Christopher A. Ferguson

The insurer brought a preliminary motion to bar the insured's appeal for statutory accident benefits on the basis that the insured failed to attend scheduled independent medical examinations (IEs) and failed to provide requested medical information.

The insured argued that the insurer failed to properly arrange the IEs and that the assessment facility was not independent.

The Tribunal rejected the insured's arguments, finding that the insurer properly scheduled the IEs and that the insured's refusal to attend was without merit.

The Tribunal held that the appeal was statute-barred under section 55 of the Schedule due to the insured's non-compliance with section 44.

The insurer's request for an order restraining the insured from contacting its IE providers was dismissed for lack of jurisdiction, and both parties' requests for costs were denied.

The applicant was injured in a motor vehicle accident in 2004 and sought statutory accident benefits.

The insurer denied claims for attendant care and housekeeping benefits in 2005, issuing an Explanation of Benefits (OCF-9) indicating a refusal to pay.

The applicant did not appeal this denial until 2017, after being deemed catastrophically impaired.

The insurer raised a preliminary issue that the appeal was statute-barred under s. 51 of the Schedule.

The Tribunal found that the 2005 denial was clear and unequivocal, triggering the two-year limitation period.

Consequently, the applicant's appeal was dismissed as statute-barred.

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

The insurer suspended benefits after the applicant failed to provide requested post-accident bank records.

The Tribunal found that the insurer's request under s. 33 of the Schedule was reasonable, given surveillance evidence showing the applicant at her employer's premises and the fact that her employer was a company owned by her husband.

Because the applicant failed to comply with the reasonable request, the insurer was not liable to pay the benefits.

The application was dismissed.

The applicant was struck by a public transit bus and sought attendant care and non-earner benefits.

The insurer denied the claims and raised preliminary issues regarding the applicant's failure to comply with requests for medical information under s. 33 of the Statutory Accident Benefits Schedule.

The Tribunal found that the applicant completely failed to provide the requested medical documentation for over three years without a reasonable explanation.

The applicant's reliance on a law firm policy not to produce records older than one year pre-accident was rejected as an unreasonable excuse.

Consequently, the insurer was found not liable to pay the disputed benefits, and the appeal was dismissed.

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

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

The applicant argued for removal from the MIG due to pre-existing conditions, chronic pain, and psychological injuries.

The Tribunal found that the applicant failed to provide compelling evidence to establish any of these exceptions, preferring the objective evidence of the insurer's examiners over the applicant's self-reported symptoms and clinical impressions.

The Tribunal also dismissed the claim for Income Replacement Benefits, finding insufficient evidence of a substantial inability to perform the essential tasks of pre-accident employment.

The appeal was denied.

Economical Mutual Insurance Company applied to the Licence Appeal Tribunal for repayment of $3,245.86 in income replacement benefits (IRBs) paid to the respondent between January 1, 2016, and August 3, 2017.

The Tribunal had previously determined that the respondent's IRB entitlement for this period was $0.00.

The respondent argued that Economical failed to provide a valid notice of repayment within the required 12-month period under section 52(3) of the Statutory Accident Benefits Schedule.

The Tribunal found that Economical's initial notice in March 2016 was substantially correct and valid.

Consequently, the Tribunal ordered the respondent to repay the overpaid amount of $3,245.86, plus interest starting from August 31, 2017.

The applicant was injured in a motor vehicle accident and sought medical benefits for physiotherapy and costs of examination for orthopaedic, attendant care, and psychological assessments.

The insurer denied the benefits, arguing the applicant's injuries had resolved or were related to a subsequent accident.

The Licence Appeal Tribunal dismissed the application, finding the applicant failed to prove the treatments and assessments were reasonable and necessary.

The Tribunal gave significant weight to the insurer's examination reports and noted the applicant's lack of candor regarding a second motor vehicle accident.

The applicant sought non-earner benefits and various medical benefits following a motor vehicle accident.

The Licence Appeal Tribunal dismissed the application, finding the applicant failed to prove a complete inability to carry on a normal life.

Evidence showed the applicant continued to play hockey and work as a sheet metal worker post-accident.

The claims for medical benefits were also dismissed for lacking evidence that they were reasonable and necessary.

The applicant, who was deemed catastrophically impaired following a motor vehicle accident, sought payment for four physiotherapy treatment plans.

The insurer denied the claims on the basis that the applicant had reached maximal medical recovery for his musculoskeletal injuries.

The adjudicator preferred the evidence of the insurer's medical examiners, finding that the applicant's pain complaints had a strong non-organic component and that further physiotherapy would not be beneficial.

The adjudicator also found that the insurer's notices of denial were sufficient.

The application was dismissed.

Aviva requested a reconsideration of an Adjudicator's decision that awarded the applicant the full cost of disputed treatment plans plus interest and a 25% special award for unreasonable delay.

Aviva argued that the Adjudicator erred by not applying a credit for money already paid prior to the hearing and by granting the special award on insufficient evidence.

The Adjudicator conducting the reconsideration dismissed the request, finding no significant error of law.

The original Adjudicator correctly applied the interest provisions and reasonably concluded that Aviva's delay in paying the benefits after receiving all necessary information was unreasonable, justifying the 25% special award.

The applicant sought reconsideration of a Licence Appeal Tribunal decision that denied his claims for income replacement benefits, chiropractic treatment, and psychological treatment following a motor vehicle accident.

The applicant argued the Tribunal violated the rules of natural justice and made significant errors of fact and law, including misapplying the burden of proof and failing to consider the insurer's alleged non-compliance with the Statutory Accident Benefits Schedule.

The Adjudicator dismissed the request for reconsideration, finding no evidence of procedural unfairness or significant errors in the original decision.

The applicant sought statutory accident benefits after slipping and falling on ice in a parking lot after exiting and locking her vehicle.

The insurer denied the claim on the basis that the incident was not an 'accident' under the Schedule.

The Tribunal applied the Greenhalgh test and found that the use or operation of the vehicle was not a direct cause of the injuries, as the icy surface was an intervening act that broke the chain of causation.

The Tribunal also held it lacked jurisdiction to apply the doctrine of estoppel against the insurer.

The application was dismissed.

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

The insurer raised a preliminary issue, arguing the appeal was statute-barred because it was not commenced within two years of a 2012 denial letter.

The Tribunal found the 2012 letter was not a clear and unequivocal denial, as it was contingent on the applicant's status under the Minor Injury Guideline.

A subsequent 2014 letter confirming removal from the guideline reset the limitation period, and the true denial occurred in 2018.

The Tribunal held the appeal was not statute-barred and could proceed.

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

The insurer raised preliminary issues, arguing the applicant was barred from proceeding with her appeal for failing to attend an in-home occupational therapy assessment, and that the Tribunal lacked jurisdiction over an unpaid but approved psychological assessment.

The Tribunal found the applicant was not barred from proceeding with her non-earner benefits claim because the insurer failed to provide sufficient reasons for the requested assessment.

However, the Tribunal concluded it lacked jurisdiction over the psychological assessment claim because the insurer had approved it and was merely awaiting requested information from the provider, meaning no dispute over entitlement existed.

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

The insurer denied the claims, asserting the injuries fell within the Minor Injury Guideline (MIG).

The insurer raised a preliminary issue that the appeal should be barred because the applicant failed to attend a scheduled psychological insurer's examination (IE).

The Tribunal found that the applicant failed to provide a reasonable explanation for not attending the IE, barring the appeal under s. 55(1)2 of the Schedule.

In the alternative, the Tribunal found the applicant failed to prove his physical or psychological injuries fell outside the MIG, preferring the evidence of the insurer's experts.

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

A preliminary issue hearing was held to determine whether the costs of assessments to determine catastrophic impairment (CAT assessments) are included in the $50,000 limit on medical and rehabilitation benefits under the Statutory Accident Benefits Schedule.

The Tribunal held that CAT assessments are not included in the $50,000 cap, as section 25(1)5 of the Schedule requires the insurer to pay reasonable fees for preparing a CAT application, independent of the section 18(3) limits.

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

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

She provided no information about her pre-accident employment, duties, or income, and failed to address discrepancies in the medical evidence or the impact of her paid maternity leaves and return to work.

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

The respondent insurer denied a treatment plan for $1,252.55, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 limit had been exhausted.

The applicant argued she suffered from chronic pain, which would remove her from the MIG.

The Tribunal found the applicant failed to prove she sustained a chronic pain condition as a result of the accident, noting a lack of medical evidence linking her complaints to the accident and evidence of her returning to normal activities.

The application was dismissed.

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

The insurer denied a treatment plan on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG).

The applicant argued the insurer was precluded from relying on the MIG due to prior approvals, and alternatively, that her pre-existing obesity and alleged post-concussion syndrome removed her from the MIG.

The Tribunal held the insurer provided proper notice and was not precluded from applying the MIG.

The Tribunal further found the applicant failed to provide compelling evidence that her obesity was a documented pre-existing condition that prevented recovery within the MIG cap, or that she suffered a concussion caused by the accident.

The appeal was dismissed.

The applicant was involved in a motor vehicle accident and sought non-earner benefits, which the respondent insurer denied.

The insurer raised a preliminary issue arguing the applicant's appeal was statute-barred under s. 56 of the Statutory Accident Benefits Schedule for failing to commence it within the two-year limitation period.

The Tribunal found that subsequent correspondence from the insurer rendered the initial denial equivocal, extending the limitation period.

Alternatively, the Tribunal held that the applicant met the criteria for an extension of time under s. 7 of the Licence Appeal Tribunal Act.

The insurer's request to bar the appeal was denied.