Susan Mather

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

The respondent denied the benefits on the basis of the Minor Injury Guideline and requested the applicant attend a psychological insurer's examination to determine if the Guideline applied.

The applicant attended but did not complete the examination, and subsequently failed to attend two functional capacity assessments.

The Tribunal found that the applicant failed to comply with section 44 of the Schedule and declined to exercise its discretion to allow the application to proceed under section 55(2).

The application was dismissed.

The applicant sought statutory accident benefits for physiotherapy, acupuncture, and assistive devices following a 2015 motor vehicle accident.

The Licence Appeal Tribunal found that the applicant was not entitled to reimbursement for physiotherapy expenses incurred before submitting a treatment plan.

For two subsequent treatment plans, the Tribunal approved shockwave therapy at a reduced rate but dismissed claims for acupuncture, orthotics, and other assistive devices, finding them not reasonable and necessary given the applicant's ongoing participation in a chronic pain program and lack of evidence supporting their efficacy.

The applicant's claim for costs was dismissed.

The applicant sought income replacement benefits (IRBs) following a motor vehicle accident, claiming a substantial inability to perform the essential tasks of his self-employment as a general contractor.

The Tribunal found that the applicant's right rotator cuff tear was a pre-existing condition, not caused by the accident.

Due to significant inconsistencies in the applicant's evidence regarding his return to work and prior medical history, the Tribunal found his self-reports lacked credibility.

The Tribunal concluded the applicant failed to prove on a balance of probabilities that he suffered a substantial inability to perform his essential tasks, and dismissed the application for IRBs and interest.

The applicant sought reconsideration of a decision denying her income replacement benefits beyond 104 weeks post-accident, relying on four new multidisciplinary reports as new evidence under Rule 18.2(d).

The Tribunal dismissed the request, finding that the reports could have been obtained prior to the release of the original decision and that the applicant made a tactical decision not to seek an adjournment.

Furthermore, the Tribunal held that the new evidence would not have affected the result, as the reports relied on self-reporting that was contradicted by surveillance evidence showing the applicant engaging in various activities.

The respondent's request for costs was also dismissed.

The applicant, a self-employed taxi driver, sought income replacement benefits (IRBs) and a medical benefit for physiotherapy following a motor vehicle accident.

The insurer denied the benefits, relying on surveillance and multidisciplinary assessments that focused primarily on physical impairments.

The Tribunal found that the applicant suffered severe and ongoing psychological impairments, including major depressive disorder and post-traumatic stress disorder, which rendered him substantially unable to perform the essential tasks of his employment for the first 104 weeks, and completely unable to engage in any suitable employment thereafter.

The Tribunal awarded the claimed IRBs and interest.

Furthermore, the Tribunal ordered a 50% lump sum award under O. Reg. 664, finding that the insurer unreasonably withheld benefits by repeatedly ignoring the psychological diagnoses provided by its own assessors.

The claim for physiotherapy was dismissed for lack of evidence.

The respondent insurer requested a reconsideration of a preliminary decision which found that the applicant was involved in an 'accident' under the Statutory Accident Benefits Schedule.

The applicant had slipped and fallen on an icy driveway while walking to a waiting Lyft rideshare vehicle.

The insurer argued the Vice-Chair erred in applying the purpose and causation tests, specifically by conflating the tests and misapplying the intervening cause analysis regarding the weather.

The Vice-Chair dismissed the request for reconsideration, finding no errors of law or fact that would have altered the conclusion that the use and operation of the vehicle was a direct cause of the injuries.

The applicants were involved in a motor vehicle accident and sought attendant care benefits (ACBs) from their insurers.

Following a reconsideration decision that found an error of law in calculating the quantum of ACBs, the matter was sent back for a written hearing.

The Tribunal determined the quantum of ACBs using the 'minimum award approach' because the applicants failed to provide a breakdown of the actual hours spent on each level of care.

The Tribunal awarded S.K. $5,073.50 and R.K. $5,606.98 in ACBs, plus interest on overdue payments.

Additionally, the Tribunal found that the insurers unreasonably withheld payment of the minimum benefits owing after the reconsideration decision and ordered a lump sum award of $1,500 for each applicant under s. 10 of O. Reg. 664.

The applicant sought statutory accident benefits for psychological and chiropractic treatment following a motor vehicle accident.

The insurer denied the benefits 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 the insurer failed to provide adequate medical reasons for the denial because it did not arrange an Insurer's Examination (IE).

The Tribunal held that the insurer provided sufficient medical reasons by pointing to the lack of corroborating medical evidence in the applicant's clinical records.

Finding the applicant's psychological evidence lacked credibility, the Tribunal concluded the injuries were predominantly minor and dismissed the application.

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

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

The Tribunal found that the applicant's injuries, including a cervical strain and a left shoulder calcific tendinosis, were predominantly minor injuries or unrelated to the accident.

The Tribunal concluded that the applicant did not suffer from chronic pain caused by the accident and that the disputed treatment plans were not reasonable and necessary.

The application was dismissed.

The applicant sought statutory accident benefits for occupational therapy and assistive devices following a 2016 motor vehicle accident.

The respondent insurer denied the treatment plans.

The Licence Appeal Tribunal found that while the applicant continued to suffer impairments from the exacerbation of pre-existing degenerative disc disease, she failed to prove that the proposed occupational therapy and assistive devices were reasonable and necessary.

The adjudicator relied on the respondent's occupational therapy assessment, which concluded the applicant could perform self-care and had returned to work without the devices.

The application was dismissed.

The applicant was injured when she slipped and fell on an icy driveway while walking towards a rideshare vehicle that had arrived to take her to a medical appointment.

The respondent denied her claim for statutory accident benefits on the basis that the incident was not an 'accident' under the Schedule.

The Tribunal found that the incident met both the purpose and causation tests.

The use and operation of the vehicle began when the driver accepted the ride request, and the fact that the driver could not pull up to the entrance, requiring the applicant to walk down the icy driveway, was a direct cause of the injuries.

The Tribunal concluded the incident was an accident and the application for benefits could proceed.

The applicant sought statutory accident benefits following a motor vehicle accident, including ongoing income replacement benefits (IRBs) and medical benefits for a chronic pain assessment and physiotherapy.

The Licence Appeal Tribunal found that the applicant was substantially unable to perform the essential tasks of her pre-accident 'heavy' employment for the first 104 weeks due to chronic pain and psychological issues, entitling her to IRBs for that period.

However, she failed to prove a complete inability to engage in any suitable employment after 104 weeks.

The Tribunal also found the proposed chronic pain assessment and physiotherapy treatment plans to be reasonable and necessary, ordering them payable if incurred, along with interest on overdue benefits.

The applicants, two brothers who suffered severe burns in a garage explosion while replacing a vehicle's fuel pump, sought reconsideration of a decision finding their injuries did not result from an 'accident' under the Statutory Accident Benefits Schedule.

They argued the adjudicator breached procedural fairness by failing to analyze the Causation Test after finding the Purpose Test was not met, and alleged errors of fact and law regarding the vehicle's operability.

The Licence Appeal Tribunal dismissed the reconsideration request, holding there is no requirement to consider the Causation Test if the Purpose Test fails, and finding no errors of fact or law that would have led to a different conclusion.

The appellant sought income replacement benefits (IRBs) and medical benefits following a motor vehicle accident.

The insurer terminated IRBs on the basis that the appellant no longer suffered a substantial inability to perform the essential tasks of her employment.

The Tribunal found that the appellant failed to prove she was substantially unable to perform her pre-accident employment tasks after the termination date, noting her subsequent employment history and an intervening hand injury.

A claim for physiotherapy was denied because the treatment plan was not entered into evidence.

However, the Tribunal ordered the insurer to pay for an occupational therapy in-home assessment because the insurer failed to provide proper medical reasons for denying the treatment plan, making it payable if incurred.

The applicant sought approval for three treatment plans for chiropractic and massage therapy, and payment of the balance of a partially paid treatment plan, following a motor vehicle accident.

The insurer denied the plans on the basis that the applicant had reached maximum medical recovery.

The Licence Appeal Tribunal ordered the insurer to pay the outstanding balance on the partially paid invoices, finding that the clinical notes and records provided sufficient evidence that the services were rendered.

The Tribunal also approved the massage therapy portions of the denied plans for pain control, but denied the multiple body site therapy portions, accepting the insurer's medical examination evidence that the appellant had plateaued and the proposed therapy was not reasonable and necessary.

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

The insurer denied treatment plans for a psychological assessment and chiropractic services, arguing the appellant's injuries fell within the Minor Injury Guideline (MIG).

The Licence Appeal Tribunal found that the appellant sustained predominantly minor injuries and failed to prove that she suffered from chronic pain that would take her out of the MIG.

The Tribunal further held that the disputed treatment plans were not reasonable and necessary, relying on insurer examinations that found no psychological diagnosis and no need for further facilities-based treatment.

The application was dismissed.

The appellant sought income replacement benefits (IRBs) and attendant care benefits (ACBs) following a motor vehicle accident.

The insurer denied the IRBs and ACBs, and the appellant appealed to the Licence Appeal Tribunal.

The insurer raised preliminary issues, arguing the IRB claim was filed beyond the two-year limitation period under s. 56 of the Schedule, and the ACB claim for a specific period was barred under s. 42(5) because a Form 1 was not submitted prior to the expenses being incurred.

The Tribunal found the IRB claim was statute-barred and declined to extend the time to appeal, noting the lengthy delay and lack of evidence to support the merits of the IRB claim.

However, the Tribunal found the ACB claim was not statute-barred, interpreting s. 42(5) as not preventing an insured from submitting a retroactive Form 1 for incurred expenses.

The respondent insurer requested a reconsideration of a Licence Appeal Tribunal decision that awarded the applicant the cost of an orthopaedic assessment.

The Tribunal originally found that the insurer failed to provide a 'clear and unequivocal' denial of the treatment plan and that the insurer requested an insurer's examination more often than reasonably necessary.

On reconsideration, the Vice-Chair held that the Tribunal made significant errors of law and fact, noting that section 38(8) of the Schedule does not require a 'clear and unequivocal' denial and that the insurer's notice was compliant.

The Vice-Chair also found a breach of procedural fairness because the insurer was not given an opportunity to make submissions on the frequency of examinations.

Upon reviewing the merits, the Vice-Chair concluded the applicant failed to prove the orthopaedic assessment was reasonable and necessary, and varied the decision to dismiss the application for the assessment.

The applicant sought statutory accident benefits following a motor vehicle accident, claiming entitlement to medical and rehabilitation benefits beyond the $3,500 Minor Injury Guideline cap due to pre-existing conditions and psychological impairments, as well as income replacement benefits.

The Tribunal found the applicant's injuries were predominantly minor and that he failed to prove his pre-existing conditions prevented maximal recovery within the cap, noting significant credibility issues due to his failure to disclose prior injuries and psychological issues to assessors.

The claim for income replacement benefits was also dismissed as the applicant failed to prove a substantial inability to perform the essential tasks of his employment.

The respondent insurer requested a reconsideration of a LAT decision which found that post-accident payments made to the applicant by her mother's corporation were gifts and not deductible from her Income Replacement Benefit (IRB).

The Vice-Chair granted the reconsideration, finding that the original adjudicator's written reasons were inadequate and constituted a denial of natural justice.

The adjudicator failed to address major points in issue, incorrectly summarized the parties' positions, and did not set out a reasoning process.

The decision was cancelled and the matter was referred back to the original adjudicator for a written rehearing based on the existing evidentiary record.