Cynthia Pay

The applicant sought catastrophic impairment benefits following a motor vehicle accident.

The insurer requested five in-person insurer's examinations.

The applicant agreed to three but refused to attend an in-person physiatry examination and a cardiology examination, arguing they were excessive and unreasonable.

The insurer raised a preliminary issue that the applicant was precluded from proceeding with her application due to her non-compliance.

The Tribunal found that the in-person physiatry examination was not 'reasonably necessary' under section 44 of the Schedule, as it was overly intrusive and the insurer already had sufficient information from other assessments to conduct a paper review.

The applicant was permitted to proceed with her claim.

The applicant sought statutory accident benefits following a motor vehicle accident, including non-earner benefits, a chronic pain program, a chronic pain assessment, and psychological counselling.

The adjudicator dismissed the claim for non-earner benefits, finding that the applicant failed to prove a complete inability to carry on a normal life, as his post-accident limitations were largely similar to his pre-accident condition.

The claims for the chronic pain program and assessment were also dismissed because the applicant had a pre-existing diagnosis of chronic pain syndrome, and the medical evidence failed to establish that the accident materially contributed to it.

However, the adjudicator granted the claim for psychological counselling, finding that the accident materially contributed to an exacerbation of the applicant's pre-existing mental health symptoms, as supported by the respondent's own psychological expert.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for an in-home occupational therapy assessment and assistive devices.

The insurer initially denied the benefits on the basis that the injuries fell within the Minor Injury Guideline and the treatment plans were not reasonable and necessary.

At the hearing, the insurer conceded the injuries were outside the Minor Injury Guideline.

The adjudicator found that both treatment plans were reasonable and necessary to address the applicant's ongoing accident-related neck and back pain, granting the benefits less the cost of mileage.

The applicant sought to introduce an expert orthopaedic report two days before a written hearing, well past the deadline set by the Tribunal's order and the LAT Rules.

The respondent objected to the late submission.

The Tribunal found that while the late submission prejudiced the respondent, the report was relevant and necessary to determine the issues in dispute.

Applying Rule 3.1 to facilitate a fair process, the Tribunal admitted the report but granted the respondent 30 days to submit responding material and rescheduled the hearing.

The applicant, a pedestrian struck by a vehicle, applied to the Licence Appeal Tribunal for non-earner benefits and funding for various treatment plans.

The insurer denied the claims, arguing the applicant did not meet the test for non-earner benefits and that his injuries fell within the Minor Injury Guideline (MIG), for which the $3,500 limit had been exhausted.

The Tribunal found that the applicant failed to prove on a balance of probabilities that he suffered a complete inability to carry on a normal life, noting surveillance evidence and his ability to engage in many daily activities and work casually.

Furthermore, the Tribunal held that the applicant failed to provide medical evidence establishing a causal link between his back and shoulder issues and the accident to rebut the insurer's medical examination, thereby failing to prove his injuries fell outside the MIG.

The application was dismissed.

The applicant, a Quebec resident, was injured in a motor vehicle accident in Ontario.

She initially received income loss benefits from the Quebec SAAQ, which were later terminated.

She then applied for income replacement benefits in Ontario from the respondent insurer.

The respondent brought a preliminary issue motion arguing the applicant was precluded from claiming benefits in Ontario because she was a Quebec resident and the SAAQ was her primary source of benefits.

The Tribunal dismissed the respondent's motion, finding that the applicant met the definition of an 'insured person' under the Schedule because the accident occurred in Ontario.

The Tribunal held that the Schedule permits an insured person to claim benefits in Ontario even if they have received benefits in another jurisdiction, provided there is no double recovery for the same time period.

The applicant sought dispute resolution for non-earner benefits and two physiotherapy treatment plans following a motor vehicle accident.

The respondent insurer argued the applications were filed beyond the two-year limitation period.

The Tribunal found the non-earner benefits claim was statute-barred because the insurer provided a clear and unequivocal denial with proper dispute resolution information more than two years prior, and subsequent applications did not restart the clock.

However, the Tribunal found the treatment plan claims were not out of time because the insurer provided confusing and conflicting information in a later denial regarding the limitation period, which restarted the clock.

The treatment plan claims were permitted to proceed to a hearing.

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

The respondent insurer brought a preliminary motion to dismiss the application, arguing the applicant failed to submit a completed disability certificate because her doctor checked a box indicating she did not meet the test for the benefit.

The Tribunal dismissed the insurer's motion, finding that the applicant had clearly communicated her intention to apply for the benefit through the submitted forms, and prioritizing form over substance would violate the consumer protection purpose of the legislation.

The matter was permitted to proceed to a hearing.

The applicant, who sustained a catastrophic impairment, sought payment for mileage expenses incurred by his service providers travelling to his home for treatment.

The insurer denied the mileage claims, arguing the Statutory Accident Benefits Schedule (SABS) and related Guidelines do not require payment for provider travel costs.

The Licence Appeal Tribunal agreed with the insurer, finding that while the SABS explicitly covers transportation expenses for insured persons and their aides, it does not mandate payment for service provider mileage.

The application for mileage expenses was dismissed.