Melanie Malach

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

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

The Tribunal found the applicant had a documented pre-existing chronic back condition that prevented maximal medical recovery under the MIG, removing him from its limits.

The Tribunal approved a 2021 treatment plan for physiotherapy and chiropractic services as reasonable and necessary, but denied a 2024 treatment plan due to a lack of contemporaneous medical evidence.

Claims for a non-earner benefit and a special award for unreasonable delay were dismissed.

The applicant was a passenger on a public transit bus involved in an accident and sought statutory accident benefits.

She failed to notify the respondent of her intention to apply for benefits within the seven-day period prescribed by s. 32(1) of the Schedule, waiting over four months to do so.

The Tribunal found that the applicant did not provide a reasonable explanation for the delay under s. 34, noting she had access to legal counsel and was familiar with the accident benefits process from a prior claim.

Consequently, the applicant was statute-barred from proceeding with her application under s. 55(1) of the Schedule, and the application was dismissed.

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

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

The Tribunal found that the applicant suffered from a chronic pain condition with functional impairment, warranting removal from the MIG.

The Tribunal approved five physiotherapy treatment plans proposed by Active Therapy Works as reasonable and necessary, supported by the treating physician's records.

However, a treatment plan from The Rehab Centre was denied due to insufficient medical evidence.

The applicant was awarded interest on the approved overdue benefits.

The applicant sought entitlement to income replacement benefits (IRBs) and various medical and rehabilitation benefits following a motor vehicle accident.

The Tribunal found the applicant was entitled to pre-104-week IRBs due to psychological impairments, including driving anxiety, which caused a substantial inability to perform her pre-accident employment.

However, she was not entitled to post-104-week IRBs as she failed to prove a complete inability to engage in suitable employment.

The Tribunal also approved treatment plans for chiropractic and massage therapy but denied an orthopaedic assessment and an enhanced hourly rate for a psychotherapist providing psychological services.

The applicant sought statutory accident benefits after an incident where her shopping cart struck a trolley of plants outside a grocery store, causing the trolley to fall.

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

The Licence Appeal Tribunal found that while the applicant was using her vehicle for the ordinary purpose of grocery shopping, the use or operation of the vehicle did not directly cause her injuries.

The falling trolley was an intervening act and the dominant feature of the incident.

The application was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, including income replacement benefits (IRBs) and three treatment plans.

The respondent denied the benefits.

The Tribunal found the applicant was entitled to IRBs from February 4, 2023, onward, calculating the quantum based on the applicant's pre-accident bi-weekly income and deducting Long-Term Disability and Canada Pension Plan benefits.

However, the Tribunal denied the three treatment plans for an orthopedic assessment, physical rehabilitation, and a general practitioner assessment, finding the applicant failed to prove they were reasonable and necessary.

The Tribunal preferred the respondent's insurer's examination reports, which concluded the applicant's injuries were minor soft tissue injuries.

Interest was awarded on overdue IRBs.

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

She submitted her OCF-1 application seven months post-accident, well beyond the 30-day time limit prescribed by section 32(5) of the Schedule.

The respondent denied the claim due to non-compliance.

The Tribunal found that the applicant failed to provide a reasonable explanation for the delay, rejecting her claims of mental health issues and ignorance of the law.

The application was dismissed as statute-barred.

The insurer applied to determine whether it validly suspended the insured's non-earner benefits for failing to submit an updated disability certificate and attend insurer's examinations.

The insured raised a preliminary issue, arguing the insurer was barred by res judicata because a prior Tribunal decision had found the insured entitled to non-earner benefits.

The Tribunal held that res judicata did not apply because the current application raised a different question—the validity of a subsequent suspension for non-compliance—rather than the initial procedural denial.

The insurer was permitted to proceed to a hearing.

The insurer applied to the Licence Appeal Tribunal for repayment of income replacement benefits paid to the insured, alleging wilful misrepresentation of pre-accident employment and income.

The insured did not participate in the written hearing.

The Tribunal found that the insured had never been employed by the stated employer and had wilfully misrepresented his employment status.

The insurer was awarded repayment of $15,069.57 plus applicable interest.

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

The respondent denied a treatment plan for psychological services, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the applicant failed to provide sufficient medical evidence to prove her physical or psychological injuries warranted removal from the MIG.

Consequently, the applicant was not entitled to the disputed treatment plan or interest.

The application was dismissed.

The applicant sought statutory accident benefits for home modifications totaling $777,467.00 following a motor vehicle accident that resulted in a spinal cord injury.

Prior to the submission of the treatment plan, the applicant's family sold their pre-accident home and purchased a new bungalow.

The Tribunal found that the proposed modifications were for a home the applicant no longer resided in, and no assessment was provided for the new bungalow.

The Tribunal dismissed the application, concluding the applicant failed to prove the modifications were reasonable and necessary, and denied claims for interest and a special award.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the insurer's denial of treatment plans for chiropractic services, an occupational therapy assessment, and neurological assessments.

The insurer argued the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found the applicant suffered a concussion and ongoing impairments, removing her from the MIG.

The Tribunal granted the chiropractic treatment plans and one neurological assessment, finding them reasonable and necessary, but denied the occupational therapy assessment and a second neurological assessment due to lack of evidence or duplication.

Interest was awarded on the overdue benefits.

The applicant was injured in a motor vehicle accident while in the course of his employment and initially elected to receive WSIB benefits.

Over 18 months later, he submitted an application for statutory accident benefits (OCF-1) to the respondent insurer.

The respondent denied the claim on the basis that the application was submitted outside the prescribed timelines.

The Licence Appeal Tribunal found that the applicant failed to provide a reasonable explanation for the delay, rejecting his argument that he was waiting to determine if his injuries met the tort threshold.

Consequently, the applicant was statute-barred from proceeding with his application for benefits, and the application was dismissed.

The applicant sought attendant care benefits, interest, and an award following a motor vehicle accident.

The Tribunal found that the applicant was not entitled to additional attendant care benefits because the 260-week period for claiming such benefits had expired and the non-catastrophic monetary limit of $65,000 had been exhausted.

The applicant's preliminary motion to exclude the respondent's Insurer Examination report was also denied because the applicant had attended and participated in the examination without protest.

The application was dismissed.

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

The respondent argued the applicant was barred from proceeding because she submitted her OCF-1 application beyond the 30-day time limit under section 32(5) of the Schedule.

The Tribunal found that the applicant had a reasonable explanation for the delay under section 34, as she was experiencing significant psychological impairments, including depression and anxiety, which limited her ability to complete the forms.

Furthermore, the respondent had implicitly granted an extension and accepted the late forms without immediate objection.

The applicant was permitted to proceed to a substantive hearing.

The applicant sought entitlement to a $2,460 treatment plan for an orthopedic assessment following a motor vehicle accident.

The insurer denied the plan based on insurer's examinations (IEs) concluding the applicant's injuries fell within the Minor Injury Guideline and the assessment was not reasonable and necessary.

The Tribunal dismissed the application, finding the applicant failed to provide contemporaneous medical records supporting ongoing complaints and gave little weight to the applicant's expert who conducted a virtual assessment based solely on self-reporting.

The Tribunal accepted the in-person IE assessments which found only minor soft tissue injuries.

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

The respondent denied several treatment plans and attendant care benefits.

The Tribunal found that the applicant was barred from proceeding with claims for three treatment plans because she failed to attend scheduled insurer's examinations without a reasonable explanation.

The Tribunal also dismissed the claim for a functional cognitive assessment, finding the respondent's denial notice complied with the Schedule.

The claim for attendant care benefits was dismissed for lack of evidence and failure to attend examinations.

Interest was awarded on previously resolved treatment plans, but the claim for an award for unreasonable delay was dismissed.

The applicant sought payment of $45,054.65, representing the balance of her medical and rehabilitation policy limits following a 2014 motor vehicle accident.

The respondent insurer argued the Tribunal lacked jurisdiction because there was no specific denied benefit or treatment plan in dispute.

The adjudicator agreed, finding that under s. 280 of the Insurance Act, the Tribunal's jurisdiction is triggered only by a dispute over a denied benefit.

As the applicant had not submitted a claim for a specific benefit that was denied, there was no dispute.

The application was dismissed for lack of jurisdiction.

The applicant was involved in a motor vehicle accident and sought statutory accident benefits under his sister's insurance policy.

The respondent denied coverage, arguing the applicant was not principally dependent on his sister for care.

The Tribunal found that the applicant, a student living away from home, maintained his permanent residence with his sister and relied on her for physical and emotional support.

The Tribunal concluded the applicant was principally dependent for care on his sister and is therefore an insured person under the policy.

The applicant sought attendant care benefits under the "deemed incurred" provision of s. 3(8) of the Schedule, arguing the respondent unreasonably denied her claim by initially taking the position she was not involved in an "accident".

The Tribunal found that the respondent's initial denial was not unreasonable given the nuanced factual and legal issues surrounding the bicycle incident.

Furthermore, the applicant failed to prove that she did not incur the attendant care expenses because of the respondent's denial.

The application for attendant care benefits, interest, and an award was dismissed.