Michael Beauchesne

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

The respondent denied the benefit on the basis that it never received the required Disability Certificate (OCF-3).

The Tribunal found that the applicant failed to provide sufficient evidence, such as a fax transmission report, to prove the OCF-3 was submitted to the respondent prior to the expiry of the 104-week claim period.

As the OCF-3 was only provided with the applicant's hearing submissions, well past the expiry of the claim period, the applicant was not entitled to the benefit under section 36(3) of the Schedule.

The application was dismissed.

The applicant was involved in a 2015 motor vehicle accident and sought statutory accident benefits.

A preliminary issue hearing was scheduled after the respondent brought a motion to vacate the original videoconference hearing.

Subsequently, the respondent withdrew the preliminary issue and the parties sought to address the substantive denials.

The adjudicator ordered the written hearing on the preliminary issue vacated and directed that a case conference be scheduled to confirm the remaining issues in dispute and make hearing arrangements.

The applicant sought statutory accident benefits following a motorcycle accident.

The respondent denied benefits, arguing the applicant's policy was cancelled prior to the accident and he was excluded under s. 31(1)(a)(i) of the Schedule for driving without insurance.

The Tribunal found the respondent validly terminated the policy by registered mail and the applicant ought reasonably to have known he was uninsured.

Furthermore, the Tribunal dismissed the applicant's claims for various medical benefits and treatment plans, finding the applicant failed to provide sufficient medical evidence to prove the plans were reasonable and necessary.

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

The respondent denied the claim on the basis that the applicant's husband, who was driving the vehicle at the time of the accident, was an excluded driver under the policy.

The Tribunal found that the applicant and her husband intentionally failed to notify the respondent of a material change in risk, barring the applicant from claiming an IRB under section 31(b) of the Schedule.

However, the Tribunal awarded the applicant $2,500 for an accounting report expense incurred to calculate the IRB quantum, finding it was reasonable and necessary at the time it was obtained.

The applicant's claim for an award for unreasonable delay was dismissed.

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

The respondent insurer failed to pay the benefit, provide a notice of medical or other reasons for denial, or request further information directly from the applicant within 10 days of receiving the disability certificate, as required by s. 36(4) of the Statutory Accident Benefits Schedule.

The Licence Appeal Tribunal held that the respondent's failure to comply with s. 36(4) triggered s. 36(6), obligating the respondent to pay the IRB from the date the application was received until proper notice is given.

The applicant's claim for an award for unreasonable delay was dismissed due to a failure to disclose particulars.

The applicant sought statutory accident benefits following a motor vehicle accident, arguing that his injuries warranted removal from the Minor Injury Guideline (MIG) due to chronic pain.

The applicant relied on an independent assessment diagnosing chronic pain syndrome based on the 4th Edition of the AMA Guides.

The Tribunal rejected this evidence, preferring the 6th Edition of the Guides which requires three criteria to be met, and found the medical evidence did not substantiate the claimed functional limitations.

The Tribunal concluded the applicant's injuries were predominantly minor soft-tissue strains.

As the applicant remained in the MIG and failed to prove the disputed treatment plans for physiotherapy and a chronic pain assessment were reasonable and necessary, the application was dismissed.

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

The matter proceeded to a written hearing, but the applicant failed to submit any evidence or written submissions.

The adjudicator dismissed the application, finding that the applicant failed to meet the evidentiary burden to prove impairment or the reasonableness and necessity of the claimed medical benefits.

Claims for interest and a Section 10 award were also dismissed as no benefits were payable.

The applicant sought a determination of catastrophic impairment following a 2013 motor vehicle accident, claiming impairments under Criteria 7 and 8 of the Statutory Accident Benefits Schedule.

The Tribunal found that the applicant's medical evidence, primarily from a psychiatrist and a psychologist, was insufficient to establish either a 55% whole person impairment or a marked/extreme impairment in any domain of functioning.

The application was dismissed, and claims for housekeeping benefits, an award, and interest were consequently denied.

The applicant was injured in a motor vehicle accident and sought an income replacement benefit (IRB) beyond the 104-week mark, claiming a complete inability to work due to severe psychological impairments, including PTSD and psychosis.

The Licence Appeal Tribunal found the applicant's psychiatric evidence persuasive and concluded she met the test for post-104 IRBs.

The Tribunal also found the insurer unreasonably delayed paying the pre-104 IRB for approximately four years despite having all necessary information, and ordered a 20% award on the pre-104 IRB amount under Regulation 664.

The claim for an award on the post-104 IRB was dismissed.

The applicant sought a catastrophic impairment designation and approval for various treatment plans following a motor vehicle accident.

The Licence Appeal Tribunal found that the applicant did not meet the threshold for catastrophic impairment, as he only demonstrated marked impairment in two of the required three areas of function (social functioning and adaptation).

The Tribunal approved several treatment plans, including occupational therapy, psychological therapy, and a mobile phone, finding them reasonable and necessary to address the applicant's accident-related impairments.

Other treatment plans, including those for optometric services and a computer, were denied.

The applicant sought a determination of catastrophic impairment under Criterion 8 (mental or behavioural disorder) following a motor vehicle accident.

The Tribunal found that the applicant's multidisciplinary catastrophic impairment evaluation was not conducted by a physician as required by the Schedule, as the physicians merely rubber-stamped the findings of a neuropsychologist and an occupational therapist.

Because a neuropsychologist is precluded from determining catastrophic impairment outside of Criterion 7, the Tribunal gave no weight to the medical evidence and dismissed the catastrophic impairment claim.

However, the Tribunal ordered the insurer to pay up to $2,000 each for the neuropsychological and occupational therapy assessments, as they were reasonable and necessary to explore the applicant's impairments.

The applicant, who suffered severe physical injuries in a motorcycle accident, sought a catastrophic impairment designation under Criterion 8 of the Statutory Accident Benefits Schedule based on mental and behavioural disorders.

The Licence Appeal Tribunal found that the applicant failed to demonstrate a marked impairment in three of four functional domains or an extreme impairment in one domain.

The Tribunal gave limited weight to the applicant's psychiatric expert due to conclusory analysis and reliance on outdated occupational therapy reports, preferring the respondent's occupational therapy assessment and surveillance evidence showing the applicant retained useful functioning.

As the applicant was not catastrophically impaired and had exhausted his standard medical and rehabilitation limits, his claims for an occupational therapy treatment plan and an award for unreasonable delay were dismissed.

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

The applicant, who was self-represented, failed to attend the scheduled videoconference hearing despite receiving due notice.

The Licence Appeal Tribunal proceeded in the applicant's absence pursuant to section 7(1) of the Statutory Power Procedures Act.

Because the applicant presented no evidence to meet his burden of proof, the Tribunal found his injuries were predominantly minor and dismissed his claims for income replacement benefits, treatment plans, and an award.

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

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

The applicant argued she should be removed from the MIG due to chronic pain, psychological injuries, and a pre-existing condition of pregnancy.

The Tribunal found insufficient medical evidence to support a diagnosis of chronic pain or a psychological impairment, preferring the respondent's comprehensive psychological assessment over the applicant's provisional screening report.

The Tribunal also found no compelling evidence that the applicant's pregnancy prevented maximal recovery under the MIG.

The application was dismissed.

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

The respondent insurer denied a treatment plan for chiropractic services and goods, as well as a physiatry assessment, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and that the assessment was unnecessary due to a prior insurer's examination.

The Tribunal found the respondent's denial notice for the treatment plan was medically deficient under s. 38(8) of the Schedule, entitling the applicant to the benefits under s. 38(11).

The Tribunal also found the physiatry assessment was reasonable and necessary because the applicant's condition had substantively deteriorated since the prior examination, with new physical and psychological diagnoses emerging.

The applicant was awarded the disputed benefits and interest.

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

The respondent denied a treatment plan for physiotherapy on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 limit had been exhausted.

The applicant argued he should be removed from the MIG due to pre-existing conditions and chronic pain.

The Tribunal found that while the applicant had pre-existing conditions, they had largely resolved prior to the accident and did not prevent maximal recovery within the MIG.

The Tribunal also found insufficient evidence of chronic pain.

As the MIG limits were exhausted, the claim for further physiotherapy, along with claims for an award and interest, were dismissed.