Statutory Accident Benefits Schedule matters (SABS)

The applicant was injured in a motor vehicle accident and sought statutory accident benefits.

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

The Tribunal found the applicant sustained a psychological impairment, removing him from the MIG.

However, the applicant failed to prove entitlement to a non-earner benefit, as he returned to most pre-accident activities.

Most treatment plans were denied as not reasonable and necessary, or because the respondent cured initially deficient notices before the plans were incurred.

One psychological assessment was deemed payable under s. 38(11) because it was incurred before the respondent provided proper medical reasons for denial.

The claim for an award for unreasonable delay was dismissed.

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

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

The Tribunal found the applicant's accident-related dental injuries, which required surgery, warranted removal from the MIG.

The Tribunal ordered the respondent to pay for chiropractic services, incurred dental expenses, and replacement prescription eyeglasses.

Furthermore, the Tribunal found the respondent unreasonably delayed payment for the dental services and ordered a 15% special award under s. 10 of Regulation 664, along with interest on overdue benefits.

The applicant's request for costs was dismissed.

The applicant sought statutory accident benefits for medical cannabis and nutritionist services following a 2015 motor vehicle accident.

The respondent insurer denied the treatment plans.

The Licence Appeal Tribunal dismissed the application, finding that the applicant failed to prove on a balance of probabilities that either treatment plan was reasonable and necessary.

The Tribunal preferred the evidence of the respondent's section 44 examiners, who concluded that medical cannabis was contraindicated and unsupported by guidelines, and that nutritionist services were unnecessary given the applicant's stable weight.

The applicant, a pedestrian struck by a vehicle, sought various statutory accident benefits including attendant care, multiple treatment plans, and assessments.

The respondent denied the benefits, arguing many of the claimed needs arose from a subsequent accident rather than the subject accident.

The Licence Appeal Tribunal found the applicant was not entitled to attendant care or most of the treatment plans, as she failed to differentiate her injuries between the two accidents and lacked corroborating recommendations from treating physicians.

However, the Tribunal granted entitlement to a chronic pain assessment and an MRI, preferring the evidence of the applicant's specialized medical assessor over the respondent's family physician.

Interest was awarded on the overdue benefits.

The applicant sought statutory accident benefits following a motor vehicle accident, including a non-earner benefit and funding for psychological services.

The Licence Appeal Tribunal found that the applicant failed to prove a complete inability to carry on a normal life, as there was insufficient evidence comparing pre- and post-accident activities.

The Tribunal also denied the psychological treatment plan, preferring the insurer's examination which noted the applicant had sold his car and did not want treatment.

The application was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the respondent's denial of treatment plans for occupational therapy, assistive devices, physiotherapy, and a driving rehabilitation assessment.

The Licence Appeal Tribunal found the applicant partially entitled to the occupational therapy services and assistive devices, noting that the reasonableness of the benefits must be assessed at the time they were proposed.

However, the Tribunal denied the physiotherapy services as duplicative and exceeding guideline rates, and denied the driving rehabilitation assessment due to a lack of compelling evidence of ongoing psychological impairment.

Interest was awarded on the overdue benefits.

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

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

The applicant argued for removal from the MIG due to chronic pain with functional impairment and a psychological condition.

The Tribunal found that the medical evidence, including clinical notes and assessments, did not support the presence of chronic pain or a psychological condition.

Consequently, the applicant's injuries were deemed predominantly minor, and since the $3,500 MIG limit was exhausted, the claims for treatment plans and medication were dismissed.

Claims for a special award and interest were also dismissed.

The applicant sought accident benefits following a 2019 motor vehicle accident.

The respondent insurer denied several treatment plans on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the applicant sustained a full-thickness rotator cuff tear requiring surgery as a result of the accident, which warranted removal from the MIG.

The Tribunal approved treatment plans for a chronic pain assessment and an orthopaedic assessment due to the applicant's ongoing pain and functional impairment.

However, a treatment plan for physiotherapy was denied for lack of supporting medical evidence.

The Tribunal also declined to order a special award under s. 10 of Reg. 664, finding that the insurer's incorrect MIG determination did not amount to unreasonable conduct.

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

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

The applicant claimed she suffered from psychological impairments and chronic pain warranting removal from the MIG.

The Tribunal found the applicant failed to provide compelling medical evidence of a psychological impairment or chronic pain, preferring the respondent's expert reports which indicated no significant impairments.

As the $3,500 MIG limit had been exhausted, the applicant was not entitled to the disputed treatment plans, interest, or an award for unreasonable delay.

The application was dismissed.

The applicant, a pedestrian struck by a vehicle, sought a medical benefit for an occupational therapy treatment plan.

The respondent denied the plan but failed to provide medical reasons in its denial notices, violating section 38(8) of the Statutory Accident Benefits Schedule.

The Tribunal found the non-compliant denials engaged section 38(11), entitling the applicant to the incurred goods and services plus interest.

The applicant's claim for an award under section 10 of Regulation 664 was dismissed as the respondent's conduct was not excessive or imprudent.

The applicant sought statutory accident benefits following a motor vehicle accident, including an income replacement benefit (IRB) and numerous treatment plans.

The Tribunal held that the 'complete inability' test for IRBs applies 104 weeks after the accident, not after 104 weeks of cumulative disability, and found the applicant did not meet this standard as she transitioned between similar factory jobs.

The Tribunal approved several treatment plans for chiropractic and occupational therapy services based on ongoing physical pain, as well as a later social work plan, but denied others lacking evidentiary support.

Claims for a section 10 award and costs were dismissed.

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

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

The Tribunal found the applicant failed to provide sufficient medical evidence to prove a psychological impairment that would warrant removal from the MIG.

The Tribunal also dismissed the claim for non-earner benefits, as the applicant did not demonstrate a complete inability to carry on a normal life.

Claims for a psychological assessment, an award, and interest were also dismissed.

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

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

The Tribunal found that the applicant failed to prove on a balance of probabilities that he suffered from a psychological condition, chronic pain with functional impairment, or a pre-existing condition that would warrant removal from the MIG.

However, the Tribunal found that the respondent's denial of a $4,675.12 physiotherapy treatment plan did not comply with the notice requirements under s. 38(8) of the Schedule, rendering it payable despite the MIG limits being exhausted.

The denial of a psychological assessment was found to be compliant and was dismissed.

The applicant's claim for a special award under s. 10 of Reg. 664 was denied.

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 claimed entitlement to a $2,200 psychological treatment plan, arguing he suffered from accident-related psychological impairments.

The Tribunal found the applicant failed to meet his burden of proving his injuries warranted removal from the MIG, relying on the respondent's psychological assessment which found no impairment.

The Tribunal also rejected the applicant's procedural argument that the respondent's denial notice was non-compliant.

The application was dismissed.

The applicant sought various statutory accident benefits following a 2018 motor vehicle accident, including attendant care benefits, post-104 income replacement benefits, and several treatment plans.

The Tribunal dismissed the claims for attendant care and income replacement benefits, finding the applicant was independent with personal care and did not suffer a complete inability to engage in suitable employment.

The Tribunal granted the treatment plans for a SPECT scan and occupational therapy, finding them reasonable and necessary to address the applicant's traumatic brain injury and ongoing impairments.

Claims for other assessments, physiotherapy, speech-language therapy, and a special award were dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the insurer's denial of several treatment plans.

The Tribunal found the applicant was not entitled to an attendant care assessment because it was incurred before the treatment plan was submitted, contrary to section 38(2) of the Schedule.

The Tribunal partially approved a physiotherapy treatment plan for hourly services but denied per-procedure items that lacked evidence of compliance with the Professional Services Guideline.

The unapproved balance for chiropractic services was similarly denied.

However, the Tribunal granted entitlement to a chronic pain assessment, finding it reasonable and necessary given the applicant's persistent symptoms and functional limitations, and awarded interest on overdue payments.

The applicant sought statutory accident benefits following a motor vehicle accident, claiming entitlement to income replacement benefits (IRBs) and a neurological assessment.

The Tribunal found that the applicant failed to prove she met the disability test for IRBs, as the medical evidence did not establish a substantial inability to perform the essential tasks of her self-employment.

However, because the respondent insurer issued deficient notices suspending and terminating the IRBs, the Tribunal ordered the respondent to pay IRBs totaling $9,783.83 for the period before a compliant notice was issued.

The claim for a neurological assessment was dismissed as not reasonable and necessary.

The Tribunal denied a special award but granted $500 in costs to the applicant due to the respondent's late service of an accounting report.

The applicant sought statutory accident benefits following a motor vehicle accident, including income replacement benefits, various medical and rehabilitation assessments, and reimbursement for damaged items.

The Licence Appeal Tribunal dismissed the application in its entirety.

The Tribunal found the applicant failed to prove a substantial inability to perform the essential tasks of his employment for the pre-104 week period, and failed to provide requested documentation for the post-104 week period.

The Tribunal also found the applicant failed to prove the disputed treatment plans and assessments were reasonable and necessary, as they were either duplicative, unsupported by medical evidence, or previously approved.

The defendant insurer brought a motion for summary judgment seeking dismissal of the plaintiff’s claim for non-earner benefits arising from a motor vehicle accident.

The insurer argued that the claim was barred by the two‑year limitation period under the Insurance Act and the Statutory Accident Benefits Schedule because the benefit had been denied in 2008.

The court held that the insurer’s OCF‑9 constituted a clear refusal of benefits and that the limitation period began running from that denial.

A subsequent change in the law regarding eligibility for non‑earner benefits did not invalidate the earlier denial or revive the limitation period.

Claims for mental distress, bad faith, and negligent misrepresentation were also dismissed due to lack of evidentiary support.

A motion was brought to strike a third party claim against the Toronto Transit Commission’s insurer arising from a pedestrian injury caused by an uninsured vehicle while the pedestrian attempted to board a stopped streetcar.

The moving party argued there was no privity of contract with the injured person or the defendant and that declaratory relief was inappropriate.

The court held that potential liability could arise under the statutory accident benefits priority scheme in s. 268(2) of the Insurance Act if the streetcar was "involved in the incident." Accepting the pleaded facts as true, the court found the allegations could support such involvement and therefore disclosed a reasonable cause of action.

The third party claim was permitted to proceed and declaratory relief within the action was found appropriate to avoid multiplicity of proceedings.