Jesse A. Boyce

The applicant was struck by a vehicle while riding his bicycle in 2013 but did not apply for statutory accident benefits until 2019.

The insurer denied the claim on the basis that the applicant failed to notify it of the accident and apply for benefits within the prescribed time limits.

The Tribunal found that the applicant's transient circumstances, including periods of incarceration, homelessness, severe mental illness, and addiction, provided a reasonable explanation for the delay under section 34 of the Schedule.

The applicant was permitted to proceed with his application.

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

The insurer denied the plan, arguing it was not reasonable and necessary.

The Tribunal found that the applicant failed to demonstrate the treatment was reasonable and necessary, noting that the most recent psychological assessment revealed no diagnosable condition and that the applicant's current complaints appeared related to a subsequent accident.

The application was dismissed.

The applicant sought statutory accident benefits following an incident where a driver struck her with his vehicle door and subsequently exited the vehicle to punch her in the face.

The respondent accepted that the first phase involving the vehicle door constituted an 'accident' under s. 3(1) of the Statutory Accident Benefits Schedule, but denied benefits for the psychological impairments resulting from the subsequent assault.

The Tribunal found that the incident was severable into two distinct phases.

Applying the Purpose and Causation tests, the Tribunal held that the assault was an intervening act that broke the chain of causation and did not arise out of the ordinary and well-known activities for which automobiles are used.

The applicant's claim for benefits related to the assault was dismissed.

The applicant was injured in a motor vehicle accident and sought a catastrophic impairment designation under s. 3.1(1)2(iii) of the Statutory Accident Benefits Schedule based on a temporary Spinal Cord Independence Measure (SCIM) score of four.

The respondent denied the claim, arguing the impairment must be permanent.

The Tribunal agreed with the respondent, finding that a plain reading and purposive analysis of the Schedule requires a permanent alteration of function, measured by a permanent SCIM score between zero and five.

As the applicant's mobility impairment was temporary, she did not meet the criteria for a catastrophic impairment.

The applicant insurer sought repayment of $5,600.00 in income replacement benefits (IRBs) paid to the respondent insured, alleging the respondent wilfully misrepresented his return-to-work status.

The respondent had returned to full-time employment but continued to receive IRBs for over three months without notifying the insurer.

The respondent did not make submissions at the written hearing.

The Tribunal found that the respondent's failure to report his return to work constituted wilful misrepresentation.

The Tribunal ordered the respondent to repay the $5,600.00 overpayment plus interest.

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

The insurer denied several physiotherapy treatment plans, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the applicant's pre-existing back pain was exacerbated by the accident, resulting in chronic pain that caused functional impairment, thereby warranting removal from the MIG.

The Tribunal approved one physiotherapy treatment plan for $1,197.00 as reasonable and necessary, but denied two subsequent plans due to a lack of evidence justifying their necessity.

The applicant's request for a special award under s. 10 was dismissed as the insurer's conduct was not unreasonable.

The applicant sought medical and rehabilitation benefits following a motor vehicle accident.

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

The applicant argued her injuries were not minor, citing chronic pain and psychological impairments.

The Tribunal found the applicant's physical injuries were predominantly soft-tissue sprains and strains.

Relying on the respondent's section 44 assessments, the Tribunal concluded the applicant failed to prove her impairments warranted treatment beyond the MIG.

The disputed treatment plans were deemed not reasonable and necessary, and the application was dismissed.

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

The respondent denied the treatment plans on the basis that they were not reasonable and necessary.

The Tribunal found that the applicant failed to meet his burden of proving that the proposed chronic pain program, orthopaedic assessment, psychological assessment, and physiotherapy treatments were reasonable and necessary, noting a lack of objective medical evidence and reliance on subjective complaints.

The application was dismissed, and claims for interest and a special award were denied.

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

The respondent insurer denied the treatment plans, arguing they were not reasonable and necessary.

The Licence Appeal Tribunal found that the applicant was entitled to payment for physiotherapy and psychological services, as the evidence supported ongoing chronic pain and psychological impairments.

However, the Tribunal dismissed the claims for occupational therapy, neuropsychology testing, speech language pathology, and a dietician's assessment, finding insufficient objective medical evidence to justify these expenses.

Interest was awarded on the overdue benefits.

The respondent was involved in a motor vehicle accident and received Income Replacement Benefits (IRBs) from the applicant insurer.

The respondent subsequently returned to full-time work but failed to notify the insurer and continued to claim and receive IRBs.

The respondent abandoned his initial application to the Tribunal, and the insurer proceeded with a claim for repayment of the overpaid IRBs.

The Tribunal found that the respondent's failure to report his return to work and his submission of an election form for IRBs while working constituted wilful misrepresentation.

The insurer was ordered to be repaid $4,431.14 pursuant to section 52 of the Statutory Accident Benefits Schedule.

The applicant sought attendant care benefits, chiropractic treatment, and a psychological assessment following a motor vehicle accident.

The adjudicator found the applicant was not entitled to attendant care benefits beyond the 104-week mark as she had not been deemed catastrophically impaired.

The chiropractic treatments and psychological assessment were deemed not reasonable and necessary based on section 44 assessments and the applicant's pre-existing conditions.

The application was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the respondent's determination that his injuries fell within the Minor Injury Guideline (MIG).

The applicant argued that pre-existing back and knee conditions warranted removal from the MIG.

The Tribunal found insufficient compelling medical evidence to link the pre-existing conditions to a delayed recovery or to prove the accident exacerbated them.

The Tribunal concluded the injuries were predominantly minor and dismissed the claim for a $2,727.40 chiropractic treatment plan, finding it was not reasonable and necessary.

The applicant sought payment for two chiropractic treatment plans totalling over $16,000 following a motor vehicle accident.

The applicant also brought a motion to add several new issues to the dispute after written submissions had closed.

The Tribunal dismissed the motion to add new issues, finding it would be procedurally unfair to the respondent.

On the substantive claims, the Tribunal found that the applicant had incurred all of the chiropractic expenses prior to submitting the required treatment plans (OCF-18s).

As none of the exceptions under s. 38(2) of the Schedule applied, the insurer was not liable to pay for the expenses.

The application was dismissed.

The applicant sought a medical benefit for physiotherapy treatment following a motor vehicle accident, along with interest and an award for unreasonable delay.

The adjudicator found that the applicant failed to demonstrate that the proposed treatment was reasonable and necessary, relying on the respondent's section 44 assessment which concluded the physical impairments were soft-tissue in nature and had reached maximal medical improvement.

As no benefits were payable, the claims for interest and an award were also dismissed.

The applicant sought a Non-Earner Benefit (NEB) following a motor vehicle accident but failed to submit a completed Disability Certificate (OCF-3) until 121 weeks after the accident.

The insurer denied the claim on the basis that the OCF-3 was submitted beyond the 104-week eligibility period.

The Tribunal held that the applicant was statute-barred from proceeding with the NEB claim under section 36 of the Schedule, as the benefit is not payable for any period prior to the submission of the OCF-3, and the 104-week eligibility period under section 12 had already expired.

The applicant's argument of having a reasonable explanation for the delay was rejected as irrelevant to the mandatory procedural requirements.

The applicant sought payment of $11,533.24 for the unapproved balance of a treatment plan (OCF-18) for multi-disciplinary catastrophic impairment assessments.

The insurer had partially approved the plan for $12,000.

The Tribunal found that the unapproved assessment items were needless bifurcations or duplications of assessments already conducted by the insurer, and the applicant failed to prove they were reasonable and necessary.

The Tribunal awarded $400 for the cost of completing the OCF-18 and OCF-19 forms, but denied the remainder of the claim.

The applicant sought income replacement benefits and various medical and rehabilitation benefits following a motor vehicle accident.

The adjudicator found that the applicant failed to prove a substantial inability to perform her pre-accident employment tasks, noting evidence that she had returned to work at multiple jobs with no loss of income.

The adjudicator also dismissed the claims for medical benefits, finding that the proposed treatments and assessments were not reasonable and necessary, relying in part on the respondent's medical examinations which concluded the applicant had reached maximum medical improvement.

The applicant sought statutory accident benefits for chiropractic treatment following a motor vehicle accident.

The respondent denied the benefits, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and that one treatment plan was statute-barred due to the applicant's failure to attend a section 44 insurer's examination.

The Tribunal found the applicant was statute-barred from claiming the $1,053.84 treatment plan because he failed to attend the properly scheduled examination without reasonable explanation.

Furthermore, the Tribunal held the applicant failed to prove he suffered from chronic pain warranting removal from the MIG.

As the MIG limits were exhausted, the claims for medical benefits and interest were dismissed.

The applicant was injured in a motor vehicle accident and initially received a non-earner benefit (NEB) before it was terminated by the insurer in 2016.

The applicant's condition later deteriorated, leading to a catastrophic impairment designation and a new application for NEB in 2018.

The insurer argued the claim was statute-barred under s. 56 of the Statutory Accident Benefits Schedule as the two-year limitation period from the 2016 denial had expired.

The Tribunal applied the discoverability doctrine from Tomec, finding the applicant's cause of action for the new NEB claim only accrued when her psychological condition deteriorated in 2018.

The Tribunal held the claim was not statute-barred and, alternatively, would have granted an extension under s. 7 of the Licence Appeal Tribunal Act.

The applicant was injured in a motor vehicle accident and sought medical benefits for physiotherapy beyond the $3,500 Minor Injury Guideline (MIG) limit.

The applicant argued that chronic neck pain and pre-existing degenerative disc disease warranted removal from the MIG.

The Tribunal found insufficient medical evidence to support a diagnosis of chronic pain causing functional impairment or to show that pre-existing conditions prevented maximal medical recovery within the MIG.

The application for the physiotherapy treatment plan, interest, and a bad faith award was dismissed.