Craig Mazerolle

The respondent insurer requested a reconsideration of a decision finding two treatment plans reasonable and necessary but not payable due to missing signatures under s. 38(3) of the Schedule.

The insurer argued the Tribunal exceeded its jurisdiction by allowing the applicant to remedy the deficiency at a future date.

During the reconsideration process, the applicant provided the signed treatment plans.

The Tribunal found that accepting the signed plans promoted fairness, efficiency, and the consumer protection mandate of the Schedule.

The reconsideration request was denied, and the benefits were deemed payable once incurred.

The applicant insurer sought repayment of an income replacement benefit (IRB) overpayment of $4,800.00, alleging the respondent had returned to work while receiving benefits.

The respondent argued the repayment request was statute-barred because proper notice was not served within 12 months, as the applicant used an incorrect mailing address for the respondent and ordinary mail for her legal representative.

The Tribunal found that while the respondent did not receive the notice due to the incorrect address, the notice was properly served on her legal representative by ordinary mail under section 64(2) of the Schedule.

The Tribunal ordered the respondent to repay the $4,800.00 overpayment.

The appellant appealed a Notice of Proposal by the Registrar to revoke her registration as a salesperson under the Real Estate and Business Brokers Act, 2002.

Prior to the scheduled hearing, the parties reached a settlement and requested a consent order.

The Tribunal issued the consent order, suspending the appellant's registration for three months and imposing conditions including mandatory education, a prohibition on arranging mortgage financing for 12 months, and direct supervision of trades for 12 months.

The appellant appealed an order to pay a $2,500 administrative penalty issued by the Registrar of the Retirement Homes Regulatory Authority for allegedly failing to report suspected neglect and failing to prevent the neglect of a resident.

The parties reached a settlement and requested a consent order.

The Licence Appeal Tribunal issued a consent order rescinding the finding that the appellant failed to report suspected neglect under s. 75(1) of the Retirement Homes Act, 2010, and closed the file.

The applicant brought a motion to add a claim for $150,000 in punitive damages to their statutory accident benefits dispute before the Licence Appeal Tribunal.

The applicant argued that the Tribunal inherited the court's co-extensive jurisdiction, including common law remedies.

The Tribunal dismissed the motion, finding that the Legislature intentionally limited the Tribunal's remedial powers to those explicitly provided in the Statutory Accident Benefits Schedule and related regulations, which do not include punitive damages.

The respondent insurer brought a motion to suspend the applicant's statutory accident benefits due to his failure to attend a scheduled Examination Under Oath (EUO).

The applicant argued that the notice for the EUO was deficient and that the timing of the request, shortly before the hearing, was improper.

The Tribunal found that the insurer provided valid notice under section 33(4) of the Schedule and that there is no statutory restriction on the timing of an EUO request.

The Tribunal also held that section 34 of the Schedule, which excuses non-compliance with time limits if there is a reasonable explanation, does not apply to section 33(2) because it does not create a time limit.

The motion was granted, and the applicant's benefits were suspended effective the date of the missed EUO.

The applicant sought statutory accident benefits following a motor vehicle accident, arguing his injuries, including chronic pain and a pre-existing knee condition, warranted removal from the Minor Injury Guideline (MIG).

The applicant passed away before the decision was rendered, but the Tribunal found the proceeding was not moot as a decision could impact deemed incurred expenses.

The Tribunal held that the applicant failed to establish on a balance of probabilities that his injuries fell outside the MIG, noting a significant 14-15 month gap in treatment and compelling medical evidence attributing his worsening pain to degenerative changes.

However, the Tribunal found the respondent failed to deny a February 2017 treatment plan within the required 10 business days under s. 38(8) of the Schedule, precluding it from relying on the MIG to deny that specific plan.

No interest was awarded.

The respondent insurer raised a preliminary issue of whether the applicant's slip and fall on ice while attempting to enter her vehicle constituted an 'accident' under s. 3(1) of the Statutory Accident Benefits Schedule.

The adjudicator applied the two-part Greenhalgh framework.

While the purpose test was met, the causation test was not.

The adjudicator found that the dominant feature of the incident was the icy ground, not the use or operation of the vehicle.

Therefore, the incident was not an accident and the applicant was not entitled to statutory accident benefits.

The respondent insurer brought a motion seeking an order to compel the applicant to attend an Examination Under Oath (EUO), an adverse inference for non-attendance, and a suspension of benefits.

The applicant argued the EUO request was improper and abusive as it was made after the respondent agreed to a written hearing on a preliminary issue.

The Tribunal held that it lacks the statutory authority to order an applicant to attend an EUO.

However, the Tribunal found that the insurer has a broad right to request one EUO per claim under s. 33(2) of the Schedule, subject only to a low threshold of relevance.

Because the applicant failed to attend the scheduled EUO without a reasonable explanation, the Tribunal ordered that she is not entitled to any payment of benefits from the date of the scheduled EUO until she complies.

The applicant sought medical benefits following a motor vehicle accident.

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

The Tribunal found that the applicant suffered from an accident-related psychological impairment, removing him from the MIG.

However, while the Tribunal ordered payment for a psychological assessment, it denied the claims for physical therapy and psychological services, finding the physical therapy had plateaued and the psychological services were reasonably available through OHIP.

The respondent insurer requested a reconsideration of a previous Tribunal decision that awarded the applicant various medical and rehabilitation benefits, including physical therapy, a chronic pain assessment, a chronic pain program, and a disability certificate.

The insurer alleged several factual and legal errors, including the Tribunal's treatment of expert evidence and the legal test applied.

The adjudicator dismissed the request, finding that while there were minor errors in the original decision, none were significant enough that they would have likely led to a different result.

The adjudicator also clarified that under s. 25(1) of the Schedule, an insurer is not required to request a disability certificate before it becomes payable.

The respondent insurer brought a motion to dismiss the applicant's claims for an income replacement benefit and two treatment plans, arguing they were barred by the two-year limitation period under s. 56 of the Statutory Accident Benefits Schedule.

The adjudicator found that the claim for the income replacement benefit was not barred because the limitation period was suspended by O. Reg. 73/20 (the COVID-19 Limitations Regulation) before the two-year mark.

However, the treatment plans were denied more than two years before the application was filed.

The adjudicator held that the Tribunal does not have the authority under s. 7 of the Licence Appeal Tribunal Act to extend limitation periods set out in a regulation such as the Schedule.

Consequently, the applicant was permitted to proceed with the income replacement benefit claim, but the claims for the two treatment plans were dismissed.

The respondent insurer brought a motion seeking a determination that the applicant was not entitled to an income replacement benefit due to her failure to comply with recommended treatment under s. 57 of the Statutory Accident Benefits Schedule.

The Tribunal dismissed the motion, finding that the respondent failed to provide proper notice under s. 57(4) before terminating the benefit.

The respondent's correspondence instructed the applicant to seek treatment but failed to warn her that her benefits could be stopped if she did not comply.

Because the notice was invalid, s. 57 could not act as a bar to the applicant's claim.

Both parties' requests for costs were denied.

The applicant sought medical benefits for chiropractic and physiotherapy treatment plans following a motor vehicle accident.

The applicant argued the insurer failed to provide proper notice of denial under s. 38(8) of the Statutory Accident Benefits Schedule.

The Tribunal found the insurer's denials were timely and contained sufficient medical reasons.

On the merits, the Tribunal held the applicant failed to meet his evidentiary burden to establish the treatment plans were reasonable and necessary, noting a lack of medical evidence and a failure to account for a post-accident shoulder fracture.

The claims for benefits, an award, and costs were dismissed.

The respondent insurer brought a motion seeking to compel the applicant to attend an Examination Under Oath (EUO) and to suspend her accident benefits for failing to attend a previously scheduled EUO.

The Tribunal held that it lacks the statutory authority to order an insured person to attend an EUO.

However, because the applicant failed to attend a properly requested EUO without a reasonable explanation, the Tribunal ordered that she is not entitled to any payment of benefits under the Schedule from the date of her non-attendance onwards, until she complies.

The applicants, who both required leg amputations following a motorcycle accident, sought funding for home modifications under the Statutory Accident Benefits Schedule.

The parties presented competing modification plans, with the applicants proposing a one-storey expansion and the respondent proposing a two-storey build.

The adjudicator found the applicants' plan to be reasonable and necessary, as it accommodated their wheelchair needs while preserving their pre-accident lifestyle and avoiding the safety risks of a two-storey design.

The adjudicator also awarded the applicants 25% of the value of a back-up generator under section 10 of Regulation 664, finding that the respondent unreasonably delayed its approval.

Both parties requested reconsideration of a previous Tribunal decision regarding statutory accident benefits.

The respondent argued the Tribunal erred in awarding psychological services and an award for a functional impairment assessment, and breached procedural fairness by deeming the assessment incurred under s. 3(8) without notice.

The applicant argued the Tribunal erred by requiring attendant care services to be incurred.

The Tribunal upheld the respondent's request in part, finding a breach of procedural fairness regarding the s. 3(8) deeming provision, and struck that portion of the decision.

The applicant's request was dismissed in full.

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

The respondent denied the benefit, arguing the applicant failed to provide sufficient documentation to calculate his pre-accident self-employment income and that surveillance evidence showed he continued to work post-accident.

The Tribunal found that under s. 4(3) of the Schedule, the applicant's pre-accident income was established by his Canada Revenue Agency Notices of Assessment, entitling him to the benefit for the end of 2017.

However, the Tribunal accepted the respondent's surveillance evidence demonstrating the applicant worked post-accident.

Because the applicant failed to provide reasonably required information regarding his post-accident income, he was barred under s. 33(6) from receiving the benefit from January 1, 2018 onwards.

The request for a special award was dismissed.

The applicant was injured in a motor vehicle accident and sought a catastrophic impairment designation under the Statutory Accident Benefits Schedule due to a mental or behavioural disorder.

The respondent insurer denied the designation.

The Tribunal found that the applicant suffered a Class 4 (marked) impairment in the domains of activities of daily living and adaptation to work or worklike settings, caused by an accident-related Somatic Symptom Disorder.

The Tribunal concluded the applicant was catastrophically impaired effective October 19, 2016.

The applicant was injured in a motor vehicle accident and sought an income replacement benefit and a chronic pain assessment under the Statutory Accident Benefits Schedule.

The respondent denied the benefits, arguing the applicant did not suffer a substantial inability to perform his pre-accident employment and questioning his credibility and reported income.

The Tribunal found that the applicant's accident-related left knee pain caused a substantial inability to perform the essential physical tasks of his restaurant manager position.

The Tribunal also accepted the applicant's updated Canada Revenue Agency filings to calculate the quantum of the benefit and found the chronic pain assessment to be reasonable and necessary.

The application was allowed.