Melody Maleki-Yazdi

The respondent insurer brought a preliminary issue hearing seeking to bar the applicant from proceeding with his application to the Tribunal under s. 55(2) of the Statutory Accident Benefits Schedule, arguing he failed to attend scheduled insurer's examinations (IEs).

The applicant argued the IE notices did not comply with the Schedule.

The Adjudicator found that the IE notices for the attendant care and psychological assessments failed to provide sufficient 'medical and any other reasons' as required by s. 44(5) of the Schedule, and no notice was provided for the physiotherapy treatment plan.

Because the notices were non-compliant, s. 55(1)2 did not apply, and the applicant was not precluded from proceeding with his application.

The preliminary issue was dismissed.

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

The insurer denied several treatment plans and scheduled an insurer's examination (IE) for a psychological assessment, which the applicant failed to attend.

The applicant applied to the Licence Appeal Tribunal to dispute the denied benefits.

The Tribunal found that the applicant failed to provide a reasonable explanation for her non-attendance at the IE.

Consequently, pursuant to section 55 of the Statutory Accident Benefits Schedule, the applicant was statute-barred from proceeding with her application until she attended the examination.

The substantive issues were not considered.

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

The insurer denied payment for psychological services, arguing the provider failed to comply with an information request, and denied two chiropractic treatment plans as not reasonable and necessary.

The Tribunal found it had jurisdiction over the psychological services dispute and ordered payment, finding the provider had sufficiently complied with the information request.

The Tribunal dismissed the claims for chiropractic services, finding the applicant's injuries had resolved.

The Tribunal also granted a 25% award under Regulation 664 against the insurer for unreasonably delaying payment of the psychological services invoice.

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

The Licence Appeal Tribunal found that the applicant's right wrist impairment pre-dated the accident and was not caused by it.

The Tribunal granted the applicant's claims for a knee brace, chiropractic and physiotherapy treatment, a psychological assessment, and a chronic pain assessment, finding them reasonable and necessary.

However, the Tribunal dismissed the claims for income replacement benefits, finding the applicant did not suffer a substantial inability to perform his sedentary pre-accident employment as a debt collector.

The claim for attendant care benefits was also dismissed as the expenses were not incurred and the applicant was found to be independent with personal care tasks.

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

The insurer denied a treatment plan on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Licence Appeal Tribunal found that the applicant suffered from chronic pain, taking his injuries outside the MIG.

The Tribunal ordered the insurer to pay the $3,788.16 treatment plan for physiotherapy, massage therapy, chiropractic, and acupuncture treatment, finding it reasonable and necessary, along with interest on overdue payments.

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

The respondent denied a treatment plan for a chronic pain assessment, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) limit of $3,500.

The Tribunal found that the applicant suffered from chronic pain, removing her from the MIG.

The Tribunal ordered the respondent to pay $2,000 for the chronic pain assessment and interest on overdue payments, but denied the applicant's claim for an award under Regulation 664 as there was no evidence of unreasonable delay.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits, which the respondent insurer denied on the basis that her injuries fell within the Minor Injury Guideline (MIG).

The Licence Appeal Tribunal found that the applicant suffered from chronic pain, removing her from the MIG.

The Tribunal awarded medical benefits for two treatment plans and a chronic pain assessment, but denied a third treatment plan and a psychological assessment as duplicative.

The Tribunal also found the applicant suffered a substantial inability to perform the essential tasks of her pre-accident employment as a cleaner, entitling her to income replacement benefits.

A claim for a special award under Regulation 664 was dismissed.

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

The respondent insurer denied the claims, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and were subject to the $3,500 limit.

The Tribunal found that the applicant suffered from chronic pain and psychological impairments that caused functional disability, removing him from the MIG.

The Tribunal concluded that all disputed treatment plans, including chiropractic services, psychological services, and various assessments, were reasonable and necessary.

The applicant was awarded the claimed benefits and interest on overdue payments.

The applicant sought statutory accident benefits for physiotherapy and a chronic pain assessment following a motor vehicle accident.

The adjudicator found that the applicant's right hip injury was caused by a subsequent fall from a truck, not the accident.

Relying on the insurer's examination report, the adjudicator concluded that the applicant had already received adequate soft tissue rehabilitation and did not exhibit signs of chronic pain requiring further assessment.

The application was dismissed, and no benefits or interest were awarded.

The applicant was injured in a motor vehicle accident and sought a medical benefit of $10,600 for a chronic pain treatment program, which the respondent insurer denied.

The Licence Appeal Tribunal found that the applicant proved on a balance of probabilities that the treatment plan was reasonable and necessary, preferring the evidence of the applicant's experts who diagnosed chronic pain over the respondent's assessors who did not specifically evaluate for chronic pain.

The Tribunal ordered the respondent to pay for the treatment plan and interest on overdue amounts, but denied the applicant's request for a special award under Ontario Regulation 664, finding no evidence that the insurer unreasonably withheld or delayed payment.

The applicant was injured in a motor vehicle accident and sought medical benefits for chiropractic treatment.

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

The applicant argued that he suffered from chronic post-traumatic headaches and post-concussion syndrome, which would remove him from the MIG.

The Tribunal found that the applicant failed to prove on a balance of probabilities that he suffered from post-concussion syndrome, noting a lack of ongoing medical treatment and his quick return to full-time work.

The Tribunal concluded that the applicant's injuries were predominantly minor and dismissed the application.

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

The respondent denied the claims, arguing the injuries fell within the Minor Injury Guideline (MIG) and its $3,500 limit.

The Tribunal found that the applicant's pre-existing psychological issues were exacerbated by the accident, resulting in diagnoses of depression and anxiety that removed her from the MIG.

The Tribunal preferred the evidence of the applicant's psychologist over the respondent's insurer examination psychologist.

Consequently, the Tribunal ordered the respondent to pay for the disputed physical treatment, psychological assessment, and psychological treatment, finding them all to be reasonable and necessary, along with interest on overdue payments.

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

The respondent insurer denied the claims on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG).

The applicant argued that pre-existing injuries from a prior accident and chronic pain exempted him from the MIG.

The Tribunal found that the applicant's prior injuries had resolved before the subject accident and that he did not suffer from chronic pain causing functional impairment.

Consequently, the applicant failed to meet the onus of proving his injuries fell outside the MIG, and the application for benefits was dismissed.

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

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

The applicant argued she suffered from psychological impairments and chronic pain that removed her from the MIG.

The Tribunal preferred the evidence of the respondent's psychologist over the applicant's psychologist, finding the applicant did not suffer from a psychological impairment.

The Tribunal also found insufficient evidence of chronic pain caused by the accident.

The application was dismissed as the injuries fell within the MIG.

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

The respondent denied the claim for a psychological assessment on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG).

The applicant argued the respondent was barred from relying on the MIG because it failed to provide notice of denial within the 10-day period prescribed by section 38(8) of the Schedule.

The Tribunal found that the respondent sent the denial notice to the wrong address, meaning it was not received within the required timeframe.

Consequently, the respondent was prohibited from taking the MIG position and was required to pay for the incurred treatment.

The Tribunal adjusted the cost of the assessment to reflect the hourly rate of a psychometrist, as the assessment was conducted by a social worker rather than a psychologist.

The applicant sought statutory accident benefits for dental treatment plans totaling $4,310.00 following a motor vehicle accident.

The insurer denied the plans, arguing the applicant's temporomandibular joint (TMJ) issues were not caused by the accident.

The Licence Appeal Tribunal reviewed the medical evidence and found that the applicant had a pre-existing history of nocturnal teeth clenching and TMJ symptoms that were substantially similar to her post-accident complaints.

Applying the 'but for' test for causation, the Tribunal concluded the applicant failed to establish that her TMJ impairments were sustained as a result of the accident.

The application for medical benefits was dismissed.

The applicant sought payment for a neurological assessment and the disputed balance of a driving evaluation assessment following a motor vehicle accident.

The Tribunal found the neurological assessment was not reasonable and necessary, as the insurer's examination concluded injuries were soft tissue in nature and the applicant provided no corroborating expert evidence.

For the driving evaluation assessment, the Tribunal allowed the cost of preparation services but denied the costs for mental health counselling (which duplicated an earlier psychological assessment) and the treatment provider's mileage (which is not payable under the Schedule).