Jesse A. Boyce

The applicant insurer sought repayment of income replacement benefits (IRBs) paid to the respondent following a motor vehicle accident.

The insurer alleged the respondent failed to notify it of his return to work, resulting in an overpayment.

The respondent did not participate in the written hearing.

The Tribunal found the insurer met the requirements under section 52 of the Statutory Accident Benefits Schedule and ordered the respondent to repay $10,428.55 plus interest.

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

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

The applicant failed to provide submissions demonstrating that his injuries, including alleged chronic pain and pre-existing conditions, warranted removal from the MIG.

The Tribunal found the applicant did not meet his burden of proof.

As the MIG limits were exhausted, the treatment plan was not payable, and claims for interest and an award for unreasonable delay were dismissed.

The applicant sought medical benefits for physiotherapy following a motor vehicle accident.

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

The applicant claimed chronic pain in his right elbow warranted removal from the MIG.

The Tribunal found the applicant failed to demonstrate chronic pain causing functional impairment or meet the AMA Guides criteria.

The Tribunal concluded the injuries were predominantly minor, the treatment plans were not reasonable and necessary, and dismissed the claims for benefits, interest, and a section 10 award.

The applicant sought payment for a $2,189.98 treatment plan for physiotherapy and massage following a 2014 motor vehicle accident.

The respondent denied the claim.

The Licence Appeal Tribunal found that the applicant failed to prove the treatment was reasonable and necessary or incurred.

The applicant had previously received similar treatment with little reported benefit, and the medical evidence did not support the need for further facility-based treatment.

The application was dismissed.

Both the applicant and the respondent insurer requested a reconsideration of a Licence Appeal Tribunal decision regarding the calculation of income replacement benefits (IRBs).

The insurer argued the Tribunal erred by not deducting the applicant's $120,000 long-term disability (LTD) settlement from her IRBs, asserting it resulted in double recovery.

The applicant argued the Tribunal erred by refusing to grant a special award under s. 10 of O. Reg. 664 for unreasonable withholding of benefits.

The Vice-Chair dismissed both requests, finding no significant errors of law or fact.

The LTD settlement was a lump sum covering multiple heads of damages and could not be clearly apportioned as an income continuation benefit, and the insurer's conduct in disputing the claim was not excessive or unreasonable.

The applicant sought statutory accident benefits for a $4,470 physiotherapy treatment plan following a 2018 motor vehicle accident.

The insurer denied the plan on the basis that it was not reasonable and necessary, relying on an independent medical examination which concluded the applicant had reached maximal medical recovery.

The Tribunal agreed with the insurer, finding that the treatment plan was identical to a previously approved plan and the applicant failed to demonstrate why continued facility-based treatment was required given his pre-existing conditions and lack of objective accident-related impairments.

The application was dismissed, along with claims for interest and a special award.

Jevco Insurance sought repayment of $7,181.76 in Income Replacement Benefits (IRBs) paid to the respondent, alleging he made a material misrepresentation regarding his primary residence to secure lower insurance premiums.

The respondent failed to participate in the hearing.

The Tribunal found that the respondent intentionally misrepresented his address, living in Etobicoke rather than Ottawa, which resulted in a $3,990 reduction in his premium.

The Tribunal ordered the respondent to repay the IRBs with interest, plus $106 in costs.

The applicant insurer sought repayment of an income replacement benefit (IRB) in the amount of $3,257.14 from the respondent insured.

The respondent had returned to work but failed to notify the insurer, resulting in an overpayment.

The respondent did not participate in the written hearing.

The Tribunal found that the insurer met the requirements under section 52 of the Statutory Accident Benefits Schedule, having provided timely notice of the overpayment.

The Tribunal ordered the respondent to repay the IRB amount of $3,257.14 plus interest.

The applicant sought medical and rehabilitation benefits, the cost of an assessment, and the cost of a disability certificate following a motor vehicle accident.

The respondent agreed to fund the treatment plans but disputed the proposed hourly rates, which exceeded the maximums in the Superintendent's Guideline.

The Tribunal found that the insurer is not required to pay expenses exceeding the Guideline rates and approved the treatment plans at the applicable maximum hourly rates for chiropractors and physiotherapists.

The claims for a social work assessment and the cost of an additional disability certificate were dismissed as the applicant failed to prove they were reasonable and necessary.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits beyond the $3,500 Minor Injury Guideline (MIG) limit, claiming chronic pain and psychological impairments.

The Tribunal found insufficient evidence of a psychological condition or functional impairment caused by chronic pain to warrant removal from the MIG.

As the MIG limits were exhausted, the disputed treatment and assessment plans were not payable.

Claims for an award, interest, and costs were also dismissed.

The applicant insurer sought repayment of an overpayment of income replacement benefits (IRBs) in the amount of $8,650.60.

The respondent insured had returned to work but failed to notify the insurer, resulting in the overpayment.

The Tribunal found that the insurer complied with all procedural requirements under section 52 of the Statutory Accident Benefits Schedule and acted diligently upon discovering the return to work through a section 44 assessment report.

The Tribunal ordered the respondent to repay the overpayment amount plus applicable interest.

The applicant was injured in a motor vehicle accident and sought an income replacement benefit (IRB).

The insurer deducted the applicant's Employment Insurance (EI) sickness benefits from the IRB, arguing they constituted 'gross employment income' under the Statutory Accident Benefits Schedule.

The Tribunal found that the Schedule contains conflicting provisions regarding EI benefits but concluded that EI sickness benefits, unlike other EI benefits, are received in respect of an impairment and are specifically excluded from deduction under section 47(3).

The Tribunal ordered the insurer to pay the improperly deducted amount of $5,901.00 plus interest.

The applicant sought statutory accident benefits after sustaining injuries during an altercation that began when he was sitting in his running rental vehicle.

The respondent denied the claim on the basis that the incident was an assault, not an 'accident' under the Statutory Accident Benefits Schedule.

The Tribunal found that the dominant feature of the incident was an unprovoked assault, which constituted an intervening act that broke the chain of causation.

The application was dismissed as the incident did not meet the definition of an accident.

The applicant sought medical and rehabilitation benefits under the Statutory Accident Benefits Schedule following a motor vehicle accident.

The respondent insurer denied the treatment plans for chiropractic care, a psychological assessment, and a chronic pain assessment on the basis that they were not reasonable and necessary.

The Tribunal dismissed the application, finding that the applicant failed to meet his burden of proof.

The adjudicator relied on the insurer's section 44 examination reports, which found no objective evidence of ongoing accident-related impairments requiring the disputed treatments, and noted that the applicant's psychological and knee issues were pre-existing and well-documented.

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

The insurer denied a medical benefit claim, and the applicant applied to the Licence Appeal Tribunal.

The insurer raised a preliminary issue that the application was statute-barred under s. 56 of the Statutory Accident Benefits Schedule because it was not commenced within two years of a valid denial.

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

As the applicant filed the application outside the two-year period and provided no evidence of exceptional circumstances, the Tribunal held the application was statute-barred and dismissed the claim.

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

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

The applicant sought removal from the MIG based on chronic pain, psychological impairments, and a pre-existing headache condition.

The Tribunal found that the applicant failed to provide compelling medical evidence to justify removal from the MIG under section 18(2) or the AMA Guides criteria for chronic pain.

As the MIG limits were exhausted, the disputed treatment plans were deemed not reasonable and necessary, and claims for interest and a section 10 award were dismissed.

The applicant was injured in a motor vehicle accident and sought an income replacement benefit (IRB).

The respondent insurer delayed payment of the IRB for over a year despite receiving all necessary documentation.

The Tribunal found the insurer's conduct in handling the claim was imprudent, immoderate, and unyielding.

The Tribunal ordered a special award under s. 10 of O. Reg. 664 in the amount of $4,025.00, representing 25% of the total IRB payable, plus interest.

The applicant requested a reconsideration of a Tribunal decision that found her accident-related impairments fell within the Minor Injury Guideline (MIG) and denied her claims for an income replacement benefit (IRB) and various treatment plans.

The applicant argued the Tribunal made errors of fact and law, failed to provide sufficient reasons, and violated procedural fairness.

The Vice-Chair dismissed the request, finding no errors in the original adjudicator's assessment of the insurer's notices, the substantive denial of the IRB, or the handling of preliminary evidentiary issues.

The Vice-Chair also rejected the applicant's allegations of bias and advocacy by the original adjudicator.

The respondent insurer requested a reconsideration of a Tribunal decision that found the applicant was not subject to the Minor Injury Guideline and was entitled to a non-earner benefit and treatment plans.

The insurer argued the adjudicator erred in fact and law regarding causation, ignored medical evidence, and violated procedural fairness by not addressing costs.

The Vice-Chair dismissed the request, finding that while the adjudicator made a minor factual error regarding the withholding of medical records, it would not have changed the outcome.

The adjudicator properly applied the 'but for' test for causation and did not deny procedural fairness in declining to award costs against a successful and credible applicant.

The applicant sought an income replacement benefit (IRB) of $400 per week following a motor vehicle accident, claiming psychological and physical impairments prevented him from performing his essential tasks as an AutoCAD technician.

The respondent denied the claim, arguing the applicant returned to work immediately, was terminated for being a poor fit, and lacked objective medical evidence of disability.

The Licence Appeal Tribunal dismissed the application, finding the applicant failed to provide contemporaneous, objective medical evidence demonstrating a substantial inability to perform his pre-accident employment tasks during the disputed period.

As no benefits were payable, the claim for interest was also dismissed.