Paul Gosio

The applicant sought entitlement to a non-earner benefit, an attendant care benefit, and a treatment plan for psychological services following a motor vehicle accident on December 3, 2010.

The respondent denied the benefits, arguing the injuries were minor and the treatment plan was not reasonable and necessary.

The Tribunal found that the applicant failed to establish causation for the non-earner and attendant care benefits, noting her current complaints mimicked those from a prior 2008 accident for which she was already receiving benefits.

The Tribunal also found the claim for psychological services was statute-barred because the applicant failed to dispute the clear and unequivocal denial within the two-year limitation period.

The application was dismissed in its entirety.

The 13-year-old applicant was struck by a vehicle and sustained a fractured femur and a traumatic brain injury.

He applied for a catastrophic impairment designation under section 3.1(1) 5.i of the Statutory Accident Benefits Schedule based on a positive SPECT scan conducted months after his hospital discharge.

The Tribunal held that the word 'with' in the provision requires the positive finding of intracranial pathology to occur while the insured is admitted on an in-patient basis.

Because the applicant's positive scan occurred months later, he did not meet the statutory criteria for catastrophic impairment.

The applicant sought statutory accident benefits following a motor vehicle accident, including an income replacement benefit (IRB), physiotherapy, catastrophic impairment assessments, and a special award.

The Tribunal found the applicant was substantially unable to perform his pre-accident employment due to chronic pain, entitling him to an IRB up to the 104-week mark.

However, the applicant failed to prove a complete inability to engage in any suitable employment, denying him post-104 week IRBs.

The disputed treatment plans for physiotherapy and catastrophic impairment assessments were deemed not reasonable and necessary.

The claim for a special award was dismissed as the insurer reasonably relied on its medical assessments.

The applicant sought non-earner benefits following a motor vehicle accident, claiming physical and psychological impairments prevented her from carrying on a normal life.

The adjudicator applied the Heath framework and found that while the applicant experienced some changes in her post-accident life, she could still perform many of her pre-accident activities, including childcare and self-care, without significant restrictions.

The application for non-earner benefits, along with claims for an award and interest, was dismissed.

The applicant sought income replacement benefits (IRB), the cost of an IRB calculation report, and an award under O. Reg. 664 following a motor vehicle accident.

The Tribunal found the applicant failed to prove a substantial inability to perform the essential tasks of his pre-accident employment as a self-employed floor installer, noting limited medical evidence and an altered disability certificate.

The claim for IRB was dismissed.

However, the Tribunal found the cost of the IRB calculation report was reasonable and necessary given the applicant's self-employment, awarding the cost subject to the Schedule's limits, plus interest.

The claim for a special award was dismissed as the insurer gave reasonable consideration to the information available.

The applicant sought entitlement to an income replacement benefit and several treatment and assessment plans following a motor vehicle accident.

The respondent denied the income replacement benefit, arguing that the applicant's inability to work was due to congestive heart failure, a stroke, and cardiac arrhythmia that were not caused by the accident.

The adjudicator applied the 'but for' test and found that the applicant failed to establish a causal link between the accident and his subsequent cardiac and neurological conditions.

Consequently, the claim for an income replacement benefit was dismissed.

However, the adjudicator found that the applicant was entitled to medical benefits for chiropractic and psychological services, as well as the cost of an attendant care assessment, because these were reasonable and necessary to treat accident-related impairments.

A treatment plan for other goods and services was denied.

The applicant sought non-earner and medical benefits following a motor vehicle accident.

The respondent insurer requested that the applicant attend insurer's examinations under section 44 of the Statutory Accident Benefits Schedule to assess entitlement.

The applicant failed to attend multiple scheduled examinations, arguing the notices were deficient for failing to provide sufficient medical reasons.

The Tribunal found the notices validly explained that the expected recovery period was inconsistent with the soft tissue injuries diagnosed.

Because the applicant failed to attend the examinations after receiving valid notices, he was barred from proceeding with his application under section 55 of the Schedule.

The respondent's request for costs was denied as the applicant's conduct during the proceeding itself was not found to be unreasonable, frivolous, vexatious, or in bad faith.

The applicant was injured in a motor vehicle accident and sought medical and rehabilitation benefits beyond the $3,500 Minor Injury Guideline (MIG) cap, arguing that she suffered from chronic pain and chronic pain syndrome.

The respondent denied the treatment plans on the basis that the injuries were predominantly minor.

The Tribunal found that the applicant failed to establish a diagnosis of chronic pain or any functional impairment that caused an adverse effect on her well-being, noting she returned to work shortly after the accident and continued her regular duties.

The Tribunal concluded the applicant's injuries fell within the MIG and dismissed the application for additional benefits.

The applicant sought an order from the Licence Appeal Tribunal declaring her entitlement to income replacement benefits, despite the respondent insurer having already reinstated the benefits and paid all arrears prior to the hearing.

The applicant argued the order was necessary to secure procedural protections under s. 281 of the Insurance Act.

The Tribunal found it retained jurisdiction because a dispute existed when the application was filed.

However, the Tribunal dismissed the request for declaratory relief, concluding that issuing an order where the dispute had already been resolved by concession would be a misapplication of resources.

The applicant, who was catastrophically impaired in a motor vehicle accident, sought a determination that the HST charged on attendant care services should be paid outside the statutory monthly limit of $6,000.

The respondent insurer had been paying the HST out of the benefit limit.

The Tribunal found that HST is a tax, not a 'reasonable and necessary expense' under section 19 of the Schedule, and therefore must be paid outside of the attendant care benefit limit.

The Tribunal dismissed the applicant's claim for a special award under O. Reg. 664, finding that the insurer's interpretation of the Schedule, while incorrect, was not unreasonable given the lack of explicit guidance on the issue.

The respondent insurer sought a preliminary determination that the applicant was barred from proceeding with his Licence Appeal Tribunal application because he failed to attend catastrophic impairment examinations.

The applicant argued he was not required to attend because the insurer failed to provide adequate medical and other reasons for its decision and for the examinations, as required by sections 45(3)(b) and 44(5)(a) of the Statutory Accident Benefits Schedule.

The adjudicator found that the insurer's notices, which merely stated its decision was based on medical documentation and that it needed to verify the applicant's impairment rating, lacked sufficient explanation of its reasoning.

Consequently, the insurer failed to meet the statutory notice requirements, and the applicant was not precluded from proceeding with his application.

The applicant sought a determination that she sustained a catastrophic impairment as a result of a motor vehicle accident.

The dispute centered on whether she suffered a class 4 marked impairment in the Adaptation domain due to a mental or behavioural disorder.

The Tribunal applied the three-step test from Pastore and preferred the evidence of the applicant's experts, finding her credible regarding her chronic pain, social withdrawal, and inability to cope with stress.

The Tribunal concluded that the applicant's functioning in adaptation was significantly impeded, meeting the threshold for a catastrophic impairment.

The applicant, who was catastrophically impaired in a motor vehicle accident, sought attendant care benefits of $6,000 per month.

The respondent conceded entitlement but disputed the quantum and whether past services provided by the applicant's sister were 'incurred' under the Schedule.

The Tribunal found the applicant required 24-hour basic supervisory care due to unpredictable cognitive and visual episodes, entitling her to $6,000 per month for most of the claimed period.

The Tribunal also found the sister provided services in a professional capacity, satisfying the incurred test.

The claim for a special award was dismissed as the insurer's delay was reasonable given accounting and documentation issues.

The respondent insurer sought a reconsideration of a Licence Appeal Tribunal decision that awarded the applicant a massage therapy chair and associated costs.

The insurer argued the adjudicator made significant errors of law and fact, including failing to apply the proper causation test, reversing the onus of proof, mischaracterizing medical evidence, breaching procedural fairness, and failing to address whether the expense was incurred.

The Tribunal dismissed the reconsideration request, finding no significant errors that would have materially affected the outcome and confirming that entitlement can be determined before an expense is incurred.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits, including income replacement and medical benefits.

The respondent denied the benefits, arguing the applicant did not meet the requisite disability tests and the treatments were not reasonable and necessary.

The Tribunal found the applicant suffered a substantial inability to perform the essential tasks of her pre-accident employment for the first 104 weeks, entitling her to income replacement benefits for the disputed period up to the 104-week mark.

However, the applicant failed to prove a complete inability to engage in any suitable employment thereafter.

The Tribunal also found the disputed physiotherapy and psychological treatment plans to be reasonable and necessary, ordering their payment with interest.

The applicant, who was catastrophically impaired following a motor vehicle accident, sought funding for home accessibility and alternative housing assessments.

The insurer partially approved the first assessment up to the $2,000 limit and denied the second as a duplication.

The Licence Appeal Tribunal held that both assessments are subject to the $2,000 cap under section 25(5)(a) of the 2010 Statutory Accident Benefits Schedule, as they constitute clinical evaluations or appraisals of the applicant's health status.

The applicant sought medical and rehabilitation benefits, as well as a non-earner benefit, following a motor vehicle accident.

The respondent denied the benefits, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and that she did not meet the test for a non-earner benefit.

The Tribunal found that the applicant failed to prove her chronic pain was not a sequelae of her soft tissue injuries, and failed to provide compelling evidence of a pre-existing condition that would prevent maximal recovery within the MIG.

The Tribunal also found the applicant did not suffer a complete inability to carry on a normal life, as she continued to engage in many of her pre-accident activities.

The application was dismissed.

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

The insurer denied further medical benefits and a non-earner benefit, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and that he did not suffer a complete inability to carry on a normal life.

The Tribunal found that the applicant's psychological impairments took him outside the MIG, entitling him to most of the disputed treatment plans.

However, the Tribunal dismissed the claim for the non-earner benefit, finding surveillance and medical evidence showed the applicant was not continuously prevented from engaging in substantially all of his pre-accident activities.

Claims for costs and a special award were also dismissed.

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

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

The Tribunal found the applicant suffered a fractured sternum and psychological impairments, removing him from the MIG.

The Tribunal awarded income replacement benefits, attendant care benefits, and certain medical/assessment costs.

Furthermore, the Tribunal granted a special award of 40% of the outstanding attendant care benefits, finding the respondent unreasonably withheld payment by intentionally misrepresenting its assessors' findings to keep the applicant within the MIG.

The applicant sought a housekeeping and home maintenance benefit of $8,800 following a motor vehicle accident, claiming her sister provided these services.

While the Tribunal found the applicant suffered a substantial inability to perform the tasks, it dismissed the claim because the applicant failed to prove her sister sustained an economic loss as required by section 3(7)(e) of the Schedule.

The Tribunal also dismissed the applicant's request for costs to reimburse her for obtaining her employment file, finding the respondent's request for the file was reasonable to assess her functional abilities.