Chris Sewrattan

The applicant sought reconsideration of a previous decision regarding entitlement to a $1,950 chronic pain assessment following a motor vehicle accident.

The adjudicator found that the assessment was reasonable and necessary based on medical evidence showing the applicant suffered from spinal sprains and strains.

The applicant was awarded $1,950 for the assessment plus interest.

The applicants, adult children of a woman seriously injured in a motor vehicle accident, sought payment for social worker assessments under the Statutory Accident Benefits Schedule.

The insurer denied the treatment plans and requested independent medical examinations, which the applicants failed to attend.

The Tribunal held that the insurer was not automatically required to pay for the assessments under s. 38(11) because they were incurred outside the applicable time period.

Furthermore, the Tribunal dismissed the applications pursuant to s. 55(1) of the Schedule because the applicants failed to attend the required independent medical examinations.

The applicant sought Income Replacement Benefits (IRBs) following two separate motor vehicle accidents.

The insurer denied the benefits and the applicant applied to the Licence Appeal Tribunal for dispute resolution.

The insurer brought a preliminary issue hearing arguing the applications were barred by the two-year limitation period.

The Tribunal found that the insurer had provided clear and unequivocal denials of the IRBs, along with the required dispute resolution options, more than two years before the applications were filed.

The Tribunal declined to extend the limitation period, finding no reasonable grounds to do so, and dismissed the applications as statute-barred.

The applicant sought statutory accident benefits following a motor vehicle accident, but the insurer denied further payments on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 limit had been reached.

The applicant argued that his injuries were not predominantly minor due to psychological impairments, physical injuries including chronic pain, and pre-existing conditions.

The Licence Appeal Tribunal found that the applicant failed to prove on a balance of probabilities that he suffered from a psychological impairment, a non-minor physical injury, or a pre-existing condition that would prevent maximal recovery under the MIG.

Consequently, the applicant was not entitled to the disputed medical benefits and assessments.

The applicant, injured in a motor vehicle accident, sought payment for two sets of assistive devices and a psychological assessment under the Statutory Accident Benefits Schedule.

The Licence Appeal Tribunal denied the claims for assistive devices, finding the applicant failed to prove they were reasonable and necessary given her self-reported improvement and ability to perform daily tasks.

However, the Tribunal granted the request for a psychological assessment, noting the applicant's ongoing residual symptoms of anxiety and depressed mood, and awarded corresponding interest.

Both parties' requests for costs were denied.

The applicant, who suffered catastrophic impairment in a motor vehicle accident, sought a rehabilitation benefit of $6,698.64 for travel expenses to visit family in Iran, accompanied by an attendant care provider.

The insurer denied the claim.

The Licence Appeal Tribunal dismissed the application, finding that the travel was not a necessary expense under section 16 of the Statutory Accident Benefits Schedule, nor was it a permitted type of travel expense, as it did not have a counselling or training purpose.

Claims for interest and costs were also dismissed.

The applicant was injured in a motor vehicle accident and sought a non-earner benefit after the respondent insurer stopped payments.

The adjudicator found that the applicant failed to provide sufficient evidence regarding the time commitments of his pre-accident activities.

Without this information, it was impossible to determine whether the applicant was continuously prevented from engaging in substantially all of the activities in which he ordinarily engaged before the accident.

The application for the non-earner benefit and interest was dismissed.

The applicant was injured in a motor vehicle accident and sought payment for two physiotherapy treatment plans.

The respondent insurer denied payment on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG) and the monetary limit had been reached.

The applicant argued the MIG did not apply due to a pre-existing medical condition and chronic pain.

The adjudicator found insufficient evidence to prove the pre-existing condition prevented maximal medical recovery under the MIG, and preferred the respondent's independent medical examination over the applicant's orthopaedic surgeon's report regarding chronic pain.

The application was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the insurer's determination that his injuries fell within the Minor Injury Guideline (MIG) and seeking payment for a psychological assessment.

The Licence Appeal Tribunal found that the applicant failed to prove his psychological and physical injuries were not predominantly minor, as the psychological assessment relied upon was subjective and inconsistent with objective test results.

Consequently, the applicant's benefits remained capped at $3,500 under the MIG.

However, the Tribunal found the psychological assessment was a reasonable and necessary expense, ordering the insurer to pay for it, with interest, provided there were remaining funds within the applicant's MIG limit.

The applicant sought statutory accident benefits following a motor vehicle accident, which the respondent denied on the basis that the injuries fell within the Minor Injury Guideline.

The Tribunal found that the applicant's psychological impairments, including adjustment disorder and specific phobia, removed her from the Guideline.

The Tribunal preferred the evidence of the applicant's psychologist over the respondent's assessor, noting the respondent's own testing showed the applicant tended to minimize her distress.

The Tribunal awarded the costs of examinations for psychological and chronic pain assessments, along with interest, but denied the claims for physiotherapy treatment plans as the applicant failed to prove they were reasonable and necessary.

The claim for costs was also denied.

The applicant sought payment for three physiotherapy treatment plans and a chronic pain assessment following a motor vehicle accident.

The respondent insurer denied the claims.

At the hearing, the applicant failed to provide the actual treatment plans or any submissions addressing the reasonableness and necessity of the expenses.

The adjudicator dismissed the claims, finding it impossible to determine whether the benefits sought were reasonable and necessary without the treatment plans.

The applicant, who was injured in a motor vehicle accident while riding his bicycle, sought an increased quantum for attendant care benefits provided by his mother.

The applicant argued the rate should reflect the wage his mother would have earned had she not stopped looking for employment to care for him.

The Tribunal found that the applicant failed to prove his mother suffered an economic loss within the meaning of section 3(7)(e)(iii)(b) of the Schedule, as there was insufficient evidence that she would have found employment or been able to work given her own psychological impairments.

The claim for an increased quantum was dismissed.

The applicant was injured in a motor vehicle accident and applied for accident benefits.

The insurer denied the claim for non-earner benefits in November 2011.

More than four years later, the applicant disputed the denial.

The insurer brought a preliminary issue motion to dismiss the claim as statute-barred.

The Licence Appeal Tribunal granted the motion, finding that the two-year limitation period under section 56(1) of the Statutory Accident Benefits Schedule began when the insurer issued a clear and unequivocal refusal in 2011.

The insurer's request for costs was denied as the applicant's conduct was not unreasonable, frivolous, vexatious, or in bad faith.

The applicant was struck by a vehicle while crossing an intersection as a pedestrian.

She applied for accident benefits, but the respondent insurer denied treatment plans for psychological and physiotherapy services, arguing her injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the applicant's severe major depressive disorder and situational phobia, as diagnosed by her psychologist, removed her from the MIG.

The Tribunal ordered payment for the psychological services as reasonable and necessary, but denied the physiotherapy services due to insufficient evidence supporting their necessity.

The applicant sought payment for various medical and rehabilitation benefits following a motor vehicle accident.

The Licence Appeal Tribunal denied several out-of-pocket expenses because the applicant failed to submit a Treatment and Assessment Plan prior to incurring them, as required by section 38(2) of the Statutory Accident Benefits Schedule.

However, the Tribunal awarded $14,266.59 for prescription medications, finding they fell under the exception in section 38(2)(c)(i) and were reasonable and necessary to treat accident-related physical and psychological impairments.

The Tribunal also approved a chiropractic treatment plan aimed at pain reduction, while denying a physiotherapy plan that had previously shown no improvement.

Interest was awarded on the payable benefits.

The applicant was struck by a golf cart on the driveway of a golf course and claimed statutory accident benefits.

The insurer denied the claim.

At a preliminary issue hearing, the Tribunal considered whether the golf cart was an 'automobile' under section 3 of the Statutory Accident Benefits Schedule.

Applying the Grummett test, the Tribunal found that a golf cart is not an automobile in ordinary parlance or under the policy.

While it is a motor vehicle under the Insurance Act, it did not require insurance under the Compulsory Automobile Insurance Act because the accident occurred on a private golf course driveway, not a public highway.

Therefore, the golf cart was not an automobile, and the applicant was not involved in an accident under the Schedule.

The applicant was injured in a motor vehicle accident and sought payment for an orthopaedic assessment.

The insurer denied the claim, arguing the assessment should be funded through OHIP and that the applicant fell within the Minor Injury Guideline.

The Tribunal found that the insurer failed to provide valid medical reasons for the denial within the required timeframe under s. 38(8) of the Schedule, triggering automatic payment under s. 38(11).

The Tribunal also rejected the insurer's broad interpretation of s. 47(2) regarding OHIP coverage.

The applicant was awarded the cost of the assessment and interest, but denied costs.

The applicant was injured in an ATV accident 27 days after purchasing the vehicle, but only one day after taking physical possession of it.

He applied for an income replacement benefit, which the insurer denied on the basis that he was operating an uninsured vehicle.

The Tribunal held that 'delivery' under the standard automobile policy means constructive possession, which occurred on the date of purchase when the applicant had authority to determine where the ATV would go.

Because the applicant failed to notify the insurer within 14 days of constructive possession, the ATV was uninsured.

The Tribunal further found the applicant did not reasonably believe the ATV was insured, precluding him from receiving benefits under s. 31(1)(a)(i) of the Schedule.

The applicant was injured in a motor vehicle accident and received income replacement benefits until they were terminated by the insurer.

The applicant disputed the termination but filed the application with the Licence Appeal Tribunal outside the two-year limitation period under section 56 of the Statutory Accident Benefits Schedule.

The adjudicator rejected the applicant's arguments that the insurer's notice was invalid, that the jurisdictional transfer from FSCO to the Tribunal justified relaxing the limitation period, and that the insurer should be estopped from relying on the limitation period.

The claim was dismissed as statute-barred.

The applicant sought an income replacement benefit following a motor vehicle accident.

The insurer denied the benefit and the applicant applied to the Licence Appeal Tribunal more than two years after the denial.

The applicant argued the denial was not clear and unequivocal, meaning the limitation period had not begun.

The Tribunal found the insurer's Explanation of Benefits provided a clear and unequivocal denial of the claim.

Consequently, the applicant's claim was statute-barred.

The insurer's request for costs was denied as the applicant's conduct was not unreasonable, frivolous, vexatious, or in bad faith.