S. F. Mather

The applicant was involved in two motor vehicle accidents and sought payment for various treatment and assessment plans under the Statutory Accident Benefits Schedule, which the respondent insurer denied.

The Licence Appeal Tribunal found the applicant's evidence regarding his accident details and symptoms lacked credibility, noting significant inconsistencies and a failure to disclose his return to full-time work.

The Tribunal approved an occupational therapy assessment, a psychological assessment, and assistive devices, finding them reasonable and necessary.

However, claims for ongoing chiropractic care, chronic pain programs, a neurocognitive assessment, and a vocational assessment were dismissed due to lack of credible evidence supporting their necessity and the applicant's pre-existing conditions.

The Tribunal also denied the applicant's request for a lump sum award, finding that the applicant's own refusal to attend insurer's examinations mitigated any delay by the insurer.

The applicant sought attendant care benefits following a motor vehicle collision.

The insurer initially denied the claim on the basis that the applicant's injuries fell within the Minor Injury Guideline, but later conceded entitlement.

The Tribunal found that the applicant incurred attendant care expenses and awarded $10,307.56 for the period from November 1, 2015 to December 31, 2016, plus interest.

The Tribunal dismissed the applicant's claims for a special award under Regulation 664 and for costs, finding that the insurer did not unreasonably withhold or delay payment.

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

The respondent insurer denied the claim on the basis that the applicant did not suffer a complete inability to carry on a normal life.

The Tribunal found that while the applicant sustained impairments from the accident, including exacerbation of pre-existing back issues and a concussion, she did not meet the test for a complete inability to carry on a normal life.

The Tribunal preferred the evidence of occupational therapists over the applicant's self-reports, noting she continued to engage in substantially all of her pre-accident activities, including providing childcare for her granddaughter.

The application was dismissed.

The applicant sought ongoing income replacement benefits (IRBs) following a motor vehicle accident, claiming that his daily use of marijuana to control anxiety and pain prevented him from working.

The respondent had terminated IRBs based on insurer's examinations and sought repayment of an overpayment, alleging wilful misrepresentation of the applicant's employment status.

The Tribunal found that the applicant failed to prove his marijuana dependency or other impairments resulted in a substantial inability to perform the essential tasks of his employment.

The Tribunal also dismissed the respondent's claim for repayment, finding no wilful misrepresentation and noting the respondent failed to provide notice within the 12-month limitation period.

Claims for a special award and costs were also dismissed.

The applicant insurer sought repayment of $16,325.12 in Income Replacement Benefits (IRBs) paid to the respondent following a motor vehicle accident.

The overpayment occurred because the respondent received retroactive Long Term Disability benefits from Manulife, which are deductible from IRBs under the Statutory Accident Benefits Schedule.

The respondent acknowledged liability to repay but argued the insurer was limited to collecting the overpayment by reducing subsequent IRB payments.

The Tribunal found that the insurer was not obligated to use the claw-back provisions and ordered the respondent to repay the full amount plus interest.

The applicant sought medical benefits for chiropractic treatment 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) and the $3,500 cap had been exhausted.

The applicant argued the respondent's denial notices were defective under s. 38(8) of the Schedule and that a pre-existing condition of chronic chest pain warranted treatment outside the MIG.

The Tribunal found the denial notices were compliant and that the applicant failed to provide compelling evidence of a pre-existing condition that would prevent maximal recovery under the MIG.

The claims for medical benefits, interest, a special award, and costs were dismissed.

The applicant sought attendant care benefits for a period beginning August 1, 2016.

The respondent argued the claim was barred by res judicata due to a prior FSCO arbitration decision that found no benefits were payable beyond December 31, 2013.

The Tribunal held that res judicata did not apply because the current claim was for a new period, based on new Form 1 assessments not considered by the FSCO arbitrator, and the Schedule permits ongoing applications for attendant care benefits when circumstances change.

The application was permitted to proceed to a hearing on the merits.

The applicant sought medical and rehabilitation benefits following a motor vehicle accident.

The respondent denied treatment and assessment plans for chiropractic services, a social service assessment, and an orthopaedic assessment.

The Tribunal found that the applicant failed to prove the chiropractic services and orthopaedic assessment were reasonable and necessary, largely due to insufficient evidence and an unreliable affidavit from her chiropractor.

However, the Tribunal approved the social service assessment, finding it reasonable and necessary to address the applicant's relationship and job-related issues caused by the accident.

Interest was awarded on the overdue amount, and the respondent's request for costs was denied.

The minor applicant was involved in a motor vehicle accident and sought approval for an EEG assessment recommended by her treating psychologist.

The respondent insurer denied the treatment plan on the basis that the applicant had not been diagnosed with a concussion.

The Tribunal found that the applicant's reported symptoms, including headaches and hitting her head on the car window, supported the need for the assessment.

The Tribunal ordered the respondent to pay the $1950.00 for the EEG and denied the respondent's request for costs, finding no evidence that the applicant acted frivolously or in bad faith.