Christopher A. Ferguson

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

The insurer denied the claims, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 limit had been exhausted.

The applicant argued she sustained psychological impairments that removed her from the MIG.

The adjudicator preferred the insurer's psychological assessment, which included validity testing indicating symptom magnification, over the applicant's psychological evidence.

The adjudicator concluded the applicant's injuries were predominantly minor, dismissing the claims for additional medical benefits, an award for unreasonable delay, and interest.

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

The respondent denied certain medical expenses, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The applicant contended that her post-April 2016 impairments, including lower back issues requiring surgery, were caused by the accident and thus her injuries were not predominantly minor.

The Tribunal found that the applicant's later impairments were the result of pre-existing degenerative conditions, not the accident, relying on the uncontroverted opinion of the respondent's orthopedic assessor.

The Tribunal concluded the applicant's injuries were subject to the MIG and dismissed her claims for medical expenses, interest, and a special award.

The applicant, a minor who suffered a catastrophic impairment in an automobile accident, sought rehabilitation benefits for the cost of renting an accessible home.

The Licence Appeal Tribunal determined that the respondent insurer is liable to pay a monthly benefit calculated by subtracting the average rent for a two-bedroom apartment in the applicant's community from the actual rent of her current home, plus 50% of the monthly utilities.

The Tribunal also awarded interest on overdue benefit payments.

The applicant sought a determination of catastrophic impairment after settling their claim for specific statutory accident benefits.

The respondent insurer brought a preliminary issue arguing the Licence Appeal Tribunal lacked jurisdiction to make a stand-alone catastrophic impairment determination without an underlying dispute over specific benefits.

The Tribunal held that it has jurisdiction to determine catastrophic impairment on a stand-alone basis, as such a determination directly affects entitlement to enhanced benefits and is not merely declaratory relief.

The respondent's request was denied, and the applicant's appeal was permitted to proceed.

The applicant's request for costs and an award was denied.

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

The respondent denied the claims on the basis that the applicant's injuries were predominantly minor and the $3,500 funding limit under the Minor Injury Guideline (MIG) had been exhausted.

The Tribunal found that the applicant failed to prove his physical or psychological injuries fell outside the MIG, and that his chronic pain symptoms were clinically associated sequelae to his minor injuries.

The application was dismissed.

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

The respondent insurer raised preliminary issues, arguing that several of the applicant's claims were statute-barred because she failed to appeal within the two-year limitation period, and that other claims were barred because she failed to submit them within the prescribed timelines.

The Tribunal found that the insurer's explanation of benefits for the attendant care and certain medical benefits did not constitute a clear and unequivocal denial, meaning the limitation period was not triggered and those claims could proceed.

However, the Tribunal found that the denial for the cost of examinations was clear and unequivocal, barring that claim.

The Tribunal also held that the applicant lacked a reasonable explanation for her late submission of transportation claims, barring those from proceeding.

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

The respondent insurer suspended the IRBs for a seven-week period, alleging the applicant failed to comply with an insurer's examination (IE) when he objected to the exclusion of his wife and the presence of a transcriptionist.

The Tribunal found that the applicant had a reasonable explanation for his non-compliance, given his psychological difficulties, his expectation based on past IEs that his wife could attend, and his good-faith efforts to resolve the issue at the time.

The Tribunal ordered the respondent to pay the withheld IRBs with interest, but dismissed the applicant's claim for a special award, finding the insurer's actions were not unreasonable.

The applicant sought a medical benefit for a physiotherapy treatment plan in the amount of $1,501.04 following a motor vehicle accident.

The respondent initially denied the benefit but later advised the Tribunal that it had approved the disputed treatment plan.

The adjudicator found that the respondent conceded the claim, resolving the dispute, and noted that the respondent is liable to pay interest on the overdue payment pursuant to s. 51 of the Schedule.

The applicant sought non-earner benefits following a 2013 motor vehicle accident.

The respondent denied the claim and later raised a preliminary issue, arguing the applicant's appeal to the Licence Appeal Tribunal was statute-barred under s. 56 of the Statutory Accident Benefits Schedule because it was filed more than two years after the denial.

The Tribunal found that the applicant had filed for mediation within the two-year period and commenced her appeal within the 90-day extension period following the mediator's report, as permitted by the transition rules.

The Tribunal dismissed the preliminary issue, holding the appeal was not statute-barred, and noted that even if it were, the applicant met the criteria for an extension under s. 7 of the Licence Appeal Tribunal Act.

The respondent insurer brought a preliminary issue motion arguing that the Licence Appeal Tribunal lacks jurisdiction to determine whether an applicant is catastrophically impaired when there are no associated substantive benefits in dispute.

The adjudicator dismissed the motion, finding that the Insurance Act and the Statutory Accident Benefits Schedule do not require a claim for a specific substantive benefit to accompany an application for a catastrophic impairment determination.

The Tribunal has jurisdiction to determine catastrophic impairment on a stand-alone basis.

The applicant was blinded in one eye when struck by an egg thrown from a passing motor vehicle.

She applied for statutory accident benefits, which the respondent insurer denied on the basis that the incident was not an 'accident' under the Statutory Accident Benefits Schedule.

The Licence Appeal Tribunal found that the incident was an assault, and the throwing of the egg was an independent and intervening act.

The use or operation of the vehicle was not the direct cause of the impairment.

The application was dismissed.

The applicant insurer applied to the Licence Appeal Tribunal for repayment of statutory accident benefits paid to the respondent, alleging he was not a passenger in the insured vehicle at the time of the accident.

The Tribunal found that the respondent made a wilful misrepresentation, as evidence showed he was not an occupant of the vehicle.

The respondent was ordered to repay $2,400.00 in benefits plus interest.

However, the Tribunal dismissed the insurer's claim for reimbursement of adjusting and examination costs, finding no authority in the Schedule to order repayment of such expenses.

The insurer's request for costs of the proceeding was also dismissed.

The applicant was injured in a motor vehicle accident and received income replacement benefits (IRBs) until she returned to work.

The insurer sent a letter terminating the IRBs but stating she could submit an updated disability certificate if she had to leave work again due to her injuries.

More than two years later, the applicant filed an appeal for further IRBs after stopping work again.

The insurer raised a preliminary issue, arguing the appeal was statute-barred under s. 56 of the Statutory Accident Benefits Schedule.

The Tribunal found that the insurer's termination letter was not a clear and unequivocal denial, as it suggested her options remained open if her circumstances changed.

Therefore, the limitation period was not triggered, and the appeal was allowed to proceed.

The applicant insurer sought repayment of $4,776.44 in statutory accident benefits paid to the respondent for prescription medication expenses.

The respondent had received payments from the Trillium drug benefit program for the same expenses but submitted claims to the applicant, effectively misrepresenting that she was out-of-pocket.

The respondent did not participate in the hearing.

The Tribunal found that the overpayments were the result of wilful misrepresentation, meaning no limitation period applied to the repayment request.

The respondent was ordered to repay the full amount plus interest.

The applicant sought statutory accident benefits following a motor vehicle accident, including costs for a psychological assessment, psychological treatment, and physiotherapy.

The Licence Appeal Tribunal found the insurer liable to pay for the psychological assessment because its denial notice failed to provide medical reasons as required by s. 38(8) of the Schedule.

However, the claims for psychological treatment and physiotherapy were dismissed, as the applicant failed to prove they were reasonable and necessary, with the Tribunal preferring the insurer's examination reports over the applicant's contradictory self-reporting.

The claim for a special award was also dismissed.

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

The respondent denied claims for medication expenses and a facility-based exercise program, arguing the applicant's conditions were pre-existing.

The Tribunal found that the accident caused an aggravation of the applicant's pre-existing conditions.

The Tribunal allowed the claim for medication expenses, including medical marijuana, finding them reasonable and necessary.

However, the Tribunal dismissed the claim for the facility-based exercise program, accepting the respondent's insurer's examination report that the exercises could be done at home.

The applicant sought a medical benefit for psychological services following a motor vehicle accident.

The insurer denied the treatment plan based on an insurer examination.

The Tribunal found the applicant's self-reporting to his own psychologist was contradicted by his statements to the insurer's assessor, where he minimized his symptoms.

Given the lack of corroborating evidence and the unexplained discrepancies in self-reporting, the Tribunal concluded the applicant failed to prove the treatment plan was reasonable and necessary.

The claims for the medical benefit, a special award, and interest were dismissed.

The respondent insurer brought a motion seeking the production of various documents from the applicant and an adjournment of the scheduled hearing.

The applicant did not contest the obligation to produce the documents but noted no due date was set at the case conference.

The adjudicator ordered the applicant to produce the requested documents, including tax returns, ODSP file, and particulars of her claim for an award, within seven business days.

The request for an adjournment was denied to ensure timely proceedings, as the adjudicator found the respondent would not be unduly prejudiced by proceeding as scheduled.

The applicant sought medical benefits for treatments following a motor vehicle accident.

The Licence Appeal Tribunal dismissed the application, finding that the applicant failed to prove the accident caused her impairments, which were consistent with her pre-existing arthritic and fibromyalgia conditions.

The Tribunal also rejected the applicant's procedural argument that the insurer failed to provide timely notice of its refusal to pay, finding the insurer complied with the ten-day notice requirement under the Statutory Accident Benefits Schedule.

The applicant sought statutory accident benefits following a motor vehicle accident, specifically claiming costs for an orthopedic assessment and a treatment plan for physiotherapy and massage.

The respondent insurer denied the claims based on an insurer's examination (IE) by an orthopedic surgeon, who concluded the treatments were not reasonable or necessary.

The Licence Appeal Tribunal dismissed the appeal, finding the applicant failed to provide sufficient medical evidence to prove the treatment plans were reasonable and necessary, and accepted the respondent's IE report.

As no benefits were payable, the claim for interest was also dismissed.