Jesse A. Boyce

The applicant was injured in a motor vehicle accident and sought payment for two chiropractic and physiotherapy treatment plans totaling approximately $4,000.

The insurer denied the plans based on an insurer's examination concluding the applicant had reached maximum medical recovery.

The Tribunal found the treatment plans were reasonable and necessary, preferring the evidence of the applicant's treating practitioners who diagnosed chronic pain and noted ongoing functional impairments.

The Tribunal ordered payment of the treatment plans with interest, but declined to order a special award, finding the insurer's reliance on its medical assessment was not unreasonable.

The applicant sought statutory accident benefits following a motor vehicle accident, claiming her physical and psychological impairments warranted removal from the Minor Injury Guideline (MIG).

The adjudicator found that the applicant's physical injuries were soft-tissue in nature and that she failed to demonstrate functionally disabling pain or a diagnosable psychological condition requiring treatment beyond the MIG.

The adjudicator preferred the respondent's expert reports, noting the applicant continued to work full-time and lacked corroborating medical evidence for her claims.

As the injuries fell within the MIG and the limits were exhausted, the claims for attendant care, medical benefits, and an award for unreasonable delay were dismissed.

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

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

The applicant argued that chronic pain and psychological impairments, including Adjustment Disorder and Specific Phobia, warranted removal from the MIG.

The Tribunal found that the physical injuries were soft-tissue in nature and that the applicant failed to provide sufficient medical evidence of functionally-disabling chronic pain or a diagnosable psychological impairment that would prevent maximal medical recovery within the MIG.

As the MIG limits were exhausted, the disputed treatment and assessment plans were deemed not reasonable and necessary, and the application was dismissed.

The applicant requested a reconsideration of a preliminary issue decision that found his claims for attendant care and housekeeping benefits were statute-barred.

The Tribunal originally held that the two-year limitation period began when the insurer pre-emptively denied the benefits in 2005, long before the applicant was determined to be catastrophically impaired in 2015.

Applying the recent Court of Appeal decision in Tomec, the adjudicator found that the doctrine of discoverability applies.

The applicant did not discover his eligibility for the benefits until he was deemed catastrophically impaired.

Therefore, the limitation period did not begin in 2005, and the applicant's claim is not statute-barred.

The reconsideration was granted.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits, including an income replacement benefit (IRB), medical benefits for physiotherapy and dental expenses, and education expenses.

The Licence Appeal Tribunal found that the applicant was not entitled to an IRB, relying on surveillance evidence that contradicted her claims of substantial inability to perform her pre-accident employment tasks.

However, the Tribunal granted the claims for physiotherapy and dental expenses, finding them reasonable and necessary and related to the accident.

The claims for education expenses and a special award were dismissed.

The applicant was injured in a motor vehicle accident and sought medical and rehabilitation benefits from the respondent insurer.

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

The applicant argued that her chronic back pain and psychological impairments warranted removal from the MIG.

The Tribunal found that the applicant's physical injuries were soft-tissue in nature and fell squarely within the MIG, and that she failed to provide compelling evidence of a pre-existing condition, a formal diagnosis of chronic pain, or a psychological impairment that would prevent maximal medical recovery within the MIG limits.

As the MIG funding was exhausted, the disputed treatment plans were denied.

The insurer brought an application to the Licence Appeal Tribunal seeking a determination that the insured was not catastrophically impaired and was not entitled to income replacement benefits, as well as seeking repayment of overpaid benefits.

The insured raised a preliminary issue arguing the Tribunal lacked jurisdiction because the insured had not disputed the insurer's determinations.

The Tribunal held that an insurer cannot bring an application to determine entitlement to benefits or catastrophic impairment where the insured has not disputed the insurer's denial, as no 'dispute' exists under s. 280 of the Insurance Act.

However, the Tribunal allowed the insurer's application for repayment of overpaid income replacement benefits to proceed.

The applicant was injured in a motor vehicle accident and sought medical and rehabilitation benefits, which the insurer denied on the basis that her injuries fell within the Minor Injury Guideline (MIG).

The Licence Appeal Tribunal found that while the applicant's physical injuries were predominantly minor, she demonstrated on a balance of probabilities that she suffers from chronic pain syndrome with a psychological component, warranting removal from the MIG.

The Tribunal ordered payment for one physiotherapy treatment plan, psychological assessment and treatment, and prescription expenses, finding them reasonable and necessary to address her chronic pain.

The remaining treatment plans and assessments were denied as redundant or unnecessary, and the claim for a special award was dismissed as the insurer had a genuine dispute.

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

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

The Tribunal found that the applicant's chronic pain and psychological impairments warranted removal from the MIG.

The Tribunal also held that the disputed physiotherapy treatment plan was reasonable and necessary, and awarded interest on overdue benefits.

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

The insurer denied certain medical and rehabilitation benefits, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that while the applicant's physical injuries were predominantly minor, his psychological impairments, including depression and post-traumatic stress symptoms, justified removal from the MIG.

The Tribunal ordered the insurer to pay for a psychological assessment but denied the claims for physiotherapy treatment, finding them not reasonable and necessary.

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

The insurer denied benefits beyond the Minor Injury Guideline and scheduled multiple s. 44 insurer's examinations, which the applicant failed to attend.

The insurer sought to dismiss the application under s. 55 of the Schedule.

The Tribunal held that the applicant could proceed with claims related to the MIG, a chronic pain assessment, and chiropractic treatment because he had attended the relevant physiatry examination.

However, the applicant was statute-barred from proceeding with his income replacement benefit claim due to his failure to attend reasonably necessary psychological and neurological examinations without a valid excuse.

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

The respondent insurer denied the treatment plans on the basis that the applicant's injuries were predominantly minor and subject to the Minor Injury Guideline (MIG) limit.

The Tribunal found that the medical evidence, including insurer's examinations and x-rays, consistently indicated the injuries were soft-tissue in nature and fell within the MIG.

The applicant failed to demonstrate that his physical or psychological impairments warranted treatment beyond the MIG.

The application was dismissed.

The applicant was injured in a 2005 motor vehicle accident and sought a catastrophic impairment determination in 2015.

The insurer denied the designation based on its own assessments.

The applicant sought funding for his own catastrophic assessments, which the insurer denied on the basis that the 2010 amendments to the Schedule eliminated funding for rebuttal reports.

The Tribunal held that while the 2010 amendments apply prospectively and eliminated rebuttal report funding, the applicant's requested assessments were actually his first assessments, not true rebuttals.

Denying funding would rob the applicant of his substantive right to be assessed.

The Tribunal found the assessments partially reasonable and necessary, awarding $10,500.00.

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

The insurer requested that the applicant attend several in-person section 44 insurer examinations to determine catastrophic impairment and ongoing income replacement benefit entitlement.

The applicant refused to attend, citing privacy concerns and arguing the notices were deficient.

The Tribunal found that the insurer's notices complied with the Schedule and that the requested examinations were reasonably necessary.

Consequently, the Tribunal held that the applicant was statute-barred under section 55 of the Schedule from proceeding with the application.

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

The respondent insurer denied the benefits on the basis that the applicant's injuries were predominantly minor and subject to the $3,500 limit under the Minor Injury Guideline (MIG).

The applicant argued that her physical injuries, pre-existing conditions, and psychological impairments warranted removal from the MIG.

The Tribunal found that the applicant's physical injuries were soft-tissue in nature and fell within the MIG.

The Tribunal also found insufficient evidence that any pre-existing conditions prevented maximal recovery or that the applicant suffered from a psychological impairment caused by the accident.

As the MIG limits were exhausted, the claims for treatment plans and assessments were dismissed.

The applicant requested a reconsideration of a preliminary issue decision that found his claim for post-104 income replacement benefits (IRBs) was statute-barred due to a pre-emptive denial by the insurer.

The adjudicator granted the reconsideration, applying the recent Court of Appeal decision in Tomec v. Economical.

The adjudicator found that the limitation period is tied to the accrual of the cause of action and subject to discoverability.

Because the applicant was working full-time and not eligible for IRBs at the time of the pre-emptive denial, the cause of action had not yet accrued.

The preliminary decision was reversed, allowing the applicant to proceed with his claim.

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

The insurer denied treatment plans for chiropractic care and a psychological assessment, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Licence Appeal Tribunal found that while the applicant's physical injuries were predominantly minor, she had demonstrated on a balance of probabilities that she sustained psychological and neurological impairments justifying removal from the MIG.

The Tribunal approved the $2,200 psychological assessment as reasonable and necessary, but denied the $2,095.28 chiropractic treatment plan, finding the physical complaints did not warrant further facility-based intervention.

The applicant sought income replacement benefits following a motor vehicle accident, which the respondent insurer denied.

The applicant filed her application with the Tribunal shortly after the two-year limitation period expired, arguing that the denial notice was defective and that courier delays caused the late filing.

The adjudicator found that the insurer's denial was clear and unequivocal, triggering the limitation period, and rejected the applicant's arguments regarding courier delays.

However, the adjudicator exercised discretion under section 7 of the Licence Appeal Tribunal Act to extend the limitation period, finding that the applicant had a bona fide intention to appeal, the delay was insignificant, there was no prejudice to the insurer, and the claim had potential merit.

The applicant was permitted to proceed with her claim.

The applicant was injured in a motor vehicle accident and sought payment for an orthopaedic assessment.

The respondent insurer denied the treatment plan, relying on an insurer's examination which concluded the assessment was not reasonable and necessary because the applicant was already being treated by an orthopaedic surgeon.

The Tribunal found the applicant's reports of pain were consistent and credible, and that the treating surgeon was only addressing her knee issues, not her whole-body pain.

The Tribunal concluded the orthopaedic assessment was reasonable and necessary to identify the source of her impairments and awarded the cost of $2,260.00 plus interest.

The applicant was injured in a motor vehicle accident and sought the cost of an accounting report prepared to calculate her Income Replacement Benefit (IRB).

The respondent denied the cost, arguing the calculation was straightforward and did not require a forensic accountant.

The Tribunal agreed with the respondent, finding that the applicant had only one source of income and the calculation merely required deducting short-term disability payments from the gross weekly income.

The Tribunal dismissed the claim, concluding the accounting report was not reasonable and necessary.