Andrea R. Lim

The applicant requested a reconsideration of a Licence Appeal Tribunal decision that found he was not catastrophically impaired and denied his claims for statutory accident benefits.

The applicant argued that his former counsel withdrew issues without his consent, that the Tribunal erred in its impairment ratings, and that it placed disproportionate weight on surveillance evidence.

The Vice-Chair dismissed the request, finding no breach of procedural fairness, no error of law or fact, and no new evidence that would likely have affected the result.

The applicant, a minor represented by his parent, requested a reconsideration of a Licence Appeal Tribunal decision that denied his claim for attendant care benefits.

The applicant argued that his former counsel withdrew several issues without informed consent and sought to introduce new evidence regarding his mother's economic loss.

The Tribunal dismissed the request, finding no breach of procedural fairness as it was entitled to rely on the former counsel's statements as an officer of the court.

Furthermore, the Tribunal held that the new evidence regarding economic loss pertained to a different time period and would not likely have affected the original decision.

The applicant sought statutory accident benefits following a motor vehicle accident, claiming catastrophic impairment under criteria 7 and 8, attendant care benefits, and physiotherapy services.

The Tribunal found the applicant was not catastrophically impaired, preferring the respondent's medical assessors and surveillance evidence which demonstrated the applicant maintained an active lifestyle and had significant pre-existing psychiatric conditions that were not properly accounted for by his own assessors.

The Tribunal also dismissed the claims for attendant care and physiotherapy, finding the applicant was capable of managing his daily activities independently and had reached maximum therapeutic benefit from prior treatments.

The applicant sought reconsideration of a decision denying his entitlement to income replacement benefits (IRBs).

He argued the adjudicator erred in fact and law by relying on insurer's examination (IE) reports that were allegedly procured through deficient notices.

The Tribunal dismissed the request, finding that even without the IE reports, the applicant had failed to meet his onus to prove entitlement to IRBs because he provided no contemporaneous medical evidence.

The Tribunal also noted that the applicant could not attend an IE and later claim the report was void due to improper notice.

The applicant sought various statutory accident benefits following a 2008 motor vehicle accident.

The respondent raised a preliminary issue that the applicant was barred from proceeding with her claims for attendant care and housekeeping benefits due to her failure to attend insurer's examinations.

The adjudicator found the applicant failed to comply with her obligation to attend the examinations but exercised discretion to permit the application to proceed, subject to the condition that the claims be restricted to the period ending on the date of the decision.

On the substantive issues, the adjudicator dismissed the applicant's claims for attendant care, housekeeping, and other medical and rehabilitation benefits, finding she had not demonstrated the expenses were incurred or reasonable and necessary.

The respondent's claim for repayment of non-earner benefits was also dismissed.

The applicant sought Income Replacement Benefits (IRBs), a special award, and interest following a motor vehicle accident.

The respondent had previously paid IRBs but stopped after the applicant failed to attend insurer's examinations.

The Tribunal found that the applicant failed to provide contemporaneous medical evidence demonstrating a complete inability to engage in reasonably suited employment.

The Tribunal preferred the respondent's medical assessments, which found no physical or psychological impairments caused by the accident that would prevent the applicant from working.

The application for ongoing IRBs, a special award, and interest was dismissed.

The applicant sought a determination that she sustained a catastrophic impairment as a result of a 2021 motor vehicle accident, relying on Criterion 8 (mental and behavioural impairments).

The respondent denied the claim, arguing the impairments were moderate and partially pre-existing.

The Tribunal preferred the evidence of the applicant's experts, finding that the applicant suffered marked impairments in all four spheres of function (activities of daily living, social functioning, concentration/persistence/pace, and adaptation).

The Tribunal concluded the applicant sustained a catastrophic impairment as a direct result of the accident.

The applicant, a minor injured in a motor vehicle accident, sought attendant care benefits under the Statutory Accident Benefits Schedule.

The claim was narrowed to the period between February 8, 2022, and May 5, 2022.

The Tribunal found that the applicant's mother provided the care but did not sustain an economic loss, meaning the expenses were not 'incurred' under section 3(7)(e) of the Schedule.

The Tribunal also rejected the argument that the expenses should be deemed incurred based on the Suarez decision, as that case pertained to section 38, not section 42.

The application for attendant care benefits was dismissed.

The appellant appealed a judgment dismissing an appeal from an arbitrator's decision in an insurance priority dispute.

The appellant argued the judge erred in finding the arbitrator owed no deference to the Licence Appeal Tribunal and in concluding the truck was involved in an accident.

The Court of Appeal found no error in the reasons for judgment and dismissed the appeal, awarding costs of $15,000 to the respondent.

The appellant insurer appealed an arbitrator's decision in a priority dispute regarding statutory accident benefits.

The arbitrator had found that the appellant was the priority insurer for a claimant who was catastrophically injured while loading an inoperable truck onto a trailer.

The appellant argued the truck was not an automobile and the incident was not an automobile accident, and that the arbitrator's decision was an abuse of process because it conflicted with a prior License Appeal Tribunal decision.

The Superior Court dismissed the appeal, holding that the arbitrator correctly applied the purpose and direct cause tests to find the incident was an automobile accident, and that there was no abuse of process as the arbitrator had exclusive jurisdiction over the priority dispute.

The applicant sought attendant care benefits (ACBs) following a motor vehicle accident.

The respondent had approved the ACBs up to the non-catastrophic limit but required proof that the expenses were 'incurred' under the Statutory Accident Benefits Schedule.

The Tribunal found that the applicant failed to provide sufficient evidence that the claimed expenses from a hospital, an air ambulance service, his grandmother, and a retired nurse were incurred or resulted in economic loss.

The Tribunal also found no evidence that the respondent unreasonably withheld or delayed payments.

The application for ACBs, interest, and an award was dismissed.

The applicant sought statutory accident benefits following an alleged incident in 2007.

The respondent denied the benefits and sought repayment of $67,621.07, alleging willful misrepresentation.

A preliminary issue hearing was scheduled in writing.

The applicant failed to file any submissions or evidence despite receiving notice.

The Tribunal dismissed the application, finding the applicant failed to meet the evidentiary burden to demonstrate involvement in an accident.

The applicant sought income replacement benefits (IRBs) at a rate of $400.00 per week following a motor vehicle accident.

The respondent had been paying IRBs but at a lower rate based on its own accounting reports.

The Tribunal found that the respondent's accounting reports, which relied on the applicant's actual CRA income tax returns and notices of assessment, were more reliable than the applicant's reports, which relied on estimated expenses.

The Tribunal also upheld the respondent's calculation of the reduced IRB rate after the applicant turned 65.

The applicant's claim for interest was dismissed as the respondent properly suspended benefits pending receipt of requested income information.

The applicant sought income replacement benefits following a motor vehicle accident.

The respondent insurer raised a preliminary issue, arguing the applicant was statute-barred from proceeding with his application under s. 55 of the Schedule for failing to attend scheduled insurer's examinations.

The Tribunal found that the respondent's notices of examination failed to comply with the strict requirements of s. 44(5) of the Schedule, as they did not refer to the applicant's medical condition, the specific provisions relied upon, or the credentials of the examiners.

Consequently, the preliminary issue was dismissed, and the applicant was not barred from proceeding to a hearing on the substantive issues.

The applicant requested a reconsideration of a decision that determined he was not entitled to an income replacement benefit (IRB) in excess of the statutory maximum, and that the insurer correctly calculated the ramp-down formula after he turned 65.

The applicant argued the Tribunal acted outside its jurisdiction and made errors of law by varying the IRB amount he claimed was fixed by a tort claim pleading.

The Tribunal dismissed the request, finding no jurisdictional error, as the Insurance Act grants the Tribunal authority to resolve benefit disputes, and no error of law in applying the statutory ramp-down calculation.

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

The parties participated in a case conference and subsequently advised the Tribunal that the disputed issues had been resolved.

The Tribunal ordered the file closed.

The applicant was injured in a motor vehicle accident and sought income replacement benefits (IRBs).

The insurer paid the statutory maximum of $400 per week and subsequently reduced the quantum to $16 per week after the applicant turned 65, applying the statutory 'ramp down' formula.

The applicant disputed the calculations, arguing for a higher quantum based on his annualized pre-accident income and challenging the constitutionality of the Schedule.

The Tribunal dismissed the application, finding the insurer correctly calculated the initial IRB at the statutory maximum and properly applied the ramp down formula.

The constitutional claims were dismissed for failure to serve a Notice of Constitutional Question.

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 applicant was injured in a motor vehicle accident and applied for a catastrophic impairment determination approximately 15 months post-accident.

Because the application was submitted prior to the two-year mark, the applicant was required to satisfy the additional criteria under s. 3.1(2)(b) of the Statutory Accident Benefits Schedule.

The Tribunal found that the applicant's medical experts provided projections of future impairment rather than a present determination that the applicant had a 55% whole person impairment.

Furthermore, the evidence did not establish that the applicant's condition was unlikely to improve to less than 55% impairment.

The application was dismissed as premature.

The applicant was injured in a motor vehicle accident and sought funding for chiropractic and massage therapy treatment plans outside the Minor Injury Guideline due to pre-existing conditions.

The respondent denied the plans as not reasonable and necessary.

The Licence Appeal Tribunal found that while the applicant was not bound by the MIG limits, they failed to provide contemporaneous medical evidence supporting the necessity of the treatments.

Relying on the respondent's insurer's examination, which found no ongoing impairment, the Tribunal dismissed the application and denied the applicant's request for costs.