Brian Norris

The respondent insurer requested a reconsideration of a decision granting the applicant entitlement to two treatment plans for chiropractic, massage, and physiotherapy.

The insurer argued the adjudicator erred in law by relying on subjective complaints and psychological evidence rather than objective physical evidence.

The adjudicator dismissed the reconsideration, finding no error in law in considering the totality of the evidence, including consistent subjective reporting, to determine if the treatment was reasonable and necessary.

The applicant's request for costs was also denied.

The applicant requested a reconsideration of a preliminary decision which found she was statute-barred from disputing entitlement to caregiver and housekeeping benefits due to an expired limitation period.

The applicant argued the adjudicator erred in law by finding the insurer could request a disability certificate and an insurer's examination contemporaneously, and by finding the insurer was not required to send the examination report to her health practitioner.

The adjudicator dismissed the request for reconsideration, finding no error of law or breach of procedural fairness.

The insurer was permitted to request both contemporaneously, and there was no obligation to send the report to a health practitioner because the applicant never submitted a disability certificate.

The applicant was injured in a motor vehicle accident and sought medical and rehabilitation benefits under the Statutory Accident Benefits Schedule.

The respondent insurer denied four treatment and assessment plans.

The Licence Appeal Tribunal found that the April 2018 chiropractic treatment plan was partially reasonable and necessary, and that the respondent failed to provide a compliant denial notice under section 38 of the Schedule, making it liable for incurred expenses during the non-compliance period.

The Tribunal also approved a March 2019 psychological treatment plan.

However, the Tribunal dismissed the claims for a July 2018 chiropractic plan and a physiatry assessment, finding them not reasonable and necessary.

Interest was awarded on the overdue payments.

The applicant sought statutory accident benefits for an impairment assessment, a physiatry assessment, and a treatment plan for physiotherapy and massage therapy following a motor vehicle accident.

The adjudicator found that the impairment assessment and the physiotherapy treatment plan were not reasonable and necessary, noting the applicant's return to full-time work and independence in self-care.

While the physiatry assessment was also found not to be reasonable and necessary, the adjudicator held that the respondent failed to provide a compliant denial under section 38(8) of the Schedule.

Consequently, the applicant was entitled to the incurred costs of the physiatry assessment along with interest.

The applicant was injured in a motor vehicle accident and sought medical benefits for two chiropractic treatment plans and one psychological treatment plan under the Statutory Accident Benefits Schedule.

The respondent denied the plans based on insurer's examinations.

The Licence Appeal Tribunal found the first chiropractic treatment plan reasonable and necessary, noting the applicant's ongoing pain and the physical impairments documented even in the respondent's own medical examination.

However, the Tribunal dismissed the claims for the second chiropractic plan and the psychological plan, finding insufficient evidence of ongoing physical impairment and concluding the applicant had already reached her psychological treatment goals.

The applicant was awarded the cost of the first chiropractic plan plus interest.

The applicant sought statutory accident benefits for two chiropractic treatment plans totaling $8,320.00 following a motor vehicle accident.

The insurer denied the claims, arguing the treatments were not reasonable and necessary.

The Licence Appeal Tribunal found that the applicant predominantly suffered psychological injuries rather than the claimed neurological and concussion-related injuries.

Relying on the insurer's medical examinations, the Tribunal concluded the disputed treatment plans were not reasonable and necessary.

The application was dismissed.

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

The respondent insurer denied several treatment and assessment 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 conditions and accident-related psychological injuries removed her from the MIG.

The Tribunal found insufficient evidence that pre-existing conditions precluded maximal recovery within the MIG.

Furthermore, the Tribunal preferred the respondent's psychological assessment over the applicant's, concluding the applicant did not suffer a psychological injury.

The application was dismissed, and no award or interest was payable.

The applicant sought statutory accident benefits for physiotherapy and a psychological assessment following a May 2016 motor vehicle accident.

The Licence Appeal Tribunal dismissed the application, finding the applicant failed to prove the treatments were reasonable and necessary as a result of the subject accident.

The Tribunal noted significant gaps in the medical records and unrefuted evidence of subsequent intervening accidents, including another motor vehicle accident and a cycling accident, which likely caused the current injuries.

The applicant was injured in a rear-end motor vehicle accident and sought statutory accident benefits.

The respondent insurer limited the applicant to the $3,500 Minor Injury Guideline (MIG) funding limit.

The Tribunal found that the applicant suffered accident-related psychological injuries, including depression and anxiety, which removed him from the MIG.

The Tribunal ordered the respondent to pay for a psychological assessment and a psychological treatment plan, plus interest on the incurred assessment, but denied the remaining disputed treatment plans as the applicant failed to prove they were reasonable and necessary.

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

The insurer denied certain medical benefits, arguing the injuries fell within the Minor Injury Guideline (MIG) and its $3,500 funding limit.

The Tribunal found the applicant suffered from chronic pain syndrome, removing him from the MIG.

The Tribunal ordered the insurer to pay for the disputed treatment plans, plus interest, and awarded the applicant 40% of the withheld amounts under section 10 of O. Reg. 664 due to the insurer's unreasonable denial without obtaining its own medical assessment.

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

The insurer denied funding for physiotherapy, chiropractic treatment, and a psychological assessment, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the applicant suffered from vehicular anxiety, a psychological injury that removed him from the MIG.

However, the physical treatment plans were denied as there was no evidence of physical injury.

The psychological assessment was approved subject to the $2,000 statutory limit.

The applicant sought statutory accident benefits following a motor vehicle accident and applied for a catastrophic impairment determination.

The insurer requested insurer's examinations (IEs) coordinated through a third-party assessment company, CanAssess.

The applicant attended the physical examinations but subsequently revoked her consent for CanAssess's participation, preventing the release of the IE reports.

The Tribunal held that revoking consent to the third-party assessment company's participation is tantamount to failing to participate in the IE process under section 44 of the Schedule.

The Tribunal permitted the application to proceed but stayed the substantive hearing until the applicant complies with the IE process.

The applicant sought a medical benefit of $1,417.48 for a physiotherapy treatment plan following a motor vehicle accident.

The respondent insurer denied the claim, arguing the applicant's shoulder injury was not caused by the accident.

The Tribunal reviewed the medical evidence, noting the applicant did not report shoulder issues until nearly eleven months post-accident and that a neurologist attributed the shoulder issues to a pre-existing contracture from prior bilateral prophylactic mastectomies.

The Tribunal found the shoulder injury was not accident-related and dismissed the application for the treatment plan and interest.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for lost educational expenses after withdrawing from a post-secondary program.

The Licence Appeal Tribunal found no medical evidence that the applicant's accident-related injuries prevented him from continuing his education, noting his psychological issues were workplace-related.

Furthermore, the applicant failed to submit a completed disability certificate as required by section 21(3) of the Schedule.

The application for lost educational expenses and interest was dismissed.

The applicant sought statutory accident benefits following two motor vehicle accidents.

The respondent insurer determined the applicant's injuries fell within the Minor Injury Guideline (MIG) and denied funding for various treatment plans.

The adjudicator found that the applicant suffered psychological injuries, including somatic symptom disorder and PTSD, which removed her from the MIG and its $3,500 funding limit.

However, the adjudicator dismissed the claims for in-home occupational therapy, acupuncture, and a social work assessment, finding them not reasonable and necessary for the applicant's accident-related injuries based on the medical evidence.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits.

The respondent insurer determined the injuries fell within the Minor Injury Guideline (MIG) and denied several treatment and assessment plans.

The applicant applied to the Licence Appeal Tribunal, arguing that chronic back pain and psychological injuries removed him from the MIG.

The Tribunal found that the applicant's physical injuries were predominantly soft tissue sprains and strains, and there was no compelling evidence of significant functional impairment or psychological injury.

The Tribunal also found the respondent provided sufficient medical reasons for its denials.

Consequently, the applicant's injuries were deemed minor, subject to the $3,500 funding limit, and the disputed treatment plans, interest, and award claims were dismissed.

The applicant was injured in a motor vehicle accident and sought a medical benefit of $1,285.60 for a physiotherapy treatment plan.

The applicant argued this plan was submitted to replace a previously approved but unconsumed treatment plan from a different facility.

The Adjudicator found no authority in the Schedule permitting the exchange of treatment plans and noted the applicant failed to explain a six-month gap in treatment.

Furthermore, the medical evidence did not support that the disputed plan was reasonable and necessary.

The application was dismissed, and no interest was payable.

The applicant sought funding for a psychiatric assessment and occupational therapy assessments as part of a catastrophic impairment determination following a motor vehicle accident.

The respondent denied the psychiatric assessment as duplicative of an approved psychological assessment, and disputed the number of occupational therapy assessments.

The Tribunal found the psychiatric assessment was reasonable and necessary because the psychological assessment was never performed, but capped the cost at $2,000.00 under the Schedule.

The Tribunal also found the applicant was entitled to two occupational therapy assessments, capped at $2,000.00 each.

The applicant was awarded interest on the overdue amounts but denied an award under O. Reg. 664, as the respondent's denials were not unreasonable.

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

The respondent determined the applicant's injuries fell within the Minor Injury Guideline (MIG) and refused to pay for certain medical benefits beyond the $3,500 funding limit.

The applicant argued that pre-existing chronic low back pain precluded her recovery within the MIG.

The Tribunal found that the applicant's injuries were predominantly minor, noting that clinical records and an independent medical examination showed only soft tissue injuries and no evidence that the pre-existing condition would prolong recovery.

Consequently, the disputed treatment plans were deemed not reasonable and necessary, and the claims for benefits and interest were dismissed.

The applicant was injured in a motor vehicle accident and sought funding for a physiotherapy treatment plan in the amount of $3,078.72.

The respondent denied the treatment plan.

The Licence Appeal Tribunal found that the treatment plan was not reasonable and necessary, noting significant gaps in the applicant's treatment history and a lack of improvement despite previous facility-based treatment.

The Tribunal accepted the respondent's medical examination evidence that the applicant had reached maximum medical improvement and could manage her symptoms with a home-based exercise program.

The claims for an award and interest were also dismissed.