Tami Cogan

The applicant was severely injured in a motor vehicle accident and submitted his application for accident benefits (OCF-1) nearly a year late.

The respondent denied benefits on the basis of the delay.

The Tribunal found the applicant had a reasonable explanation for the delay due to his severe brain and physical injuries, and the respondent's failure to adequately communicate the consequences of not filing or to accommodate his disabilities.

The Tribunal ordered the respondent to pay the disputed physiotherapy treatment plan, interest, and a maximum 50% special award under s. 10 of Reg. 664 for unreasonably delaying and withholding benefits.

The applicant sought a determination of catastrophic impairment and entitlement to attendant care benefits and income replacement benefits following a motor vehicle accident.

The Licence Appeal Tribunal found that the applicant did not meet the criteria for catastrophic impairment under either Criterion 7 (55% whole person impairment) or Criterion 8 (mental and behavioural disorders).

The Tribunal preferred the evidence of the respondent's experts, noting significant validity concerns and sub-maximal effort during the applicant's assessments.

Consequently, the applicant was not entitled to enhanced attendant care benefits, having exhausted her non-catastrophic limits.

The Tribunal also dismissed the claim for income replacement benefits, finding the applicant failed to prove a substantial inability to perform the essential tasks of her pre-accident employment as a personal support worker.

The self-represented applicant sought statutory accident benefits following a July 2021 motor vehicle accident, including income replacement benefits (IRBs), a physiotherapy treatment plan, and medication expenses.

The Licence Appeal Tribunal dismissed the application.

The Tribunal found the applicant was not entitled to pre-104 week IRBs as he continued to work in various roles after the accident and failed to provide medical evidence of a substantial inability to perform his essential tasks.

Consequently, he did not qualify for post-104 week IRBs.

The Tribunal also denied the physiotherapy treatment plan due to a lack of corroborating medical evidence demonstrating it was reasonable and necessary.

Finally, the Tribunal found the claimed medication expenses had already been paid in full by the respondent.

The applicant sought a determination of catastrophic impairment and entitlement to income replacement benefits and medical benefits following a 2016 motor vehicle accident.

The Tribunal found that the accident was not a necessary cause of the applicant's right hip osteoarthritis aggravation or his psychological impairments, which were instead attributed to a post-accident stroke and subsequent loss of his driver's licence.

Consequently, the applicant did not meet the 55% whole person impairment threshold for catastrophic impairment.

The claims for income replacement benefits and medical assessments were also dismissed as the applicant failed to prove they were reasonable, necessary, or caused by the accident.

The applicant was injured in a motor vehicle accident during the course of his employment and initially received WSIB benefits.

He subsequently sought statutory accident benefits from the respondent insurer, claiming he had elected to withdraw his WSIB claim to pursue a tort action.

The Tribunal found that the applicant failed to provide persuasive evidence that he had properly withdrawn his WSIB claim or obtained the required consent from the WSIB.

Furthermore, the applicant did not demonstrate a bona fide intention to pursue a tort claim, as his Statement of Claim was filed after the limitation period and not served.

Consequently, the applicant was barred under section 61 of the Schedule from pursuing accident benefits, and the application was dismissed.

The applicant sought a non-earner benefit, interest, and an award under s. 10 of Reg. 664 following a motor vehicle accident.

The Tribunal applied the Heath test and found the applicant failed to prove a complete inability to carry on a normal life, noting his pre-accident baseline involved minimal activity due to prior health issues and there was substantially little change post-accident.

The Tribunal placed little weight on the applicant's physiotherapist certificate as it lacked detail and included psychological diagnoses outside the practitioner's scope.

The application was dismissed in its entirety.

The applicant sought statutory accident benefits following a motor vehicle accident but failed to submit the OCF-1 application within the 30-day timeline prescribed by section 32(5) of the Schedule.

The applicant argued that past traumas triggered by the accident rendered her mentally incapable of applying on time.

The Tribunal applied the Horvath factors and found the applicant's explanation was not credible, noting she had actively advocated for her health, attended numerous medical appointments, and successfully navigated other government support programs during the 19-month delay.

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

The applicant was injured as a pedestrian in a motor vehicle accident but did not notify the insurer or submit an application for accident benefits (OCF-1) until 14 months later.

The insurer raised a preliminary issue that the claim was statute-barred due to the delay.

The Tribunal found that the applicant failed to provide a reasonable explanation for the delay, noting that her ignorance of the law and focus on her injuries did not justify the entire 14-month period.

Furthermore, the delay caused incurable prejudice to the insurer, as the applicant sustained multiple intervening injuries that prevented a contemporaneous assessment of the accident-related impairments.

The application was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, claiming catastrophic impairment under Criteria 6 and 7 of the Schedule.

The Tribunal found the applicant did not meet the 55% whole person impairment threshold, preferring the respondent's medical experts who assessed a 25% combined impairment over the applicant's experts whose ratings were unsupported by the AMA Guides.

The Tribunal also dismissed claims for income replacement benefits, attendant care benefits, and various treatment plans due to a lack of supporting evidence.

The respondent's claim for repayment of income replacement benefits was also dismissed for lack of evidence.

The applicant requested a reconsideration of a Licence Appeal Tribunal decision which found she did not sustain a catastrophic impairment.

The applicant alleged the adjudicator committed a material breach of procedural fairness by limiting oral submissions and excluding an Aide Memoire, and made errors of law and fact in assessing her activities of daily living, communication abilities, and expert evidence.

The Tribunal dismissed the request, finding no breach of procedural fairness as the parties were granted ample time for submissions.

The Tribunal also held that the alleged factual errors would not have changed the outcome and that the applicant was improperly attempting to re-litigate the weighing of evidence.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the respondent's denial of multiple treatment and assessment plans, medication expenses, and parking costs.

The Tribunal found that the applicant failed to prove on a balance of probabilities that the proposed in-home, attendant care, neurological, concussion, chiropractic, physiotherapy, and psychological plans were reasonable and necessary, preferring the objective findings of the respondent's assessors over the subjective reporting relied upon by the applicant's assessors.

The Tribunal awarded the cost of one prescription medication and interest on overdue payments, but denied the remaining expenses and the claim for a special award under s. 10 of Reg. 664.

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

The respondent denied a treatment plan for physiotherapy services on March 10, 2021.

The applicant filed an application with the Licence Appeal Tribunal on May 19, 2023, beyond the two-year limitation period.

The Tribunal found that the March 10, 2021 denial letter was clear and triggered the limitation period.

As the applicant did not make submissions to extend the limitation period, the claim for physiotherapy was statute-barred.

Consequently, the Tribunal held that the Minor Injury Guideline determination could not proceed as a stand-alone issue without a disputed benefit.

The application was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, including a non-earner benefit, a physiotherapy treatment plan, a psychological services treatment plan, and a special award.

The Tribunal dismissed the claim for the non-earner benefit, finding insufficient evidence to make a meaningful comparison of the applicant's pre- and post-accident activities.

The Tribunal approved the physiotherapy treatment plan, finding the goals reasonable and supported by evidence of progress.

The claim for the psychological services treatment plan was dismissed because the applicant failed to prove the provider qualified for the higher hourly rate sought.

The request for a special award was also dismissed as there was no evidence of unreasonable conduct by the insurer.

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

The applicant argued the insurer failed to comply with the 10-day response requirement under section 36(4) of the Schedule.

The Tribunal found the insurer had provided a timely response explaining the medical reasons for denial and requesting an examination.

Furthermore, the applicant failed to lead evidence demonstrating a complete inability to carry on a normal life.

The application was dismissed, and the respondent's request for costs was denied as the applicant's conduct was not unreasonable or frivolous.

The applicant sought statutory accident benefits following a 2018 motor vehicle accident.

The respondent denied treatment plans for physiotherapy and psychological services on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG).

The applicant argued that a psychological condition removed him from the MIG and that the treatment plans were payable under s. 38 of the Schedule due to late and insufficient denials.

The Tribunal found that the applicant failed to provide sufficient medical evidence linking his psychological symptoms to the accident, keeping him within the MIG limits.

The Tribunal also found that the respondent's denial notices were timely and compliant with s. 38(8).

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

The applicant sought $1,696.00 for a physiotherapy treatment plan following a motor vehicle accident.

The respondent insurer denied the plan based on an Insurer's Examination by a physical medicine and rehabilitation specialist, who opined that active therapy and modalities like acupuncture or ultrasound would not provide rehabilitation benefits due to the applicant's pre-existing spinal fusion and pain, recommending aquatic therapy instead.

The Tribunal found the proposed treatment plan lacked details on the modalities to be used and how the goals would be achieved.

The Tribunal accepted the insurer's medical evidence and concluded the applicant failed to prove the treatment plan was reasonable and necessary.

The application was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident but failed to attend the videoconference hearing or file any evidence.

The Tribunal proceeded in the applicant's absence pursuant to the Statutory Powers Procedure Act.

Finding that the applicant failed to meet his evidentiary burden, the Tribunal dismissed the claims for income replacement benefits and treatment plans, and held that the applicant remained subject to the Minor Injury Guideline.

The Tribunal awarded $250 in costs to the respondent due to the applicant's failure to withdraw the application or attend the hearing.

The applicant sought post-104-week income replacement benefits following a motor vehicle accident.

The respondent initially approved the benefits but denied them four days later based on the same Insurer's Examination reports.

The Tribunal found that the respondent's denial was a correction of the initial approval and that the applicant failed to prove a complete inability to engage in any employment for which he was reasonably suited.

The applicant's expert reports were given little weight due to a lack of objective testing and failure to outline functional limitations.

The claim for income replacement benefits and interest was dismissed.

However, the Tribunal awarded the applicant $500 in costs because the respondent breached a case conference report and order by producing documents 137 days late, which interfered with the efficiency of the dispute resolution process.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the respondent's determination that his injuries fell within the Minor Injury Guideline (MIG).

The applicant also claimed entitlement to a non-earner benefit, various treatment plans, and a special award.

The Tribunal found that the medical evidence, including clinical notes from the applicant's family physician, supported soft tissue injuries that are defined as minor under the Schedule.

The applicant failed to provide sufficient evidence of chronic pain or psychological conditions to warrant removal from the MIG.

Consequently, the disputed treatment plans falling outside the MIG were denied.

The claim for a non-earner benefit was also dismissed as the applicant provided insufficient evidence to compare pre- and post-accident activities.

The application was dismissed in its entirety.

The applicant sought statutory accident benefits following a motor vehicle accident, claiming she sustained a catastrophic impairment due to a mental or behavioural disorder under Criterion 8 of the Schedule.

The Tribunal assessed the applicant's functioning across four spheres: activities of daily living, social functioning, concentration, persistence and pace (CPP), and adaptation.

While the Tribunal found a marked impairment in CPP, it concluded the applicant only sustained moderate impairments in the other three spheres.

As the applicant did not demonstrate a marked impairment in three or more spheres, or an extreme impairment in one, the application was dismissed.