Craig Mazerolle

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

The insurer denied an income replacement benefit because the applicant was convicted of impaired driving in relation to the accident, and denied a medical benefit for counselling and case management.

The Tribunal held that the applicant was excluded from the income replacement benefit under s. 31(1)(d)(i) of the Schedule due to his conviction.

However, the Tribunal found that the insurer's denial letter for the medical benefit failed to provide sufficient medical reasons, breaching s. 38(8).

Consequently, the benefit was deemed incurred under s. 3(8) and payable under s. 38(11).

The Tribunal also awarded the applicant a 20 per cent special award under Regulation 664 for the unreasonable withholding of the medical benefit.

The applicant was injured in a motor vehicle accident and sought a non-earner benefit under the Statutory Accident Benefits Schedule.

The respondent denied the claim, arguing the applicant did not meet the threshold of a complete inability to carry on a normal life.

The Tribunal applied the Heath framework and found that the applicant's accident-related fibromyalgia and chronic pain significantly impaired her ability to engage in her pre-accident activities, particularly caring for her family and maintaining her home.

The Tribunal concluded the applicant met the threshold and awarded the non-earner benefit with interest.

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

The respondent denied the claim, arguing the applicant's activity levels were already limited by pre-existing conditions and that she retained the physical capacity to perform light tasks.

The Tribunal found that while the applicant had pre-existing physical issues, the accident caused a psychological impairment (Adjustment Disorder with Mixed Anxiety and Depressed Mood) that continuously prevented her from engaging in substantially all of her pre-accident activities, particularly her role as a homemaker.

The Tribunal awarded the non-earner benefit from the date her psychological symptoms were first documented, along with interest.

The respondent's request for costs was denied.

The applicant, an uninsured pedestrian struck by a vehicle, applied for statutory accident benefits.

The insurer denied funding for catastrophic determination assessments, arguing they were captured under the $65,000 non-catastrophic limit which had already been exhausted by hospital bills.

The Tribunal held that catastrophic determination assessments do not fall under the financial limit of s. 18(3) of the Schedule because they are not conducted in connection with any specific benefit or payment.

The Tribunal awarded $7,718.00 for the reasonable and necessary portions of the assessments, but denied the clinic file review portion as duplicative.

The claim for a special award under Regulation 664 was dismissed as the insurer's interpretation, though incorrect, was not unreasonable.

The applicant sought statutory accident benefits following a motor vehicle accident, including a non-earner benefit, neurobiofeedback, and physiotherapy.

The Tribunal found the applicant did not meet the threshold for a non-earner benefit, as his psychological impairments did not continuously prevent him from engaging in substantially all of his pre-accident activities.

The Tribunal granted the claim for neurobiofeedback, finding it reasonable and necessary to address the applicant's psychological distress and vehicular anxiety.

The claims for physiotherapy were dismissed, as the applicant had reached maximal medical recovery from a physical standpoint.

The applicant sought $2,909.47 for physiotherapy services following a motor vehicle accident.

The respondent denied the claim on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 limit under s. 18(1) of the Schedule had been reached.

The Tribunal found that the applicant failed to provide sufficient medical evidence to demonstrate that her injuries were not predominantly minor in nature.

The application was dismissed.

The applicant sought statutory accident benefits after being assaulted at an automobile repair shop following a verbal disagreement over his vehicle.

The adjudicator held a written hearing to determine the preliminary issue of whether the incident constituted an 'accident' under s. 3(1) of the Statutory Accident Benefits Schedule.

Applying the two-part test from Chisholm, the adjudicator found that while repairing a vehicle is an ordinary and well-known activity, the assault was an intervening act that broke the chain of causation.

The incident was therefore not an 'accident' and the applicant was not entitled to benefits.

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

The insurer argued the applicant was barred from proceeding because he failed to attend three requested medical and vocational examinations.

The Tribunal found the insurer provided sufficient notice for the orthopaedic assessment but not for the functional abilities or job site evaluations.

Consequently, the applicant is barred from proceeding with his claim until he attends the orthopaedic assessment.

The Tribunal also awarded the applicant 25 per cent of a delayed benefit payment under Regulation 664, but denied his request for costs.

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

The respondent insurer initially paid the benefits but terminated them after an insurer's examination by an occupational therapist concluded there was no ongoing need.

The applicant argued the expenses should be deemed incurred because the respondent unreasonably withheld payment.

The Tribunal found that the respondent's reliance on its assessor's report was not unreasonable and dismissed the application, finding the applicant was not entitled to the disputed benefits.

The applicant sought statutory accident benefits for a psychological assessment and a chronic pain assessment following a motor vehicle accident.

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

The Tribunal found that the applicant failed to prove she suffered from a psychological impairment or chronic pain that would remove her from the MIG, preferring the respondent's medical assessments which aligned with the family physician's clinical notes.

The Tribunal also found insufficient evidence that a pre-existing shoulder condition prevented maximal recovery.

The application was dismissed.

The applicant was injured in a motor vehicle accident and sought medical and rehabilitation benefits for physiotherapy.

The respondent denied the benefits 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 for removal from the MIG due to pre-existing conditions and chronic pain.

The Tribunal found insufficient evidence that the pre-existing conditions would prevent recovery under the MIG limit, and noted that the applicant's medical records showed significant improvement and a return to work.

The application was dismissed.

The applicant was struck by a truck's mirror while riding her bicycle and sought statutory accident benefits.

The respondent denied the claims, arguing the injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the applicant suffered a concussion, which falls outside the MIG, based on consistent reporting of symptoms and elevated SACT-2 scores.

The Tribunal also determined that the disputed physiotherapy treatment plans were reasonable and necessary to address the applicant's accident-related impairments.

The applicant sought statutory accident benefits for chiropractic and physiotherapy services following a motor vehicle accident.

The insurer denied the treatment plans based on its examination reports.

The Tribunal found that the applicant's contemporaneous medical records, including psychological assessments and family physician notes, demonstrated that the physical therapies were reasonable and necessary to address her accident-related impairments.

The Tribunal ordered the insurer to pay for the disputed treatment plans and interest on overdue payments, but denied the applicant's request for a special award under O. Reg. 664, finding no evidence of unreasonable conduct by the insurer.

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

The respondent denied certain medical benefits, arguing the injuries fell within the Minor Injury Guideline (MIG).

The applicant argued that psychological impairments and chronic pain removed him from the MIG.

The Tribunal preferred the respondent's psychological assessment, which utilized validity indices, over the applicant's assessment, which relied primarily on self-reporting.

The Tribunal found the applicant failed to prove his injuries were not predominantly minor, and therefore the disputed medical benefits, interest, and award were not payable.

The applicant sought statutory accident benefits following a 2013 motor vehicle accident.

The respondent insurer denied several treatment plans, arguing the applicant's injuries fell within the Minor Injury Guideline and that ongoing pain was related to a subsequent 2015 accident or a pre-existing 2005 accident.

The adjudicator found that the applicant's persistent pain was causally linked to the 2013 accident.

The tribunal approved the treatment plans for physiotherapy and chiropractic services as reasonable and necessary, and partially approved the disputed balance for a psychological assessment.

The claims for acupuncture and an orthotics assessment were dismissed for lacking sufficient evidentiary connection to the accident-related injuries.

Interest was awarded on the overdue benefits.