and an accountant's report, while the respondent calculated a lower amount due to the lack of supporting invoices or tax documents.

The Tribunal found the applicant failed to prove his self-employment income on a balance of probabilities, as bank statements alone were insufficient without corroborating evidence.

The Tribunal also dismissed claims for the balance of two psychological treatment plans, finding the proposed hourly rate for an unregulated psychotherapist unreasonable.

Claims for a special award and costs were also dismissed.

The applicant sought non-earner benefits following a 2016 motor vehicle accident.

The respondent insurer denied the benefits in August 2017.

The applicant filed an application with the Licence Appeal Tribunal in November 2019, beyond the two-year limitation period under section 56 of the Statutory Accident Benefits Schedule.

The Tribunal considered whether to extend the limitation period under section 7 of the Licence Appeal Tribunal Act, 1999.

The Tribunal found the applicant failed to establish a bona fide intention to appeal within the limitation period, the delay of four months was excessive, the respondent would be prejudiced, and the application lacked merit.

The application was dismissed as statute-barred.

The applicant sought a special award under section 10 of Ontario Regulation 664, alleging that the respondent insurer unreasonably withheld or delayed payment of a physiotherapy treatment plan.

The applicant claimed that the respondent's communications were confusing and led her to believe the plan was denied.

The Tribunal found that the respondent's communications, including an Explanation of Benefits, clearly stated that the treatment plan was approved because an insurer's examination report was not provided within 10 business days, despite the medical assessor concluding the treatment was not reasonable and necessary.

The Tribunal held that the delay was caused by the applicant's misinterpretation of clear communications and her subsequent delay in filing the application, not by any unreasonable conduct of the respondent.

The claim for a special award was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, claiming entitlement to non-earner benefits (NEB) and a medical benefit for a physiotherapy treatment plan.

The Licence Appeal Tribunal found that the applicant failed to establish a complete inability to carry on a normal life, as she was still able to partially perform her pre-accident activities, and thus dismissed the NEB claim.

The Tribunal partially approved the physiotherapy treatment plan, finding it reasonable and necessary for pain reduction, but deducted costs incurred prior to the submission of the plan pursuant to s. 38(2) of the Schedule.

The claim for a special award under Ontario Regulation 664 was dismissed as the insurer's denials were not unreasonable.

The applicant sought accident benefits following a motor vehicle accident.

The respondent determined the applicant's injuries fell within the Minor Injury Guideline (MIG) and terminated his income replacement benefits (IRB).

The Tribunal found that the applicant's physical injuries were predominantly minor, consisting of sprains and strains, and that he failed to prove he suffered from chronic pain.

The Tribunal also found the applicant was not entitled to an IRB, as there was insufficient medical evidence to establish a substantial inability to perform the essential tasks of his pre-accident employment.

The application was dismissed.

The applicant sought medical benefits for psychological and chiropractic services following a motor vehicle accident.

The respondent insurer denied the treatment plans.

The Licence Appeal Tribunal found that the applicant failed to prove the treatment plans were reasonable and necessary.

The psychological treatment plan lacked necessary details about the providers, and the applicant failed to provide requested information.

The chiropractic treatment plan was not supported by medical evidence, and the Tribunal preferred the evidence of the respondent's orthopaedic surgeon who found no objective signs of impairment.

The application was dismissed.

The applicant was involved in a motor vehicle accident and sought income replacement benefits (IRB) and medical benefits beyond the Minor Injury Guideline (MIG) limit.

The respondent denied the benefits, arguing the injuries fell within the MIG.

The Tribunal found that the applicant's physical injuries were soft tissue in nature and fell within the MIG.

The applicant failed to provide sufficient medical evidence to prove a psychological injury that would warrant removal from the MIG.

Furthermore, the Tribunal found the applicant was not entitled to IRB because he continued to work post-accident and failed to establish a substantial inability to perform the essential tasks of his self-employment as a real estate agent.

The application was dismissed.

The applicant requested a reconsideration of a decision that barred her from proceeding with her application for non-earner benefits due to her failure to attend an independent examination.

The applicant argued that the Tribunal violated procedural fairness and made errors of law and fact regarding the sufficiency of the insurer's notice and her reasons for non-attendance.

The Tribunal dismissed the request, finding no violation of procedural fairness and no errors of law or fact in the original decision.

The applicant sought entitlement to statutory accident benefits following a motor vehicle accident, including costs for a catastrophic impairment assessment, chiropractic treatment plans, and a psychological assessment.

The Tribunal found that the applicant failed to prove the proposed treatments and assessments were reasonable and necessary, noting the minor nature of the physical injuries, the applicant's return to work and daily activities, and the unreliability of the applicant's medical reports.

The application was dismissed in its entirety, with no interest or special award payable.

The applicant sought statutory accident benefits for two physiotherapy treatment plans following a motor vehicle accident.

The respondent insurer denied the plans on the basis that they were not reasonable and necessary.

The Licence Application Tribunal dismissed the application, finding that the applicant failed to meet the burden of proof.

The Tribunal preferred the evidence of the respondent's physiatrist, who opined that the applicant's condition had plateaued and further facility-based treatment would not aid recovery, over the clinical notes of the applicant's family doctor and physiotherapist which showed only modest improvement.

The applicant sought statutory accident benefits following a motor vehicle accident, claiming entitlement to income replacement benefits (IRBs) and treatment beyond the Minor Injury Guideline (MIG) limit due to chronic pain and psychological impairments.

The Licence Appeal Tribunal found that the applicant's physical injuries were predominantly soft tissue sprains and strains falling within the MIG.

The Tribunal gave little weight to the applicant's medical reports regarding chronic pain and psychological issues, preferring the respondent's independent medical examinations which found no objective evidence of ongoing impairment.

Consequently, the Tribunal held that the applicant did not suffer a substantial inability to perform the essential tasks of his pre-accident employment as a delivery truck driver.

The application was dismissed.

The applicant was injured in a motor vehicle accident and sought a medical benefit of $2,851.28 for chiropractic treatment.

The respondent denied the benefit on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the applicant's physical injuries were predominantly minor and that she failed to prove on a balance of probabilities that she suffered from a psychological impairment or chronic pain that would remove her from the MIG.

As the applicant was subject to the MIG limit, the claim for the treatment plan and interest was dismissed.

The applicant sought payment for several assessments, including a $24,400 catastrophic impairment assessment, following a 2009 motor vehicle accident.

The respondent denied the benefits, arguing the assessments were not reasonable and necessary and that any ongoing symptoms were attributable to a second accident in 2012.

The Tribunal found that the current Statutory Accident Benefits Schedule applied to the claim.

The Tribunal dismissed the application, concluding that the applicant failed to establish on a balance of probabilities that the requested assessments were reasonable and necessary for injuries resulting from the 2009 accident, given the lack of contemporaneous medical evidence and the intervening 2012 accident.

The applicant sought payment for a catastrophic impairment assessment totaling $16,000 following a motor vehicle accident.

The respondent insurer denied the treatment plan.

The Licence Appeal Tribunal found that the applicant failed to establish that the proposed catastrophic assessment was reasonable and necessary.

The medical evidence, including reports from treating physicians and independent examiners, did not suggest the applicant's injuries might reach the threshold of a 55% whole person impairment or marked impairment in three or more areas of function.

As no benefits were payable, the claims for a special award and interest were also dismissed.

The applicant requested a reconsideration of a Tribunal decision that barred her from proceeding with her application (except for an income replacement benefit claim) due to her failure to attend two section 44 independent medical examinations.

The applicant argued the Tribunal erred in law and fact by finding the examinations were necessary and that she lacked a reasonable explanation for non-attendance.

The Vice Chair dismissed the reconsideration request, finding no significant error of law or fact in the original decision and noting that a reconsideration is not an opportunity to reargue the case.

The applicant sought income replacement benefits and a medical benefit following a motor vehicle accident.

The respondent denied the benefits and raised a preliminary issue that the applicant's claims were statute-barred under s. 56 of the Statutory Accident Benefits Schedule because the application was filed more than two years after the clear and unequivocal refusals.

The applicant argued that subsequent assessments and correspondence reset the limitation period.

The Tribunal found that the initial refusals were clear and that continuing assessments or repeating the refusal did not reset the limitation period.

The Tribunal also declined to extend the limitation period under s. 7 of the Licence Appeal Tribunal Act, finding no bona fide intention to appeal within the time limit, excessive delay, prejudice to the respondent, and lack of merit.

The application regarding the disputed benefits was dismissed as statute-barred.

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

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

The applicant argued her physical injuries and pre-existing conditions, including depression and anxiety, removed her from the MIG.

The Licence Appeal Tribunal found the applicant's physical injuries were predominantly sprains and strains falling within the MIG.

Furthermore, the Tribunal held there was insufficient medical evidence to establish that any pre-existing condition prevented the applicant from achieving maximal recovery from her minor injuries.

As the MIG limit was exhausted, the disputed treatment plans were not payable, and claims for interest and a special award were dismissed.

The applicant was a pedestrian struck by a motor vehicle and sought statutory accident benefits for injuries sustained.

The respondent determined the injuries fell within the Minor Injury Guideline (MIG) and were subject to the $3,500 funding limit.

The applicant applied to the Licence Appeal Tribunal, arguing that a partial shoulder tear and a pre-existing hip injury removed her from the MIG.

The Tribunal found insufficient medical evidence to support these claims, concluding the injuries were predominantly soft tissue and fell within the MIG.

The Tribunal ordered the respondent to fund the disputed chiropractic treatment plan up to the $3,500 MIG limit, with interest, but denied the applicant's request for a special award under Ontario Regulation 664, finding the respondent did not unreasonably withhold or delay payments.

The applicant sought a medical benefit of $2,460.00 for a psychological assessment and interest under the Statutory Accident Benefits Schedule following a motor vehicle accident.

The matter proceeded by way of a written hearing.

The applicant failed to serve and file any written submissions or evidence by the deadline.

Consequently, the adjudicator found that the applicant failed to meet the onus of proving the treatment plan was reasonable and necessary.

The application was dismissed.

The respondent's request for costs was also denied, as the applicant's failure to file submissions did not amount to unreasonable, frivolous, vexatious, or bad faith conduct.