Nadia Mauro

The applicant was injured in a motor vehicle accident while driving for a ride-sharing service and applied for income replacement benefits (IRBs).

A priority dispute arose between his personal insurer and the employer's insurer (the respondent).

The respondent failed to respond to the applicant's disability certificate (OCF-3) within 10 business days as required by s. 36(4) of the Statutory Accident Benefits Schedule.

The Tribunal found that the respondent's failure to make reasonable inquiries after being notified of the priority dispute constituted non-compliance.

Consequently, under s. 36(6), the respondent was ordered to pay IRBs of $119.08 per week for the period of non-compliance, from February 22, 2023, to January 26, 2024, plus interest.

Claims for periods outside this window were dismissed as the applicant failed to provide medical evidence of a substantial inability to perform his essential tasks.

The applicant sought $1,153.17 for assistive devices following a motor vehicle accident.

The adjudicator found that the applicant failed to prove the devices were reasonable and necessary, as occupational therapy assessments indicated she could complete transfers and bathing independently.

The claims for the treatment plan, interest, and an award for unreasonable delay were dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, including an income replacement benefit (IRB), various medical and rehabilitation benefits, and an award for unreasonable delay.

The Licence Appeal Tribunal found that the applicant was not entitled to an IRB because he was not 'employed' for at least 26 of the 52 weeks prior to the accident, as he had only worked for approximately six weeks.

The Tribunal approved several treatment plans for psychological, physiotherapy, and chiropractic services, preferring the medical evidence that assessed the applicant's condition closer to the time the plans were submitted over the respondent's later assessments.

Claims for massage therapy and a duplicative neuropsychological assessment were dismissed.

The claim for a special award was also dismissed as there was no evidence the insurer acted unreasonably.

The applicant sought a determination that she sustained a catastrophic impairment as a result of a 2016 motor vehicle accident under Criteria 6, 7, and 8 of the Statutory Accident Benefits Schedule.

The Tribunal reviewed multidisciplinary assessments from both parties.

For Criterion 6 (physical), the Tribunal found a 36% whole person impairment, preferring the respondent's assessors on headaches and neurocognitive issues but the applicant's assessor on extremity impairments.

For Criterion 7 (combined physical and mental), the Tribunal added a 10% mental impairment rating based on the respondent's psychiatrist, resulting in a 42% combined impairment, falling short of the 55% threshold.

For Criterion 8 (mental/behavioural domains), the Tribunal found moderate impairments across all domains, rejecting the applicant's claims of marked or extreme impairments.

The application was dismissed.

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

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

The applicant argued that she suffered from chronic pain and psychological impairments warranting removal from the MIG, and sought a non-earner benefit (NEB) and various treatment plans.

The Tribunal found that the applicant failed to prove on a balance of probabilities that her injuries fell outside the MIG, noting a lack of compelling medical evidence linking her chronic pain and psychological complaints to the accident.

The Tribunal also dismissed the claim for an NEB, finding insufficient evidence comparing her pre- and post-accident activities.

The application was dismissed.

The applicant sought statutory accident benefits arising from a motor vehicle accident involving her mother when the applicant was seven years old.

The applicant submitted an application for benefits (OCF-1) nearly twelve years after the accident and almost two years after turning eighteen.

The insurer denied the claim due to the delay.

The Tribunal found that the applicant failed to provide a reasonable explanation for the delay in submitting the OCF-1 after reaching the age of majority.

The application was dismissed as the applicant was barred from proceeding under section 55(1) of the Schedule.

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 MRI evidence of a disc herniation warranted the applicant's removal from the MIG.

The Tribunal approved two physiotherapy treatment plans as reasonable and necessary, supported by contemporaneous medical recommendations.

However, other treatment plans for physiotherapy, a psychological assessment, and an orthopaedic assessment were denied due to a lack of supporting evidence or availability through OHIP.

The claim for an award for unreasonable withholding of benefits was dismissed.

The applicant sought entitlement to statutory accident benefits for chiropractic and psychological services following a motor vehicle accident.

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

The Tribunal relied on an insurer's orthopaedic assessment to deny the chiropractic plan and found the applicant did not justify paying a psychotherapist at a psychologist's hourly rate for the psychological services.

Claims for interest and a special award were also dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the respondent's partial denial of treatment plans for physiotherapy and psychological services.

The Tribunal found the progress report fees in the physiotherapy plans were reasonable and necessary, but denied the provider travel time.

The Tribunal denied the unapproved portion of the psychological treatment plan, finding insufficient evidence to justify paying a psychotherapist at a psychologist's hourly rate, and concluding that brokerage and planning services were not payable beyond the permitted hourly rate.

The claim for an award for unreasonable delay was dismissed.

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

The respondent insurer denied the claim because the applicant failed to submit the OCF-1 application within the 30-day time limit prescribed by section 32(5) of the Schedule.

The Tribunal found that the insurer complied with its obligation to provide the forms and explain the consequences of delay.

The Tribunal rejected the applicant's explanation for the delay as not credible, noting a lack of supporting medical evidence.

The application was dismissed as time-barred.

The applicant, a 94-year-old pedestrian, was struck by a motor vehicle and subsequently sought statutory accident benefits.

He passed away approximately eight months after the accident, and his estate continued the application.

The Licence Appeal Tribunal held that the estate was not entitled to death benefits, as such benefits attach to dependents, nor funeral benefits, as the applicant failed to prove the accident was the direct cause of his death from C. Difficile.

The Tribunal also denied attendant care benefits incurred prior to the submission of a Form 1, and lodging expenses for lack of evidence.

The applicant was awarded partial reimbursement for a wheelchair rental and a transfer pole.

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

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

As a preliminary issue, the respondent argued the application was barred by res judicata because a previous Tribunal decision had already determined the applicant was subject to the MIG.

The adjudicator found res judicata did not apply because the previous decision addressed whether the applicant had a pre-existing condition, whereas the current application argued for removal from the MIG based on chronic pain and psychological impairment.

On the substantive issues, the adjudicator found the applicant's chronic neck pain and headaches pre-dated the accident and her psychological complaints were related to this pre-existing pain.

Consequently, the applicant's injuries were deemed predominantly minor, and she was not entitled to the disputed treatment plan or an award.

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

The respondent denied several treatment plans, prompting the applicant to apply to the Licence Appeal Tribunal.

The Tribunal found the applicant was statute-barred from pursuing one occupational therapy treatment plan because she failed to attend a properly scheduled insurer's examination without a reasonable explanation.

However, the Tribunal ordered the respondent to pay for a driving assessment and a dietician assessment because the respondent failed to provide proper notice of denial under s. 38(8) of the Schedule.

Another occupational therapy plan was partially approved based on medical evidence supporting the need for cognitive and psycho-emotional support.

The claim for an award for unreasonable delay was dismissed.

The applicant was involved in a motor vehicle accident and sought $1,153.17 for assistive devices under the Statutory Accident Benefits Schedule.

The respondent denied the treatment plan.

The Licence Appeal Tribunal found that the applicant failed to prove on a balance of probabilities that the proposed assistive devices, including a raised toilet seat, tub transfer bench, and grab bar, were reasonable and necessary.

The applicant demonstrated independence in transfers and personal care, and there was no corroborating medical opinion recommending the items for safety.

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

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

The respondent denied the claim on the basis that the applicant failed to notify it of the accident within seven days and failed to submit an application for benefits within the prescribed time.

The Tribunal found that the applicant did not notify the respondent until nearly two years after the accident.

The Tribunal further held that the applicant failed to establish a reasonable explanation for the delay, as ignorance of the law alone is insufficient and the delay caused prejudice to the respondent.

The application was dismissed.

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

The adjudicator found that the applicant's physical and psychological injuries were predominantly minor and did not warrant removal from the Minor Injury Guideline (MIG).

The applicant's claim for income replacement benefits was dismissed as she failed to prove a substantial inability to perform the essential tasks of her employment.

However, the adjudicator found that the respondent's denial notices for two treatment plans were non-compliant with s. 38(8) of the Schedule, rendering the respondent liable to pay the incurred expenses under s. 38(11).

Claims for accounting reports and an award for unreasonable delay were dismissed.

The applicant applied to the Licence Appeal Tribunal for statutory accident benefits but died before the written hearing.

Counsel attempted to continue the application without an appointed estate trustee.

The Tribunal found that it lacks jurisdiction to appoint an estate trustee and that counsel had not established legal authority to continue the claim on behalf of the deceased.

The application was dismissed to prevent an abuse of process pursuant to section 23 of the Statutory Powers Procedure Act.

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

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

The applicant argued for removal from the MIG based on a pre-existing condition, chronic pain, and psychological impairment.

The Tribunal found the applicant failed to prove that his pre-existing low back pain prevented maximum recovery within the MIG, or that he suffered from accident-related chronic pain with functional impairment or a psychological impairment.

The application was dismissed.

The applicant was injured in a motor vehicle accident and sought payment for the unapproved portions of a treatment plan for catastrophic impairment assessments totaling $5,411.04.

The Licence Appeal Tribunal found that the applicant failed to prove the unapproved portions, which included file reviews, transportation, and interpretation services, were reasonable and necessary.

The Tribunal noted that file reviews are not independently billable under s. 25(5) of the Schedule.

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

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

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

The applicant argued for removal from the MIG due to a pre-existing degenerative disc condition and accident-related psychological impairments.

The Tribunal found that the applicant failed to prove the pre-existing condition would prevent maximal recovery within the MIG, relying on the insurer's medical assessment.

The Tribunal also gave little weight to the psychological diagnoses provided by a chiropractor and preferred the insurer's psychological assessment.

The application was dismissed, and the applicant was found not entitled to the disputed treatment plans or interest.