Nathan Ferguson

The applicant was involved in a severe motor vehicle accident resulting in catastrophic impairment, including a brain injury.

He sought attendant care benefits and housekeeping and home maintenance benefits, which the respondent insurer denied.

The Licence Appeal Tribunal found that while the applicant was physically capable of performing tasks, his brain injury caused significant emotional and motivational limitations.

The Tribunal concluded that the applicant was entitled to attendant care benefits for comfort, safety, and security, calculated at 240 minutes per week, as well as housekeeping and home maintenance benefits of $100 per week, plus interest on overdue amounts.

The applicant was involved in a motor vehicle accident and sought statutory accident benefits, including Income Replacement Benefits (IRBs) and chiropractic treatment, which the respondent insurer denied.

The Licence Appeal Tribunal found that the applicant suffered a concussion and was substantially unable to perform the essential tasks of his employment, entitling him to IRBs for the first 104 weeks post-accident.

However, the applicant failed to prove a complete inability to engage in any suitable employment, precluding IRB entitlement beyond 104 weeks.

The Tribunal also held that the chiropractic treatment plan was not reasonable and necessary.

Notably, the Tribunal determined that the Canada Emergency Response Benefit (CERB) received by the applicant is tantamount to "other remuneration from employment" under the Schedule and is therefore deductible from the IRB entitlement.

The claim for an award was dismissed as the insurer's denial was not unreasonable.

The applicant sought statutory accident benefits for a physiotherapy treatment plan and the balance of a psychological assessment following a motor vehicle accident.

The Tribunal found that the physiotherapy treatment plan was not reasonable and necessary, preferring the respondent's expert who conducted an in-person examination and concluded the applicant had reached maximum medical recovery.

The Tribunal also denied the balance of the psychological assessment, preferring the respondent's expert who provided a more detailed and specific description of the time and cost necessary for the assessment.

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

The applicant, who was 76 years old at the time of the motor vehicle accident, sought non-earner benefits, a psychological assessment, and an orthopaedic assessment.

The Licence Appeal Tribunal dismissed the application, finding that the applicant did not suffer a complete inability to carry on a normal life, as his post-accident activities were largely consistent with his pre-accident baseline.

The Tribunal also denied the psychological assessment due to a lack of supporting medical evidence from his family physician, and denied the orthopaedic assessment because it was reasonably available through OHIP.

The applicant sought a special award and interest under the Statutory Accident Benefits Schedule, alleging the respondent insurer unreasonably delayed and withheld payment of non-earner and medical benefits.

The Licence Appeal Tribunal found that while the insurer made adjusting errors, including a 44-day delay in initial payment and a 7-month delay in providing section 44 assessment reports, these errors did not amount to unreasonable withholding or delay of benefits.

The application was dismissed, and no award or additional interest was ordered.

The applicant sought statutory accident benefits following a motor vehicle accident, arguing that chronic pain, psychological impairments, and pre-existing conditions warranted removal from the Minor Injury Guideline (MIG).

The Licence Appeal Tribunal found that the applicant's injuries were predominantly minor and that there was insufficient medical evidence of chronic pain, psychological diagnosis, or functional impairment to justify removal from the MIG.

As the applicant had not exhausted the MIG limits, the disputed treatment plans were deemed not reasonable and necessary.

The application was dismissed.

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

The respondent initially denied several treatment plans but reversed its decision prior to the hearing.

The sole issue at the hearing was whether the applicant was entitled to an award under Ontario Regulation 664 for unreasonable delay or withholding of payments.

The Tribunal found that the respondent's reliance on medical assessments and subsequent reversal of its position did not constitute unreasonable behaviour.

The application for an award was dismissed.

The applicant sought a determination that she sustained a catastrophic impairment due to a mental or behavioural disorder following a motor vehicle accident.

The adjudicator applied the three-step approach from Pastore and found that while the accident caused a mental or behavioural disorder, the impact on the applicant's life was limited.

Preferring the respondent's medical experts who noted symptom exaggeration and validity concerns, the adjudicator concluded the applicant was only mildly impaired and did not meet the threshold for catastrophic impairment.

The application was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, including funding for chiropractic and psychological treatment plans, and argued for removal from the Minor Injury Guideline (MIG) due to chronic pain and psychological impairments.

The adjudicator found that the applicant's physical injuries were predominantly minor, consisting of sprains and strains, and that the evidence did not support a chronic pain diagnosis sufficient to warrant removal from the MIG.

Relying on the insurer's psychological assessment, the adjudicator also found no diagnosable psychological condition.

Consequently, the applicant failed to meet the burden of proving entitlement to treatment outside the MIG, and the disputed treatment plans were deemed not reasonable and necessary.

The application was dismissed.

The applicant sought payment for a multidisciplinary catastrophic impairment (CAT) assessment totaling $25,779.25 following a 2013 motor vehicle accident.

The Tribunal held that entitlement to a CAT assessment is a qualified right governed by section 15 of the Schedule, requiring each constituent assessment to be reasonable and necessary, rather than a substantive right under section 25.

Reviewing the medical evidence, the Tribunal found the applicant displayed normal range of motion, functioned independently, and had minimal ongoing treatment, which was inconsistent with the severity of impairment required for a CAT designation.

The application was dismissed, along with claims for interest and a special award.

The applicant sought a medical benefit of $1,914.86 for occupational therapy to treat concussion symptoms following a motor vehicle accident.

The respondent denied the treatment plan, arguing the concussion was caused by a subsequent workplace injury.

The Tribunal found that the medical records did not support a concussion diagnosis following the accident, but rather following a blow to the head at work two months later.

The application was dismissed as the treatment plan was not reasonable and necessary for accident-related impairments.

The respondent's request for costs due to late filing was also denied.

The applicant sought medical benefits for chiropractic, physiotherapy, and massage services following a motor vehicle accident.

The respondent denied the treatment plans on the basis that they were not reasonable or necessary.

The Licence Appeal Tribunal found that the applicant had likely reached maximal medical recovery for her physical injuries and that further passive treatment would provide negligible benefit.

The application was dismissed.

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

The insurer denied the benefits because the applicant failed to submit the application forms within the 30-day time limit prescribed by section 32 of the Schedule.

The applicant argued she had a reasonable explanation for the delay, citing confusion and issues with mail delivery.

The Tribunal applied the six-part test for reasonable explanation and found the applicant's evidence lacked credibility, noting she had successfully applied for WSIB and EI during the same period.

The Tribunal concluded there was no reasonable explanation for the 17-month delay, and the application was statute-barred under section 55 of the Schedule.

The applicant sought medical benefits for injuries sustained in a motor vehicle accident.

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

The applicant contended that chronic pain and psychological impairments removed her from the MIG.

The Tribunal found insufficient evidence of chronic pain or pre-existing conditions, noting a prolonged absence of treatment.

The Tribunal also found the psychological assessment unpersuasive due to reliance on self-reporting and inconsistencies.

The application was dismissed, and the injuries were deemed subject to the MIG limit.

The applicant sought payment for a capacity assessment and the legal costs of a court application for guardianship following a motor vehicle accident.

The Licence Application Tribunal dismissed the application, finding that the capacity assessment was incurred before the treatment plan was submitted and did not meet the emergency exception under s. 38(2)(b) of the Schedule.

Furthermore, the Tribunal held that the legal costs for a guardianship application are not covered as medical or rehabilitation benefits under the Schedule.

The applicant sought statutory accident benefits following a motor vehicle accident, specifically disputing the insurer's denial of treatment plans for catastrophic impairment assessments and physiotherapy.

The Tribunal found that the catastrophic impairment assessments were not payable because they were completed by an occupational therapist rather than a physician, as required by the 2010 SABS.

However, the Tribunal approved the treatment plan for physiotherapy, finding it reasonable and necessary based on the medical evidence.

The Tribunal also ruled that HST is not included in the calculation of medical and rehabilitation benefit limits, but declined to order a special award, finding the insurer's contrary position was not taken in bad faith.

The applicant sought statutory accident benefits after being injured while loading a refrigerator onto a trailer attached to a parked vehicle.

The respondent denied the claim on the basis that the incident was not an 'accident' under the Statutory Accident Benefits Schedule.

The Tribunal applied the purpose and causation tests, finding that while loading the trailer was an ordinary use of the vehicle, the direct cause of the injuries was the malfunction of the dolly holding the refrigerator.

The dolly's failure constituted an intervening act that broke the chain of causation.

The application was dismissed.

The applicant sought non-earner benefits following a motor vehicle accident, arguing that his pre-existing cerebral palsy combined with accident-related impairments resulted in a complete inability to carry on a normal life.

The Licence Application Tribunal dismissed the application, finding that the applicant continued to engage in substantially all of his pre-accident activities, including driving, housekeeping, volunteering, and recreational pursuits.

The Tribunal relied on the applicant's family physician's disability certificate and clinical records, which indicated ongoing improvement and mild symptoms.

As no benefits were payable, the claim for interest was also dismissed.

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

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

The Tribunal found that the applicant suffered from chronic pain syndrome, which removed her from the MIG.

The Tribunal further determined that the proposed physiotherapy treatment plan was reasonable and necessary to provide temporary pain relief and improve function.

The applicant was awarded the $1,877.00 benefit and interest on overdue payments.