Jesse A. Boyce

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

The respondent insurer raised preliminary issues arguing the applicant was statute-barred from proceeding with claims for non-earner, medical, and attendant care benefits due to a failure to notify the insurer of the circumstances giving rise to the claim within seven days, and a failure to submit an application for attendant care within 104 weeks.

The Tribunal found the applicant had a reasonable explanation for the delay in providing notice and allowed the claims for non-earner and medical benefits to proceed.

However, the Tribunal found the applicant was barred from proceeding with the attendant care claim because she failed to submit a Form-1 within the 104-week period.

The applicant sought payment for a chiropractic treatment plan following a motor vehicle accident.

The insurer denied the plan based on an insurer's examination which concluded the applicant had reached maximum medical recovery and that further clinic-based treatment was not reasonable or necessary.

The Tribunal agreed with the insurer, finding that the applicant's condition was relatively mild, that he had achieved maximum therapeutic benefit from previous treatment, and that he had not demonstrated why further facility-based treatment was necessary over independent home-based exercises.

The claims for the treatment plan, interest, and a special award were dismissed.

The applicant sought medical and rehabilitation benefits and an income replacement benefit (IRB) following a motor vehicle accident.

The respondent denied the benefits, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and that he was self-employed, requiring different documentation for the IRB.

The Tribunal found that while the applicant's physical injuries were predominantly minor, his pre-existing chronic back pain prevented maximal medical recovery within the MIG, thereby removing him from its limits.

However, the Tribunal agreed with the respondent that the applicant was a self-employed "controlling mind" of his salon business, and dismissed the IRB claim because the applicant failed to provide sufficient documentation to calculate the benefit.

The claim for an award for unreasonable withholding of benefits was also dismissed.

The applicant was injured in a motor vehicle accident and sought the cost of various catastrophic impairment assessments.

The respondent insurer partially denied the treatment plan, arguing the assessments were not reasonable and necessary.

Following a written hearing, the adjudicator found that only the Functional Review Evaluation was reasonable and necessary to procure accurate digital measurements under the AMA Guides.

The remaining assessments, including the AMPS, collateral interview, file review, and consensus opinion, were deemed duplicative or not essential.

The applicant was awarded the cost of the Functional Review Evaluation plus interest.

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

The insurer denied the applicant's claim for a non-earner benefit on the basis that she was self-employed at the time of the accident and therefore eligible for an income replacement benefit instead.

The applicant applied to the Licence Appeal Tribunal more than two years after the denial.

The Tribunal found that the insurer's denial was clear and unequivocal, triggering the two-year limitation period.

The Tribunal also declined to extend the limitation period under section 7 of the Licence Appeal Tribunal Act, finding no compelling evidence of a bona fide intention to appeal within the time limit and noting the lack of merit in the claim given the applicant's self-employment status.

The application was dismissed as statute-barred.

The applicant sought post-104-week income replacement benefits (IRBs) following a 2013 motor vehicle accident.

The respondent insurer denied the claim, arguing the applicant failed to dispute its initial 2013 denial within the two-year limitation period.

The applicant argued the 2013 denial was not clear and unequivocal because it used the word 'eligible' rather than 'entitled' and he had not intended to apply for IRBs at that time.

The Tribunal found the 2013 denial was valid, clear, and unequivocal, triggering the limitation period.

The Tribunal also declined to extend the limitation period under section 7 of the LAT Act due to the significant four-year delay and lack of bona fide intention to appeal within the time limit.

The application was dismissed as statute-barred.

The applicant was injured in a motor vehicle accident and sought approval for psychological and physiatry assessments.

The insurer denied the treatment plans on the basis that they were not reasonable and necessary, noting that it had already approved nine other assessments related to a catastrophic impairment determination.

The Tribunal found that the requested assessments were duplicative and not reasonable and necessary given the comprehensive slate of assessments already approved.

The claims for the costs of examination and interest were dismissed.

The insurer's request for costs was also dismissed.

The applicant sought post-104-week income replacement benefits following a motor vehicle accident.

The respondent argued the claim was barred by res judicata and the expiry of the limitation period, as a previous Tribunal decision had already denied the applicant's entitlement to these benefits.

The Tribunal agreed, finding that the previous decision was a final judgment on the merits between the same parties.

Furthermore, the Tribunal declined to extend the limitation period under section 7 of the Licence Appeal Tribunal Act, noting the unreasonable delay, lack of bona fide intention to appeal, prejudice to the respondent, and lack of merit to the claim.

The applicant was injured in a motor vehicle accident and received income replacement benefits (IRBs) from the respondent.

The respondent later denied post-104-week IRBs based on several Insurer's Examinations.

The applicant applied to the Tribunal but withdrew the claim pending a catastrophic assessment, and the parties agreed to toll the limitation period.

The applicant failed to recommence the application before the tolling period expired.

The applicant argued the initial denial was invalid because the respondent failed to provide all examination reports to her treating practitioner under section 37(5) of the Schedule.

The Tribunal found the denial was clear and unequivocal, triggering the limitation period.

The Tribunal declined to extend the limitation period under section 7 of the LAT Act, finding the applicant was statute-barred from proceeding.

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

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

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

The Tribunal found that the applicant failed to prove on a balance of probabilities that he suffered from psychological impairments or chronic pain caused by the accident.

The Tribunal concluded the injuries were predominantly minor and treatable within the MIG.

Furthermore, the applicant was not entitled to a non-earner benefit as he did not suffer a complete inability to carry on a normal life, nor was the proposed chiropractic treatment reasonable and necessary.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for an adjustable mattress and a filing cabinet.

The respondent partially denied the treatment plan.

The Tribunal found that the adjustable mattress was reasonable and necessary to address the applicant's severe sleep disturbances and chronic pain, which were exacerbated by the accident.

However, the Tribunal found that the filing cabinet was not reasonable and necessary, as the applicant already possessed one and failed to demonstrate the necessity of an additional unit.

The applicant was awarded the cost of the mattress and interest on the overdue benefit.

The applicant was injured in a motor vehicle accident and sought payment for four physiotherapy treatment plans under the Statutory Accident Benefits Schedule.

Although the applicant had been removed from the Minor Injury Guideline for psychological reasons, the adjudicator found that the physical injuries were minor sprains and strains.

The applicant failed to provide objective medical evidence to prove the physical treatments were reasonable and necessary, relying only on a clinic letter and OHIP summary.

The adjudicator accepted the respondent's section 44 medical examination report, which concluded the applicant had reached maximum medical recovery physically.

The application was dismissed.

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

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

The Tribunal found that while the physical injuries were predominantly minor, the applicant demonstrated on a balance of probabilities that she sustained psychological impairments removing her from the MIG.

The Tribunal ordered payment for the psychological assessment and treatment plans, along with interest, but denied the chiropractic treatment plan as not reasonable and necessary.

The applicant sought post-104-week income replacement benefits following a motor vehicle accident.

The insurer denied the benefits based on insurer's examinations concluding the applicant did not suffer a complete inability to engage in suitable employment.

The Licence Appeal Tribunal dismissed the application, finding the applicant failed to provide sufficient recent medical evidence to rebut the insurer's expert reports and prove a complete inability to work.

Claims for interest and a special award were also dismissed.

The applicant requested a reconsideration of a decision that found him catastrophically impaired but denied post-104 income replacement benefits, attendant care, housekeeping, and a special award.

The applicant argued the denial of these benefits was logically inconsistent with the catastrophic impairment finding.

The adjudicator dismissed the request, finding no significant errors of law or fact in the original decision.

The adjudicator held that the applicant's psychological impairments, which warranted the catastrophic designation, did not preclude him from performing his pre-accident casual work, and that the attendant care and housekeeping benefits were properly denied as they were not incurred.

The applicant was struck by a streetcar as a pedestrian and sought a catastrophic impairment designation under the Statutory Accident Benefits Schedule due to psychological, emotional, and behavioural impairments.

The respondent denied the designation.

The Tribunal found that the applicant sustained a traumatic brain injury resulting in a Class 4 (Marked) impairment in the Adaptation domain under Chapter 14 of the AMA Guides.

The Tribunal preferred the evidence of the applicant's experts, noting the applicant's inability to cope with stressors, recurring need to escape uncontrolled situations, and suicidal ideations.

The Tribunal concluded the applicant sustained a catastrophic impairment and is entitled to extended medical and rehabilitative treatment limits.

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

The insurer suspended the IRB after eight months based on insurer's examinations.

The Licence Appeal Tribunal dismissed the application, finding the applicant did not suffer a substantial inability to perform the essential tasks of his pre-accident employment.

The Tribunal preferred the evidence of the insurer's medical assessors, noting significant symptom magnification, a lack of objective physical findings, and surveillance footage showing the applicant working at another job.

The insurer filed a request for reconsideration of a Tribunal decision that awarded the insured post-104 week attendant care benefits and deemed those benefits incurred.

The adjudicator granted the request, finding that the Tribunal made two significant errors of law.

First, the Tribunal lacked jurisdiction to award attendant care benefits beyond 104 weeks because the insured had not been designated as catastrophically impaired, as required by s. 20(2)(a) of the Schedule.

Second, the Tribunal erred in deeming the expenses incurred under s. 3(8) without making any finding that the insurer unreasonably withheld or delayed payment.

The decision was amended to limit attendant care benefits to the 104-week period and to require the insured to prove the expenses were actually incurred.

The applicant requested a reconsideration of a decision denying her income replacement benefits following a 2016 motor vehicle accident.

She argued the Tribunal made significant errors of fact regarding her credibility and sought to introduce a new medical report as new evidence.

The adjudicator dismissed the request, finding that even if the alleged factual errors regarding her disclosure of modified work and a prior back injury were corrected, the original decision was supported by objective medical evidence and would not have changed.

The motion to admit the new report was also dismissed as it could have been obtained earlier and was merely a new opinion based on existing file information.

The applicant sought statutory accident benefits for physiotherapy, chiropractic treatment, and the cost of completing an OCF-18 following a motor vehicle accident.

The Tribunal found the $2,495.48 treatment plan reasonable and necessary to assist in the applicant's recovery.

However, the $3,260.64 treatment plan was dismissed as the applicant was statute-barred under s. 55 for failing to attend an insurer's examination.

The claim for the cost of completing the OCF-18 was also dismissed as it did not meet the criteria under s. 25(1)3.

The Tribunal declined to order an award under s. 10 of O. Reg. 664, finding no evidence that the insurer acted in bad faith.