Kate Grieves

The applicant sought statutory accident benefits after slipping and falling in a parking lot while approaching his parked vehicle to temporarily repair a broken window.

The respondent denied benefits, arguing the incident did not meet the definition of an 'accident' under section 3(1) of the Statutory Accident Benefits Schedule.

The Tribunal applied the two-part test for an accident and found that the applicant was engaged in the ordinary and well-known activity of repairing his vehicle.

The Tribunal concluded that the use of the vehicle was a direct cause of the applicant's injuries, satisfying the definition of an accident.

The applicant sought statutory accident benefits after being attacked with a baseball bat by an assailant while sitting in his parked van.

The respondent denied benefits on the basis that the incident was not an 'accident' under section 3(1) of the Statutory Accident Benefits Schedule.

The Tribunal applied the purpose and causation tests, finding that while sitting in a parked vehicle meets the purpose test, the assault was an intervening act that broke the chain of causation.

The Tribunal concluded that the assault, not the use or operation of the vehicle, was the dominant feature and direct cause of the applicant's injuries.

The application was dismissed.

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

The respondent denied benefits and requested the applicant attend insurer's examinations under section 44 of the Schedule.

The applicant failed to attend, arguing she did not receive the notices due to a change of address.

The Tribunal found the notices were properly served on the applicant's legal representative.

As the applicant failed to comply with section 44, she was barred from proceeding with her application under section 55 of the Schedule.

The application was dismissed.

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

The respondent insurer denied benefits and scheduled insurer's examinations (IEs) to assess entitlement to medical benefits and non-earner benefits.

The applicant failed to attend the IEs.

The respondent argued the applicant was barred from proceeding with his application under section 55 of the Schedule.

The Tribunal found that the notices of examination for the medical benefits did not comply with section 44(5) as they lacked sufficient medical or other reasons.

However, the notices for the non-earner benefits were compliant.

Therefore, the applicant was permitted to proceed with his claim for medical benefits but barred from proceeding with his claim for non-earner benefits.

The applicant sought statutory accident benefits after slipping and falling on wet grass while approaching his parked vehicle to cover a broken window with garbage bags.

The respondent denied benefits, arguing the incident did not meet the definition of an 'accident' under section 3(1) of the Statutory Accident Benefits Schedule.

The Tribunal applied the two-part test from Caughy and found that attempting to repair a parked vehicle is an ordinary and well-known activity to which automobiles are put.

The Tribunal concluded that the use of the vehicle was a direct cause of the applicant's injuries, satisfying the causation test, and ruled that the incident was an accident.

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

The respondent denied the benefits and raised a preliminary issue that the applicant failed to notify them of his intention to claim benefits within seven days of the accident, as required by section 32(1) of the Schedule.

The applicant notified the respondent approximately six months after the accident and provided no explanation for the delay.

The adjudicator found that the applicant failed to establish a reasonable explanation for the delay under section 34.

Consequently, the applicant is statute-barred from proceeding with his application pursuant to section 55(1)1 of the Schedule, and the application was dismissed.

The applicant requested a reconsideration of a preliminary issue decision which found her application statute-barred for failing to dispute a denial within the two-year limitation period.

The applicant argued the Tribunal erred in finding the denial notice was valid and triggered the limitation period.

The adjudicator dismissed the request, finding no error in the original decision that the denial was clear, unequivocal, and sufficient to trigger the limitation period, and that the applicant was merely attempting to re-litigate the issues.

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

The respondent denied the benefit and raised a preliminary issue that the applicant failed to submit a completed disability certificate (OCF-3) within 104 weeks of the accident.

The Tribunal found that the OCF-3 was not submitted until 240 weeks after the accident.

Applying the Statutory Accident Benefits Schedule, the Tribunal held that the failure to submit the OCF-3 within the 104-week period barred the claim.

The application was dismissed.

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

The respondent insurer denied the claims, and the applicant applied to the Tribunal more than two years after the denials.

The preliminary issue was whether the claims were statute-barred under s. 56 of the Schedule.

The Tribunal found that the denial notice for non-earner benefits was defective as it lacked specific medical reasons, meaning the limitation period was not triggered for that claim.

However, the denial notices for the treatment and assessment plans were valid and triggered the limitation period.

As the applicant did not file within two years and provided no grounds for an extension under s. 7 of the Licence Appeal Tribunal Act, the claims for the treatment and assessment plans were statute-barred.

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

The insurer denied the benefits, and the applicant applied to the Licence Appeal Tribunal.

The insurer raised a preliminary issue that the application was statute-barred because it was filed beyond the two-year limitation period under section 56 of the Statutory Accident Benefits Schedule.

The Tribunal found that the insurer had issued valid denial notices for all disputed benefits, triggering the limitation periods.

As the application was filed after the limitation periods expired and the applicant provided no submissions to justify an extension, the Tribunal dismissed the application as statute-barred.

The applicant sought a non-earner benefit following a motor vehicle accident but failed to submit a completed disability certificate (OCF-3) until July 21, 2023.

The insurer denied the benefit for the period prior to the submission of the OCF-3.

The Licence Appeal Tribunal held that under section 36 of the Statutory Accident Benefits Schedule, no non-earner benefit is payable for any period before the OCF-3 is submitted.

The application was dismissed.

The applicant sought statutory accident benefits following a 2019 motor vehicle accident.

The respondent insurer denied benefits and argued the applicant was barred from proceeding to the Tribunal because she failed to submit an application for benefits (OCF-1) within 30 days of receiving the forms, as required by section 32(5) of the Schedule.

The applicant claimed she had submitted the form and alternatively argued her pre-existing brain injury provided a reasonable explanation for any delay.

The Tribunal found the applicant's explanation was not credible, noting a further six-month delay in submitting the OCF-1 even after she retained counsel and was explicitly advised the form was missing.

The application was dismissed pursuant to section 55(1) of the Schedule.

The applicant sought income replacement benefits following a motor vehicle accident.

The insurer argued the application was barred by the two-year limitation period under section 56 of the Schedule, relying on a January 2020 letter that ceased benefits but requested further paystubs to calculate possible benefits owed.

The Tribunal found the denial letter was ambiguous and failed to meet the clear and unequivocal standard required by Smith v. Co-operators.

As the limitation period was not validly triggered, the applicant was permitted to proceed to a hearing.

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

The insurer denied income replacement benefits and two treatment plans in April 2021.

The applicant filed an application with the Licence Appeal Tribunal in May 2024, beyond the two-year limitation period.

The Tribunal found that the insurer's denial notices were valid and compliant with the Schedule.

As the applicant provided no submissions to justify extending the limitation period, the Tribunal dismissed the application as statute-barred.

The applicant sought statutory accident benefits following a motor vehicle accident that occurred while she was in the course of her employment as a delivery driver.

The insurer denied benefits on the basis that the applicant was entitled to Workplace Safety and Insurance Board (WSIB) benefits.

The Tribunal held a preliminary issue hearing to determine if the claim was barred under section 61 of the Schedule.

The applicant failed to file submissions or provide evidence that she had elected to bring a tort action under section 30 of the Workplace Safety and Insurance Act.

Consequently, the Tribunal found the applicant was barred from pursuing her claim for accident benefits and dismissed the application.

The applicant sought statutory accident benefits following a motor vehicle accident while he was a passenger in a stolen truck.

The Tribunal found that the applicant knew or ought to have known the vehicle was stolen, barring him from receiving income replacement benefits under section 31 of the Schedule.

The Tribunal also determined that the applicant did not sustain a catastrophic impairment, preferring the respondent's expert evidence that the applicant's mental and behavioural issues, including substance abuse, predated the accident.

All claims for benefits, interest, and awards were dismissed.

The respondent was awarded $300 in costs due to the applicant's unreasonable conduct in failing to attend cross-examination.

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

The insurer raised three preliminary issues: failure to submit the OCF-1 on time, material misrepresentation regarding a change of address, and failure to attend insurer's examinations.

The Tribunal found the applicant was not barred for the OCF-1 delay as the insurer argued the wrong statutory provision.

However, the Tribunal held the applicant intentionally failed to disclose her move from Hamilton to Toronto, constituting a material change in risk, thereby barring her claim for income replacement benefits.

The applicant was also barred from claiming a biopsychosocial assessment due to her unexcused failure to attend scheduled insurer's examinations.

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

The respondent denied benefits and raised preliminary issues regarding the applicant's failure to notify the insurer and submit the application for benefits (OCF-1) within the prescribed timelines.

The Tribunal found that while the applicant provided timely notice, he failed to submit the OCF-1 within 30 days of receiving the forms.

The applicant argued that his recovery from a recent heart surgery and other pre-existing health issues provided a reasonable explanation for the delay.

The Tribunal rejected this argument, finding no medical evidence that his conditions prevented him from completing the application.

The application was dismissed as statute-barred.

The applicant was involved in a motor vehicle accident on December 29, 2022, but did not notify the respondent insurer of his intention to claim accident benefits until May 3, 2023.

The respondent denied benefits on the basis of late notification.

The Tribunal held a preliminary issue hearing to determine if the applicant was statute-barred.

The Tribunal found that the applicant failed to provide a reasonable explanation for the delay, as the only evidence submitted was an incomplete disability certificate that did not identify specific injuries or explain how they prevented timely notification.

The application was dismissed as statute-barred pursuant to section 55(1)1 of the Schedule.

The applicant sought statutory accident benefits following a motor vehicle accident while a passenger in a stolen truck.

The Tribunal found that the applicant knew or ought to have known the vehicle was stolen, barring him from receiving income replacement benefits under section 31(1)(c) of the Schedule.

The Tribunal also determined that the applicant did not sustain a catastrophic impairment under Criterion 8, preferring the respondent's medical assessments which indicated his mental and behavioural impairments were largely pre-existing and related to longstanding substance abuse.

The applicant's claims for benefits, interest, and an award were dismissed, and costs of $300 were awarded to the respondent due to the applicant's failure to attend cross-examination.