Kathleen Wells

The applicant sought a non-earner benefit (NEB) following a motor vehicle accident.

The respondent denied the NEB but failed to provide the applicant with a benefit election form or clear notice of her requirement to elect between an income replacement benefit and an NEB, triggering the 'shall-pay' provisions of the Schedule.

However, the applicant failed to comply with the respondent's subsequent requests for information under s. 33.

The Tribunal ordered the respondent to pay the NEB for the period between the submission of the disability certificate and the applicant's non-compliance with s. 33, with interest.

The claim for an award for unreasonable delay was dismissed.

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

The applicant claimed entitlement to a non-earner benefit, various treatment plans, and an award for unreasonable delay.

The Tribunal found that the applicant failed to prove on a balance of probabilities that she suffered from a pre-existing condition, physical injuries, psychological impairment, or chronic pain with functional impairment that would warrant removal from the MIG.

The Tribunal also dismissed the claim for a non-earner benefit due to a lack of evidence regarding the applicant's pre- and post-accident activities.

As the applicant remained subject to the MIG, the treatment plans were not considered, and the application was dismissed in its entirety.

The applicant sought $798.00 for a physiotherapy treatment plan following a motor vehicle accident.

The respondent denied the benefit.

The Tribunal found that the applicant failed to prove the treatment was reasonable and necessary, as the supporting medical recommendation was over a year old and lacked contemporaneous evidence.

The Tribunal also dismissed the applicant's request for costs, finding the respondent's erroneous limitation defence did not meet the threshold for bad faith.

The applicant sought statutory accident benefits following a motor vehicle accident, including an income replacement benefit (IRB) and funding for chiropractic, physiotherapy, and psychological treatment plans.

The respondent denied the benefits, relying on insurer's examinations which concluded the applicant did not suffer a substantial inability to perform his pre-accident employment and that the proposed treatments were not reasonable and necessary.

The adjudicator found that the applicant failed to provide sufficient medical evidence to meet his burden of proof for the IRB and the treatment plans.

The adjudicator also dismissed the claims for interest and an award for unreasonable delay, as no benefits were found to be overdue or unreasonably withheld.

The application was dismissed in its entirety.

The applicant sought entitlement to various statutory accident benefits for psychological and chiropractic services, as well as an advanced X-ray assessment, following a motor vehicle accident.

The Licence Appeal Tribunal dismissed the application, finding that the applicant failed to meet her burden of proving on a balance of probabilities that the disputed treatment plans were reasonable and necessary.

The Tribunal preferred the evidence of the insurer's examination reports, which concluded the applicant had reached maximum medical improvement and suffered no ongoing accident-related impairment.

The applicant sought entitlement to several treatment plans for psychological, chiropractic, orthopedic, and TMJ services following a motor vehicle accident.

The Tribunal found that the applicant failed to meet her burden of proving that most of the treatment plans were reasonable and necessary, often due to a lack of corroborating medical evidence or failure to justify the costs and hourly rates claimed.

However, the Tribunal approved a $2,200 treatment plan for a chronic pain assessment, finding reasonable grounds based on contemporaneous medical records and a TMJ assessment report.

The claim for an award for unreasonable delay was dismissed.

The applicant sought statutory accident benefits following the death of his son in a motor vehicle accident.

The insurer denied the claims on the basis that the applicant was not a 'dependant' of the deceased under section 3(7)(b) of the Schedule.

The Tribunal found that the applicant was not principally dependent on his son for financial support or care, as the financial contributions from the son did not amount to 51% or more of the applicant's household expenses.

The Tribunal also dismissed the claim for funeral benefits because the applicant failed to prove he incurred the expenses.

The application was dismissed.

The applicant sought statutory accident benefits, including a death benefit and a psychological assessment, following the death of her son in a motor vehicle accident.

The respondent denied the benefits on the basis that the applicant was not a 'dependant' under s. 3(7)(b) of the Schedule.

The Tribunal applied the Miller factors and found that the applicant was not principally dependent on the insured for financial support or care, as the financial contributions from the insured did not amount to 51% or more of the applicant's household expenses.

The application was dismissed.

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 based on insurer examinations.

The Tribunal found that the applicant failed to meet his burden of proving the treatment plans were reasonable and necessary, placing greater weight on the contemporaneous insurer examination reports which concluded the applicant had reached maximum medical recovery and had no ongoing accident-related impairments.

The application was dismissed in its entirety.

The applicant was injured in a motor vehicle accident and sought various medical and rehabilitation benefits under the Statutory Accident Benefits Schedule, which the respondent insurer denied.

The Licence Appeal Tribunal reviewed seven treatment plans for physiotherapy, psychological treatment, and various assessments.

The Tribunal found that only the initial July 17, 2023 treatment plan for physiotherapy was reasonable and necessary, as it was supported by contemporaneous medical recommendations from the applicant's family doctor.

The remaining treatment plans were dismissed because the applicant failed to provide sufficient medical evidence or submissions to meet her burden of proof.

The applicant was awarded the cost of the approved physiotherapy plan plus interest on overdue payments.

The applicant sought statutory accident benefits following a motor vehicle accident but failed to notify the insurer or submit an application within the time limits prescribed by section 32(1) of the Schedule.

The insurer raised a preliminary issue that the claim was statute-barred.

The Tribunal found that the applicant's ignorance of the law did not constitute a reasonable explanation for the five-month delay, and that the delay prejudiced the insurer's ability to investigate the claim contemporaneously.

The application was dismissed as statute-barred.

The applicant sought statutory accident benefits following a 2014 motor vehicle accident.

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

The Tribunal found the applicant was barred from claiming a non-earner benefit because she failed to submit a disability certificate within 104 weeks of the accident.

The Tribunal also found the applicant was barred from claiming various treatment plans because she failed to dispute the insurer's valid denials within the two-year limitation period.

The Tribunal declined to extend the limitation period under section 7 of the Licence Appeal Tribunal Act, noting the applicant provided no evidence of an intention to appeal or explanation for the delay.

The application was dismissed.

The applicant, a minor struck by a car while riding a bicycle, sought statutory accident benefits including a non-earner benefit and funding for chiropractic treatment plans.

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

The Tribunal found the applicant failed to prove his injuries warranted removal from the MIG, as medical evidence indicated only soft tissue injuries.

The Tribunal also dismissed the claims for a non-earner benefit, finding insufficient evidence of a complete inability to carry on a normal life, and found the treatment plans were not payable.

The application was dismissed.

The applicant was involved in a motor vehicle accident and sought statutory accident benefits for various treatment plans, including physiotherapy and multiple assessments (FAE, in-home, orthopaedic, chronic pain, neurological, cognitive, and biopsychosocial).

The respondent denied the benefits based on insurer examinations which concluded the applicant sustained minor soft tissue injuries and contusions that did not warrant further treatment or assessment.

The Tribunal found that the applicant failed to provide contemporaneous medical evidence to corroborate his ongoing complaints and did not meet his burden to prove the treatment plans were reasonable and necessary.

The application was dismissed in its entirety, including claims for interest and an award for unreasonable delay.

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

The respondent denied several treatment plans, and the applicant applied to the Licence Appeal Tribunal.

The applicant argued that the respondent's explanation of benefits (EOB) notices were non-compliant with s. 38(8) of the Schedule, triggering payment under s. 38(11).

The Tribunal found that while one EOB was non-compliant, a subsequent EOB rectified the issue before the expense was incurred.

The remaining EOBs were found to be clear, unequivocal, and compliant with s. 38(8).

As the applicant provided no evidence regarding the reasonableness and necessity of the treatment plans, the application was dismissed in its entirety.

The applicant sought a Non-Earner Benefit (NEB), interest, and an award under the Statutory Accident Benefits Schedule following a motor vehicle accident.

The Licence Appeal Tribunal found that the applicant failed to prove a complete inability to carry on a normal life, noting inconsistencies in his self-reports and a lack of evidence regarding his pre-accident activities.

The Tribunal preferred the respondent's insurer examination reports over the applicant's psychological assessments, which failed to review medical records or delineate the impact of multiple accidents.

The application was dismissed in its entirety.

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

The Tribunal found that the applicant's injuries were predominantly minor and subject to the $3,500 Minor Injury Guideline (MIG) limit, as he failed to prove chronic pain with functional impairment.

The applicant's claim for a non-earner benefit was dismissed because the insurer's denial was compliant and there was no obligation to provide an election of benefits when the applicant was not eligible for multiple specified benefits.

However, the Tribunal ordered the insurer to pay for three chiropractic treatment plans pursuant to s. 38(11) of the Schedule, finding that the insurer's denial notices were insufficiently detailed and failed to comply with s. 38(8).

A claim for a psychological assessment was denied, and the request for an award for unreasonable delay was dismissed.

The applicant sought payment for various treatment plans (psychological, chiropractic, and orthopaedic assessment) following a motor vehicle accident.

The respondent denied the benefits.

The Licence Appeal Tribunal found that the applicant failed to meet his burden of proving the treatment plans were reasonable and necessary.

The applicant relied on an OCF-3 that was inconsistent with contemporaneous hospital records, and failed to provide sufficient medical evidence or submissions to support the claimed expenses.

The application was dismissed in its entirety, including claims for interest and an award.

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

The respondent insurer denied the benefits.

The Licence Appeal Tribunal dismissed the application, finding that the applicant failed to prove the treatment plans were reasonable and necessary.

The Tribunal preferred the evidence of the insurer's examination physician over the applicant's assessor, noting that the applicant's reports of pain were inconsistent and uncorroborated by contemporaneous clinical notes and records.

The applicant sought statutory accident benefits following a motor vehicle accident, including an income replacement benefit (IRB) and funding for an electrophysiological assessment.

The Licence Appeal Tribunal dismissed the application, finding the applicant failed to prove entitlement to either a pre-104 or post-104 week IRB due to a lack of evidence regarding employment or educational history.

The Tribunal also denied the treatment plan, noting the lack of detail, uncorroborated diagnosis, and hospital records indicating neurological results were within normal limits.

Claims for interest and an award were consequently dismissed.